4.06 HIPAA Transactions and Code Sets: 4.06 HIPAA TCS Contingency Planning for the October 2003 Compliance Deadline June 6, 2003 4.06 HIPAA Transactions and Code Sets: Contingency Planning for the October 2003 Compliance Deadline Christine Stahlecker, Principal Consultant Computer Task Group Healthcare Solutions WEDI SNIP Co-Chair HL7 A-SIG Co-Chair Chris Stahlecker, Computer Task Group

Contingency Planning for the October 2003 Compliance Deadline 4.06 HIPAA TCS Contingency Planning for the October 2003 Compliance Deadline June 6, 2003 Contingency Planning for the October 2003 Compliance Deadline Industry Readiness WEDI Request to HHS CMS on Enforcement Implementation Checklists Other Considerations On Contingency Planning Contingency: unforeseen event; emergency; incident; possibility; eventuality Chris Stahlecker, Computer Task Group

Industry Readiness How can we really know? 4.06 HIPAA TCS Contingency Planning for the October 2003 Compliance Deadline June 6, 2003 Industry Readiness How can we really know? Self reporting from presenters tells us Payers are ready to test Vendors are looking for payers to test with Clearinghouses are certified Providers are waiting for the Addenda release from their vendors Chris Stahlecker, Computer Task Group

Industry Readiness WEDI Conference The ‘survey’ says… Payers (48) Providers (21) Clearinghouses (6) Vendors (12)

Industry Readiness WEDI Conference A Certification group states current tests show Review of straight translation, 0 compliant With normal differential, content indicates testers are about 60% compliance Supplemental (Situational) data shows high variances within a batch Some payers’ claims are 96-98% good Other payers’ claims are 3-5% compliant Cannot know if the business rules are met until end-to-end testing is performed

Industry Readiness WEDI Conference 4.06 HIPAA TCS Contingency Planning for the October 2003 Compliance Deadline June 6, 2003 Industry Readiness WEDI Conference From Empire BCBS, Chris Stahlecker, Computer Task Group

Industry Readiness WEDI Conference From Empire BCBS: Software and/or Vendors used by their trading partners are reportedly ‘not ready’ Submitters who are ‘good to go’ do not want to cut over yet Best Practice Recommendation: be in production with both formats; submitters manage their own transition by ‘throttling back’ on UB92/1500, ‘throttle up’ on 837. Submitter testing problems traced to starting to test before they fully understood and installed the Implementation Guides and Companion Guides requirements Be sure to test the most complex situations; production problems when test data was limited

Industry Readiness WEDI Conference From a Clearinghouse, 60% of production claims are now on version 4010 There are 1100+ Payers; not testing with all yet The scope of change was not just new content but holding current content to a tighter level The regulations were just finalized a few weeks ago (i.e., version 4010A) The detailed data gap analysis, payer by payer, is underway The number of clearinghouses that responded to the survey was low but their results were concerning as 67% reporting in at the early stages.

WEDI Suggests 2 Alternatives to HHS Permitting compliant covered entities to utilize HIPAA TCS standard transactions that may not contain all required data content elements, if these transactions can otherwise be processed to completion by the receiving entity, until such time as compliance is achieved or penalties are assessed. Permitting compliant covered entities to establish a brief transition period to continue utilizing their current electronic transactions in lieu of reversion to paper transactions.

WEDI Request to HHS “WEDI respectfully requests that the Secretary provide guidance to the healthcare industry not only on these courses of action, but also on what is meant by the term “compliance,” the interpretation of which may provide some short-term transitional space for attaining a successful implementation of HIPAA TCS standards. WEDI also would like to emphasize the time sensitivity of its request for guidance, and respectfully requests that the Secretary provide such guidance to the industry within 60 days, by June 15, 2003. This timing is necessary for effective communication of such guidance to the healthcare community”.

AHA Request to CMS Adopt a System-wide implementation plan “The Office of HIPAA Standards would require all health plans to maintain current claims processing volumes and cash flow cycles for each hospital” No processing slow down after October 16 End-to-End testing of transactions Hospitals are currently having difficulty getting health plans to commit to conducting end-to-end testing

AHA Request to CMS Identification of Claim Deficiencies 4.06 HIPAA TCS Contingency Planning for the October 2003 Compliance Deadline June 6, 2003 AHA Request to CMS Identification of Claim Deficiencies CMS should recommend the use of adjunct transactions to confirm the receipt of a transaction (e.g. the acknowledgement transaction) Any deficiencies in rejected claims should be specifically identified so that providers can correct and resubmit them timely Only deficient claims should be returned, not the entire batch; remaining claims without deficiencies or errors should be processed Chris Stahlecker, Computer Task Group

