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HIPAA TIPS for Smaller Providers: Will You Get Paid October 16 and Other Problems HIPAA Summit West Session 2.07 June 5, Presented by: Steven M. Fleisher, J.D. Fleisher & Associates
Welcome
Please be sure you have signed in so that you get CME credit
Time for Questions at the end
How many have been to a HIPAA class before? Started gap analysis? Started implementation planning?
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Agenda
Transaction and Code Set Rule
Problems & Risk
Questions to Ask
Options
Enforcement
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Why Worry about TCS?
Just a technical problem for the geeks and CIOs? No!!
Next compliance deadline
Providers might not get paid given current realities!!!!
This is a little technical but humor the speaker
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4. The Uniform Transactions
Health care claims or coordination of benefits
Retail drug NCPCP v. 32
Dental claim ASC X12N 837: dental
Professional claim ASC X12N 837: professional
Institutional claim ASC X12N 837: institutional
Payment & remittance advice ASC X12N 835
Health claim status ASC X12N 276/277
Plan enrollment ASC X12 834
Plan eligibility ASC X12 270/271
Plan premium payments ASC X12 820
Referral certification ASC X12 N 278
(The following Implementation Guides are pending further development and publication of their NPRM and Final Rule)
First report of injury ASC X12
Health claims attachments ASC X & HL7 TBD
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The Uniform Code Sets
ICD-9-CM (vol. 1 & 2)
Diseases, injuries, impairments, other health related problems, their manifestations, and causes of injury, disease, impairment, or other health-related problems
CPT, CDT, or ICD-9-CM (vol. 3) -
Procedures or other actions taken to prevent, diagnose, treat, or manage diseases, injuries and impairments
NDC - drugs
HCPCS
Other health related services, other substances, equipment, supplies, or other items used in health care services
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6. Claims Submissions: October 16, 2003
Covered Entities must submit “X12N” “standard” format electronic transactions or use paper
Non-compliant/non-standard electronic transactions are legally barred
Applies to all 8 transactions
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7. Transaction Rule: Potential Benefits for Providers
Elimination of claim form and coding variations (content and format)
No need to train staff on multiple payor requirements
No denials based on failure to comply with arcane, unique rules
No unanticipated changes in the rules (uniform, annual update)
Elimination of “telephone tag”
Electronic eligibility & referrals
Electronic verification of receipt
Fewer “lost” Claims
Faster payment (14 vs 27 day minimum for Medicare)
Conclusion: improved bottom line
Get rid of the 10 foot shelf of claims manuals!
Up to one-third of rejected claims are never re-submitted; with static reimbursement, this is only way to increase revenue
Imagine shopping for toilet paper and there were 450 different sizes and shapes
Cost reduction; consistent reporting
eHealth translated to improved patient safety
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Testing
By law testing was to have begun by April 16, 2003
It has but most believe it will be far from complete by October 16
Scope of testing
Internal testing for consistency with standards
Ability of software to correctly interface with all trading partners (“end to end” testing)
Every link has to be tested:
ProviderCH/BillerPayor
Provider [software]Payor
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9. Compatibility and Transition Issues
Changes in data required and new data elements for Claims form (837)
4 to 25 relationship codes
Local codes to standard codes
New non-medical codes
Payer variation in detailed rules (Companion Guides)
Effective testing presents complex problems
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Potential Problems
Payer compliant, provider/vendor not
Provider/vendor compliant, payer not
Testing not complete
Payers unable/unwilling to run dual systems (paper & electronic)
Limited capacity
Legal concerns about accepting non-compliant transactions or decision not to (Medicare)
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Possible Bad Results
Electronic claims rejected for not being in standard form or not containing all required data elements with no quick fix
Providers retreat to paper claims overwhelming a system gearing up to go electronic
A potential “train wreck”
Providers do not get paid timely!
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Vendor Inquiries
Need to immediately work with vendors of practice management/billing systems
Need to dig down and ask hard questions
Expect lots of weasel words, incomplete answers or form letters
Find the right person
Make written inquiry now asking for written assurances within 30 days
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Vendor Inquiries
Timeline: testing started 4/16/03?
Internal testing
Will they test with your payors
Will they get third party certification (from whom)
When will they be complete (client needs time to test)
Software modifications?
Compliant for content: format and content?
New data capture requirements?
All 8 transactions covered?
Mandatory use of clearinghouse? Fees?
Security measures?
Cost?
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Vendor Inquiries
More questions:
When will you be ready to upgrade my system?
Will I require any new hardware?
Will you send me a schedule of upgrades and testing?
Can I upgrade incrementally?
Do you offer data mapping for my system?
A crucial potential roadblock
Requires individual assessment
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Vendor Issues
Alternative vendors: check
(WEDI Vendor Readiness Directory)
Also CMS EDI Software Vendor Guide
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16. Clearinghouse Solution
Many will use clearinghouse solution
Fees
Be sure Clearinghouse is really ready
Can they do the necessary translation of information both ways?
Tested
Possibly costly but you should get paid
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17. Clearinghouse Inquiries
Does CH have any third party certification (Claredi, Edifax or Foresight)?
Will CH edit claims for each payor’s companion guide requirements?
Will both HIPAA validation and companion guide edits be done at the same time?
If “transition” period given by payor relaxing standards, can CH also relax its standards?\
All these go to the speed and success of transactions submitted through CH
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18. Health Plan/Payer Inquiries
Parallel problems to vendors
Also need to ask the hard questions
Generally, the plans are ahead of many vendors and clearinghouses (more resources/bigger enforcement targets)
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19. Health Plan/Payor Inquiries
When will you be ready to accept a HIPAA compliant claim?
When will you be able to handle the additional transactions?
If you are not ready, will you designate a clearinghouse and pay for it?
Have you tested internally? With vendors and clearinghouses?
Are you obtaining third party certification? From whom? When?
Will provider have to test directly with plan?
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20. Health Plan/Payor Inquiries
Will you send me your schedule of upgrades and testing?
Your Companion Guide (revised Claims Manual)?
How will local codes be translated to standard codes?
Will payments for these services remain the same?
Will there be “transition period” where claims which are deficient in form or content will be processed?
Will an entire batch be rejected if some contain errors or are not in conformity?
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21. More Health Plan Questions
Will you be providing any free software?
Medicare is providing free billing software For more information on this go to:
Can I submit using the Medicare billing software?
Do you have a back up plan for handling a sudden increase in paper claims
Check WEDI info on plans at
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Options
Stay with paper
Make your software work
Use a clearinghouse
Go back to paper if all else fails (lots of downsides)
Everyone
Get a line of credit or save a nest egg
Submit early and often before 10/16
Stay informed (WEDI, medical society, listserves, etc.)
PrivaPlan HIPAA ToolKit (TCS guides)
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Enforcement
CMS is enforcement agency
Complaint forms on line
Enforcement policy like OCR: persuasion, education, complaint driven
Civil actions? Breach of contract?
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Lawyer’s Role
You are their lawyer, not their TCS technician
Important to understand issues
Small practices/IPAs may be clueless: do them a service and get them started asap
Avoid the inevitable mad dash in September
Can point them in the right direction to be sure they get paid
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Contact Information
Steven M. Fleisher, JD
Fleisher & Associates
Chief HIPAA Consultant, California Medical Association
35 Corwin Drive, Alamo, Ca 94507
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