Transaction & Code Set HIPAA Implementation Issues HIPAA Summit West Seattle, WA - June 6, 2003 Michael D. Jorgensen Director, HIPAA PMO Blue Cross Blue Shield of Georgia 3350 Peachtree Road, N.E. Atlanta, GA

Purpose Describe the outreach initiatives of WellPoint Health Networks operating companies to promote Provider HIPAA awareness Provide an overview of Provider outreach initiatives: –Lessons learned –Transaction and Code Set (TCS) implementation issues

Provider Outreach Initiatives Publications: –Articles / tools in network publications –Specific HIPAA Newsletters for Providers Provider education: –“Road shows” and other forums to promote readiness and awareness –Program content: qBegin with 101 level education and build to a 201+ level qReview of all HIPAA rules qIdentification of TCS business and testing impacts / issues qIdentification of “revenue” and “opportunity” transactions qResource identification / other helpful information

Provider Outreach Initiatives Major Lessons Learned Most Providers will not attend if a fee exists Provider level of HIPAA knowledge: –Limited knowledge of the mandate or its requirements –Wide spread confusion due to myths and erroneous information –Knowledge must be built (e.g., begin with the basics and build over each succeeding wave) Response to invitations: –15 to 20% of contacted Providers respond –70 to 80% of responding Providers attend

Provider Outreach Initiatives Major Lessons Learned (cont’d) Provider expectations: –Most are extremely appreciative of the time and material presented; especially the listing of possible resources –Some want and demand “cook books” or specific task lists of actions that must occur to become HIPAA compliant –Those that are aware require specific information Providers assume their vendors (clearinghouse and/or software) are their solution to achieving compliance with HIPAA’s TCS rule and that no action is required on their part - a “turn key” solution will be provided by the vendor

Industry TCS Implementation Challenges General state of Provider awareness and overall TCS readiness: –ANSI ASC X12 Implementation Guides (IG): qLimited to no knowledge of the IG qLimited to no knowledge of how or when required situational data elements must be used –Medical Code Set remediation: qLimited to no knowledge of the potential impact qUnknown impact of required changes to Provider billing systems –Reliance on vendors to make the Provider HIPAA ready, yet no word from the vendor –Perception that all transactions must be implemented concurrently

Industry TCS Implementation Challenges (cont’d) Vendors (Software and Clearinghouses): –Who will stay and who will exist the industry? –Some vendors are not remediating software that allows a Provider to submit transactions direct to a Payor Testing standard: –Test 4010 and the 4010A1 (Addenda) as separate events, or …… –Move to and test the 4010 / 4010A1 Addenda as a single event Providers do not understand what they must do to test / exchange transactions with their clearinghouse

HIPAA Testing Bubble - Worse Case

HIPAA Testing Bubble - Best Case

Industry TCS Implementation Challenges (cont’d) Transaction implementation: –Priority: Only those actions now being performed electronically (or should be performed electronically) qClaims and COB (837) qRemittance Advice (835 RA) –Secondary: Other transactions being performed manually or via paper - those that can generate an ROI Return on Investment (ROI): –Software to allow use of the 835 RA (e.g., automatic posting to patient accounts) –“Sell” the use of 270 / 271 and 276 / 277 as a means to get off of the telephone and gain some ROI

HIPAA’s Revenue Transactions

HIPAA’s Opportunity Transactions

Industry TCS Implementation Challenges (cont’d) Supporting or non-medical code sets: –Less descriptive and fewer in number than the proprietary codes used today –A major Provider education and awareness effort should be expected –Significant vendor support requirements to map existing codes to HIPAA codes in Provider billing systems Who will arbitrate differences between Payors and Clearinghouses or between Payors and Software vendors regarding interpretation of the ANSI ASC X12 Implementation Guides?

Industry TCS Implementation Challenges (cont’d) Identification of implementation or production cut- over dates for: –Medical code sets –Remittance Advice and other non-medical code sets –Each ANSI transaction Use of “HIPAA codes” on paper transactions Technically, Payors are required by the TCS rule to reject non-compliant transactions: –Who, besides Payors, should communicate this message to Providers? –Who will support Payors when they comply with the TCS rule?

Industry TCS Implementation Challenges (cont’d) Absence of a recognized “national” advocate for HIPAA implementation The expectation that HIPAA is a one-time event should be reset - applies to all rules Vendors (Software or Clearinghouses) are the Resources by which a Provider will become HIPAA ready: –Payors cannot directly make Providers HIPAA ready! –Knowledge transfer by vendors requires improvement! Preclude a return to paper!

Summary Significant work to occur in a relatively short period of time Key dates: –June 6, 2003: Approximately ….. to required compliance q131calendar days q89 business days (Monday - Friday) –September 1, 2003 (in the testing que): The latest reasonable date testing of an electronic transaction can begin –October 16, 2003 (compliance required): Current electronic transactions must be exchanged using HIPAA compliant formats and standards