CMS Enforcement CMS is ‘getting started’ with enforcement in 2003 4.06 HIPAA TCS Contingency Planning for the October 2003 Compliance Deadline June 6, 2003 CMS Enforcement CMS is ‘getting started’ with enforcement in 2003 Lori Davis is CMS Team Lead on Enforcement ‘Reasonable’ differentiation equated to Hapless versus Willful non-compliance CME will provide Technical Assistance Enforcement protocols are yet to be published; Request for Comments on the Prelude document (April 17 Fed Reg) Complaint driven enforcement initially; ultimately market driven enforcement Chris Stahlecker, Computer Task Group

Checklist Questions - Payer What are your specific LOB requirements? Are there Companion Guides? Will multiple formats be allowed from a trading partner during the transition? How long will this dual-path capability be available on a ‘need to use’ basis? Can a provider revert prior to October? after October 2003?

Checklist Questions - Payer Are there recommended ‘phase in’ strategies? Do you offer test support (e.g. Help Desk)? Will the same telecommunication methods be used for all transactions? Are there new connectivity protocols available or required? If there are reports today affected by standardized code sets, will source databases be converted? How will they be tested and reviewed (e.g. clinical pathways, Decision Support, Formulary)?

Checklist Questions - Provider Have you done a detailed data gap analysis (using the 4010A requirements) for each inbound and outbound transaction you will be performing? Have you resolved all source and destination data locations? Has each affected application vendor (Patient Reg, Clinical, HIM, Billing Office, Patient Accts, etc.) responded to your inquiry regarding their remediated software?

Checklist Questions - Provider Do you have the latest software that was remediated for HIPAA version 4010A? Do you have unapplied updates that must preceed the HIPAA version? Has your vendor, clearinghouse, BA certified this version? If not certified, who have they tested with? Who supplied the data for these tests? Are the payers that your vendor tested with, the same payers that are important to you? Consider the various Lines Of Business.

Checklist Questions - Provider Will your vendor, clearinghouse, BA enable/support your testing with payers? If not, are they guaranteeing reimbursement? Exactly what does the HIPAA compliant version NOT include? What are your options to implement these other transactions? Are there more releases or versions required from your vendor to supply all of the capabilities of the standard transactions (e.g. is COB included now or another release)? Have you established a HIPAA test environment, team, coordinator, plan?

Checklist Questions - Vendor What version is your customer really using? Are backlogged updates required? What installation check are you requiring to assure upgrades are successfully installed? Have you certified your products? Are you recommending that your customers certify? Are you supporting your customers need to perform interface tests? Tests with their mission critical partners?

Checklist Questions - Clearinghouse Are you testing with each Payer? Are you testing with each Provider? Are you testing with other Clearinghouses? How many must be tested; How many have been tested? How long does each take? (Figure out if there will be a pathway for your claims). Are you supporting your customers need to test with their mission critical partners? What observations can you share with those yet-to-test from approaches taken that are successful?

Best Practices Certify. Test with one of the certification services. Complete internal testing and certification before testing with your trading partner. Plan and prepare to test; follow your plan. Using current production data is not sufficient. Use selective, specific Test cases Consider production parallel (if supported) to really be able to compare future results

Best Practices Certification Facilitates Unit Testing of key Inputs and Outputs Unit Testing should focus on controlled test cases, scenarios and predicted results Unit Test is limited in the volume of transactions Certification Facilitates System Testing May be used to ‘stress test’ with large volumes of transactions Certification Facilitates User Acceptance Testing Cases address Companion Guide edit criteria Certification Does Not Replace Provider-Payer testing

Best Practices Considerations ‘Hands off’ testing made available between CEs Use of production programs in test cycles for actual results ‘Migrate’ the workload to new TCS rather than cut-over Business processes need to be addressed, it is not just the computer Streamlined error correction, not just the original submission Build test systems to last (internal thru external) – we will need them annually Provider Identifier is expected next

Cash Flow Brown-Out Even if you’re on the right track, you’ll get run over if you just sit there. Will Rogers, Humorist Bad news early is good news. [On early problem detection]. Shamelessly stolen from Empire BCBS Assure yourselves – know your performance baseline; anticipate changes; monitor closely

Dependencies Don’t be the weakest link Communicate openly, honestly, often Collaborate Failure will not be a singular event. We are in this together.

4.06 HIPAA Transactions and Code Sets: 4.06 HIPAA TCS Contingency Planning for the October 2003 Compliance Deadline June 6, 2003 4.06 HIPAA Transactions and Code Sets: Contingency Planning for the October 2003 Compliance Deadline Chris.Stahlecker@ctghs.com (315) 461-9136 voice (315) 461-0548 fax (315) 727-9493 cell Chris Stahlecker, Computer Task Group