Of all the 1,000 cuts I’ll be featuring in this blog series, Electronic Data Interchange / EDI enrollment is the least publicly discussed and the most poorly understood. Because it seems so onerous and difficult to struggle through, and can be so incomprehensible, many clinicians avoid it. Instead, they stay with time-consuming, manual processes. Or else skip important revenue cycle management functions altogether, risking significant financial losses.
What’s EDI enrollment?
It’s the ironic act of requiring paperwork to obtain permission to engage in electronic transactions with insurance payers. Even though “paperwork” is now usually one or more web-based registration forms, it can be inefficient and the cause of costly delays – for which clinicians pay the price, not only in terms of lost revenue, but also lost time. In other words, one of the “1,000 cuts” that contributes to burnout.
EDI enrollment isn’t usually required anymore to submit claims, except for government payers. But electronic remittance advice (ERA), which is the way to receive Explanation of Benefits (EOB) forms electronically, almost always requires enrollment.
This is the general process of EDI enrollment:
Step 1. You decide to enroll to receive ERA from a payer.
Step 2. Complete your EHR and/or clearinghouse’s enrollment request.
Step 3. Paperwork from your clearinghouse, the payer, and/or an intermediary downloads, requiring either completion on a web portal or a pdf (or both). Sometimes the pdfs require a live signature, so you have to print, sign, scan back in.
What’s an intermediary?
Not all systems have direct connections to all payers. So they form agreements with another entity who transmits directly to/from the payer. That entity (usually another clearinghouse) is the intermediary, sometimes called a trading partner.
On February 21, 2024, the world found out just how critical intermediaries are. The largest one, Change Healthcare, was breached in a cyberattack that caused massive devastation to healthcare commerce.
Step 4. (yes, there’s more…!) You upload/submit your paperwork to the payer and/or intermediary.
Step 5. You notify your clearinghouse that your enrollment was submitted. This step is critical; forget it, and there will be no follow-up on your enrollment.
Step 6. Hurry up and wait. If you’re lucky, ERA enrollment takes no more than a week. But I’ve also known it to take more than 6 months.
EDI Enrollment is awful when: Congressional intervention is required!
True story! A psychologist moved to a new EHR, thus requiring all new EDI enrollments. About two months previously, she’d changed her address, updated Medicare and received a letter confirming the change. However, when the psychologist filed her new EDI enrollment paperwork, the Medicare contractor rejected it. Why? “Incorrect address.”
After an hour on the phone during which I was transferred 4 times and must have said 50 times, “our address was changed, the reference number on the approval letter is 12345678,” the EDI department refused to help, insisting I talk to Provider Enrollment. Because after all, Provider Enrollment handles address changes. Provider Enrollment said “we changed the address, you have the confirmation letter, EDI handles EDI enrollment, we don’t get involved with that and they should have the provider’s address, we did our job.”
I was a hot potato no one wanted to touch. God forbid they should talk to each other, I mean, they only work for the same company…
Finally, a Provider Enrollment supervisor said he would notify EDI. Following up two weeks later was another hour on the phone where I impersonated a tennis ball. And it was the same story: EDI stubbornly refused to approve enrollment despite me offering to send them a copy of the address update confirmation. Absolutely not! It had to come from Provider Enrollment – and them alone. But they were unwilling to contact Enrollment.
After 4 months of trying various strategies, during which time the psychologist was unable to submit claims to Medicare (and be paid), I suggested she file a Congressional complaint. Frustrated beyond belief, she contacted her Representative’s office.
Without admitting any fault, the EDI department suddenly, mysteriously, managed to “find” the psychologist’s new address and accepted her EDI enrollment. In June, 2025, after 6 months, she finally began receiving payments from Medicare.
EDI Enrollment is awful when: Change Healthcare is involved!
In case you’re thinking the Medicare example is just government bureaucracy and that it’s not so bad in the commercial world, try enrolling for ERA with Aetna. Their ERA enrollment process runs through Change Healthcare. If you begin receiving ERA in under 4 months, that’s an impressive speed.
Pre-cyberattack, Change denied a psychologist I was enrolling on the grounds that his voided check was a “mismatch.” His voided check showed First Name Last Name PH D but he filled out the online form as First Name Last Name PhD.
You can’t make this stuff up!
Payers take responsibility? Nah…
Post-Change cyberattack, many clinicians were required to re-do EDI enrollment for ERA with other intermediaries. But there were payers who never took the trouble to find new EDI routes. During the long months of the Change outage, did those payers turn back time to 2001 and mail paper EOBs?
