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What Does EDI Mean for Medical Billing?

July 18, 2016

Benefits of EDI flowchart

I was asked to write a blog post about what I do as the Director of EDI and Business Systems at PMG. If you do not know much about EDI then you are definitely not alone! Many people are unsure about what I do all day and how it helps PMG’s clients. Let’s start with a basic definition – EDI stands for Electronic Data Interchange which is the transfer of data from one computer system to another by standardized formatting. EDI can be found in just about any industry but at PMG we deal with healthcare and claims data so this is where EDI comes into play in my world.

It all begins with our client health center’s electronic medical records (EMR). The data in the EMR then needs to go to a TON of different places; practice management (PM) systems, patient portals, lab companies and any other entity that requires the electronic exchange of medical record information. With multiple systems that may or may not play nicely together someone needs to be directing the flow of information and ensuring it gets where it needs to go. This is exactly what the EDI team does (with some help from our friends in IT).

It all sounds so simple when I put it like that… info is flying back and forth and claims are getting processed and everyone is happy right? I wish! If it was that straight forward I would be able to go home early every day. But as with all things in community health billing, things don’t always work as expected. To begin with each community health center can have a different EMR and/or PM system. Each system is unique in how they are configured to suit the needs of that health center. At PMG we say it all the time, “if you’ve seen one health center, you’ve seen one health center.” We do our best to analyze each system to ensure things go smoothly but once we hit go there is inevitably a snag somewhere in the process.

On top of working in multiple systems we also need to consider the multiple parties involved in the EDI process; PMG staff, community health center clients, IT departments, payers, clearinghouses, and, well, anyone involved in the process of getting a claim paid. Everyone involved has their own part in the EDI process and we don’t always share the same point of view or reasoning. Just as we coordinate data electronically, the EDI team is often tasked with coordinating information from multiple parties who do not necessarily ‘speak the same language’. In many cases it’s easier to get the systems to work together than it is to get multiple people to do the same.

The biggest issue for EDI is what happens when information is not being transferred as needed. getting to the bottom of this question is not as easy as you might think. Each day I am asked; How do I…? Why doesn’t…? Can I…? What does this mean?  And what is our typical response to any questions asked? As least three more questions, and that’s just to start! I’ve learned my lesson about answering questions right when they are asked rather than digging deeper to ensure it was the right question in the first place. It is so important to gather all of the pertinent information from all of the pertinent parties before establishing the best plan of attack.

Then there is a chance that the aforementioned plan will need to be tossed out of the window. In EDI priorities are a moving target. Our team must be able to constantly take in the latest information, reassess and then move forward. This is why EDI is not for the faint of heart… you definitely need patience and an ability to shift gears at a moment’s notice while still keeping your end goals in sight.

I hope you have enjoyed this window into the glamorous and exciting world of EDI. We are here any time there is an issue. It is rarely easy and at times it can push just about anyone to the edge. That is why I am here… to take that stress off of our clients. In stressful times I try to think of it as a massive puzzle that I need to figure out. That intrigues me and keeps me going. Perhaps that sounds crazy to some but what to they say? “You don’t have to be crazy to work here, we’ll train you.”

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