In the healthcare world, Health Level Seven (HL7) and healthcare interoperability are the topics most often front of mind. After all, HL7 deals with the patient process, and that is what healthcare is all about, after all. But there’s another component to the healthcare industry that’s also very important: finances. Specifically, the EDI X12 standard.

X12 is a standard for EDI developed and maintained by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC). It’s very different from HL7, and not many people outside the billing process understand it. 

Read on to learn more about what EDI X12 is and why it’s so important to healthcare providers, as well as some common issues organizations face when it comes to implementing EDI X12.

What is EDI X12?

At its core, the X12 standard governs the exchange of business documents such as purchase orders, invoices, healthcare claims, and so forth in standard electronic formats between trading partners. For example, X12 dictates that invoices are designated “810,” purchase orders are “850,” and healthcare claims are “837.”

Primarily used for billing, the X12 standard allows the facilities, hospitals, and county healthcare systems to be paid for their services so that they can pay their staff and other operating expenses. As healthcare organizations depend on cash flow to operate, (like most other businesses), the more quickly and cleanly they can get billing claims submitted to their payers, the better their cash flow. 

Challenges with EDI X12

While X12 makes the billing process more seamless, there are some challenges in getting an organization up and running when it comes to using the standard. If you’ve ever seen a hospital bill, for example, you know that there are thousands of records in just a single claim. And if you’re dealing with a more complex situation, such as a COVID-19 patient in the ICU, there are even more records.

Understanding all the nuances of this billing format is complex, to say the least, so if you’re not already familiar with hospital billing practices and EDI X12, things can get messy quickly. Here are some of the most common challenges our experienced EDI X12 consulting team has seen healthcare organizations struggle with over the years. 

Converting the Data

A recent client of ours was working with XML transactions which would then get converted to EDI. To build interfaces that would convert XML to EDI, our consultant needed to go through roughly a dozen iterations of the format to make sure that the data was converted correctly. 

On top of that, our client works with multiple payers (Medicare, Medicare, commercial insurers, etc.), which meant that we needed to make sure the conversion process worked correctly through all these different connections. The whole project took nearly two years to ensure the XML to EDI conversion was viable and that things would be paid by the payers.

Keeping Billing Processes and Formats Up to Date

If you didn’t already know, X12 formats change around every eight years or so. The last change was from a 4010 to a 5010 format, and in a few years, we’ll move to another format after that. Additionally, hospitals and clinics are constantly implementing different kinds of claims and processes as our healthcare systems get bigger, faster, broader, and cover more. Items can also get put to the side because they’re not used anymore at a given hospital.

As you can imagine, staying up to date on the latest formats and accounting processes involved is a never-ending struggle for nearly any size of healthcare organization. 

Shortage of EDI Experts

Another common issue we find clients running into when it comes to X12 EDI is that there are very few people who understand and can handle EDI transactions in the industry. Many people get into the field and decide after a few years that it’s not what they want to do. The ones who do stick with it are few and far between, making them incredibly valuable.

One of our consultants, for example, has not only worked with HL7 and X12 for more than 15 years but also understands the accounting and billing processes within the average healthcare environment. This amount of experience and knowledge is exceedingly difficult to find. 

Benefits of Working with an X12 Expert

In the second part of our X12 series, “Benefits of Working With an EDI X12 Healthcare Expert,” we’ll explain the benefits of working with a third-party consultant and the value they bring to your organization. Because at the end of the day, implementing EDI X12 isn’t merely a “nice to have.” Cash flow keeps the business running—the quicker providers can get paid, the more smoothly everything operates, including your ability to care for your patients. 

Surety Systems has an expansive network of senior-level healthcare interoperability consultants with experience in many different EHR systems and platforms. No matter how challenging your situation might be, we can connect you with the right consultant to help you tackle your healthcare integration issues. 

Contact us today to get started.