Some did. But others said: “We’re giving you the means to look up your remittance data on Availity (or some other portal).” If pressed, they admitted sure, one-by-one lookup followed by manual payment posting isn’t efficient for practices.
But so what? Did anything Change? (pun intended) No, of course not. And why not? Because making life easier for healthcare professionals would cost them part of their profits. GASP!
Even without extreme SNAFUs, it’s an exhausting, confusing maze.
EDI enrollment forms can be multiple pages. Take a look at this one from ECHO.
Even shorter and “easier” enrollments, such as Humana’s ERA through Availity, feature wickedly complex instructions. Why is all this necessary?
It wasn’t always like this. Fifteen years ago, ERA was in common use, but none of these complex EDI enrollment gyrations were required.
So why has it become more difficult?
Payers began to require financial transaction (EFT) enrollment be paired with EDI remittance enrollment, opening the doors for additional profit-making schemes. I’ll explore this in the next “1,000 cuts” blog.
There’s a darker motivation here. These complex processes keep clinicians/billers busy chasing our tails hunting down basic financial and remittance data in order to balance our books and invoice clients. The result is a loss of time and/or energy to challenge denials and underpayments.
A second-order consequence is that clinicians may stay with EHR/practice management systems that don’t meet their needs. Because changing to something that would work better means EDI re-enrollment for all payers, with significant revenue delays and a frustrating transition.
When a practice management software platform doesn’t work effectively, who profits? Oh yeah…insurers. They don’t have to pay claims.
And then there’s Medicare’s eligibility enrollment…
Their EDI enrollment paperwork is written in gobbledygook – extremely difficult to understand and follow the directions. I’ve given many consultations dedicated solely to guiding clinicians through Noridian’s EDISS enrollment system. Of course it’s nice to have job security, but…really, can someone please explain why EDI enrollment needs to be so convoluted that you have to hire someone to help you? Is that really in the best interests of the efficiency of the healthcare ecosystem?
This summer, Medicare introduced even more hurdles. In order to get automated eligibility inquiries through your clearinghouse, everyone now has to attest annually to the HIPAA Eligibility Transaction System (HETS) Rules of Behavior. Clinicians in First Coast, Novitas, and Noridian jurisdictions are already subject to the attestation requirement. Palmetto and CGS go live this month, with WPS debuting in December. If you don’t do it, automated eligibility inquiry privileges are cancelled. Your only way of obtaining this information will be manual direct data entry on the Medicare contractor’s portal. With a complex enrollment process!
Keeping your sanity
Aside from saying the Serenity Prayer repeatedly, what can you do?
I have a few suggestions:
- Concentrate your efforts on only those payers you interact with most often.
- Enrolling for direct deposit (EFT) may cancel paper remittances from commercial payers. If you’re not ready to enroll for ERA, stay away from direct deposit, if you have that option.
- Significant Medicare volume makes things worse. Why? Because there are so many Medicare supplement payers to enroll with! And a lot of them use intermediaries who charge fees (more on that in the next “1,000 cuts” blog).
- My advice? Other than AARP and Tricare for Life, stay away from ERA with Medicare supplement plans.
- Be careful if you do decide to sign up for EFT in order to get ERA. There are intermediaries who charge fees, deducting a percentage of your reimbursement for the “privilege” of receiving what the law says you’re entitled to.
- Always read everything prior to signing.
- Keep a list of payers who don’t remit by ERA. Once or twice a month, run a report to see which claims are still outstanding, and follow up on any older than 30 days old. If a particular payer is troublesome, consider enrolling for ERA with that one,
- Ask your clearinghouse or software vendor for help with the EDI enrollment forms. That’s why you pay them the big bucks!
- If you really need ERA from a particular payer and are having a hard time with the enrollment, I can help!
I also don’t mind admitting that this is one area in which I like to make some noise! I tell payer, intermediary, and/or clearinghouse representatives why I’m not signing up for ERA if they’re trying to get me to do so and I’ve decided not to proceed. Especially if it involves payment, if I feel that the forms are too difficult, or if the “ERA” turns out to be only a web portal that’s going to involve more labor on my/the clinician’s part and only benefits the payer.
Don’t be afraid to “just say no” to EDI enrollment that, for whatever the reason, is going to make life more rather than less complicated. Mailed paper EOBs certainly have their disadvantages, but on the whole it’s less work than chasing your remittance data through 1,001 web portals. Fighting denials is enough of a challenge.
