EDI Rate -- Metric Definition

This section outlines a definition for the claims metric EDI rate.

EDI Rate is generally a well understood claims process metric. A secondary discussion between payers and providers often revolves around EDI claims submission rates -- or how to get providers to stop submitting paper claims.

Key Terms. There are a number of terms which make it easier to critical to the EDI Rate definition.

1. Total Count of EDI Claims. The numerator of our EDI Rate metric is the Total Count of EDI Claims. An EDI claim is a claim that was SUBMITTED in electronic format. Sometimes payers count paper claims that are keyed by clearinghouses or other vendors as EDI Claims because they look like EDI claims when the payer receives them. They are not EDI claims. EDI is a measurement of provider submission behavior. If providers are submitting on paper, then their respective EDI performance should reflect those paper submissions -- even if they pass through steps that make them look like EDI claims before they arrive at a payer.
2. Total Claim Count. The denominator of our EDI Rate metric is the Total Claim Count Amount.
3. Exclusions. Common EDI Rate exclusions include adjusted claims.

Frequency. The EDI Rate is generally not a daily operational metric. In general, a payer should monitor the EDI Rate each week. A comprehensive EDI picture includes the weekly EDI Rate for the whole plan, the EDI Rates for each line of business, the top 25 providers, the top 25 self-funded employers. It can be helpful to manage EDI reciept volume on a daily basis to make sure appropriate file and batch process steps took place.

Operational Uses. The EDI rate is not a metric used to manage daily production (as noted above in the frequency section). It is used on a periodic basis (weekly/monthly/quarterly) to manage:

1. EDI Rate for a Provider. The EDI Rate is a fundamentally a provider management metric. A very common operational use of the EDI rate is to report it for individual providers, particular large hospital systems -- which tend to be more aggressive about managing submissions and tend to have higher claim volumes. In general, a target EDI rate for a large hospital system is approximately 85%
2. EDI Rate for a Line of Business(LOB). Certain lines of business may be characterized by EDI patterns that are important to track. For example, lines of business such as Medicare Secondary, which require a EOB also benefit by tracking the EDI rate.
3. EDI Rate for an ASO/Self-Funded Employer. Tracking EDIs and EDI reasons for self funded employers is helpful in managing their expectations around administrative costs -- paper claims have a higher administrative cost.

Issues, Notes and Challenges. As a metric the EDI Rate also has a number of notes and issues.

1. Receipt EDI Rate versus Finalized EDI Rate? In plans with batch process issues, the EDI Rate is sometimes measured each day for receipts. This can be helpful to
2. 'Almost' EDI Claims. As noted above, some claims are submitted on paper, but because of arrangements with a clearinghouse or other intermediary, the claims arrive at the payer as EDI claims. This is a discretionary area of the EDI definition. At the end of the day the goal is for providers NOT to create additional input costs for payers. If providers make arrangements with clearinghouses to enter claims and those costs are not passed to payers, then its a coin toss -- treat them as paper or EDI. At the end of the day the EDI Rate is a tool to tell a payer which providers need support/encouragement to move to EDI submission.
3. Claim Attachments. Depending upon the lines of business, generally between 5 and 10 percent of claims have some type of attachment. With ongoing HIPPA transaction standards these are slowly moving to EDI formats, but today many remain on paper -- and as such the claims that they are attached to are submitted on paper. Providers may say "We would have submitted EDI -- but for the attachment..." but they didn't and those claims are not EDI claims.
4. EDI Remittances. EDI Rate is focussed on Receipts. We're working on and EDI remit rate -- stay tuned.
5. Adjusted Claims. For most payers, claims adjustments are a world onto themselves. Generally speaking between 2 and 5 percent of claims are adjusted. Because of the exception related (and often strange) things that happen to adjustments it is better to exclude them from the EDI Rate definion.
6. Input Edits on EDI Claims. An EDI Claim is and EDI Claim, no matter what happens to it after it comes through the firewall. Some EDI claims require provider and/or member matching. They're still EDI claims.

Attributions.

1. Sources. This metric was developed during the fifteen years of association with health plans.
2. Update History. This definition was last updated March 11th, 2007.