HC-415 HIPAA EDI Train Wreck · Title: Microsoft PowerPoint - HC-415 HIPAA EDI Train Wreck.ppt...

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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com

The HIPAA EDI Train Wreck

What will it look like?Why will it happen?Can you get out of the way?How?


A Bit of HIPAA Perspective

HIPAA ObjectiveImprove the Medicare program under Title XVIII of the SSA,

the Medicaid program under title XIX of the SSA, and the efficiency & effectiveness of the U.S. health care system

Improve efficiency & effectiveness ofMedicareMedicaidU.S. health care system

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A Bit of HIPAA Perspective

1. Claims 2. Claims payment & remittance advice3. Benefits eligibility inquiry4. Claims status inquiry5. Authorizations, referrals request

At the same timeEnsure confidentiality of health informationSafeguard health information

StrategiesImplement standardized, electronic transmission of

administrative & financial transactions typically carried out manually on paper

Ensure privacy and security of health information


The Devil is in the Details!!!

Tactical Battle Plan

Common privacy rules for all

health information

Common security requirements rules

for all electronic health information

Standard formats for

administrative transactions

Standard codes

Standard data

Standard identifiers for

providers, health plans,

employers

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Standards, Standards, Standards . . . Have we got standards!

FormattingX12 Standards

UB92, NSF, HCFA1500 prohibitedBut will still have a key role to play

DataHIPAA specifies WHAT data elements are required or may be in a claimHIPAA specifies what codes are allowed

Codes not specified are PROHIBITEDe.g., local billing/revenue codes


Can a HCFA1500 - UB92 – NSF form translate successfully into HIPAA 837 Claim?

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Can a HCFA1500 - UB92 – NSF form translate successfully into HIPAA 837 Claim?

Short Answer:Short Answer:NO!NO!


Continuing Role for HCFA1500 - UB92 – NSFA starting point for the interface file from your patient accounting/practice management system to . . .

A clearinghouse

Billing or financial management services company

BUT . . . they are inadequate to the task

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The HCFA 1500 Paper FormContains a subset of data that is present in the 837P transactionContains some data that is NOT present in the 837P transactionIs a paper form that can be turned into an electronic print image


The UB92 (HCFA 1450) Paper Form

Contains a subset of data that is present in the 837I transactionContains some data that is NOT present in the 837I transaction

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National Standard Claim Format (NSF)

32 record formats in this systemRecords are

"Required", "Optional“ or "Conditional“Conditional records "Required" when data in these records is required to process the claim


NSF Hierarchy Of Record FormatsAA0 – FILE HEADER (Required)

BA0 – BATCH HEADER (Required)BA1 – BATCH HEADER (Optional)

CA0 – CLAIM HEADER (Required)CA1 – INDIAN HEALTH SERVICES (Optional)CB0 – LEGAL REPRESENATATIVE (Optional)DA0 – INSURANCE INFORMATION (Required)DA1 – MEDICARE SECONDARY PAYOR (Conditional)DA2 – MEDICARE SECONDARY PAYOR (Conditional)EA0 – CLAIM DETAIL (Required)EA1 – CLAIM DETAIL (Optional)FA0 – LINE ITEM DETAIL (Required)FB0 – LINE ITEM DETAIL MEDICAL (Optional)FB1 – LINE ITEM DETAIL MEDICAL (Optional)FB2 – LINE ITEM DETAIL MEDICAL (Optional)GA0 – AMBULANCE (Conditional)GC0 – CHIROPRACTIC (Conditional)HA0 – NARRATIVE RECORD (Conditional)XA0 – CLAIM TRAILER (Required)

YA0 – BATCH TRAILER (Required)ZA0 – FILE TRAILER (Required)

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How paper HCFA 1500/1450 forms are typically created today

Practice management system has claim data in a text fileText file is printed onto blank HCFA 1500 or 1450 claim form

Can be single sheet or continuous feed forms

Some providers print claim forms in multiple copies for file and COB claimsText files can contain data not intended to be printed on the form

Prints or resides “outside the margin”

Some providers don’t print formsSend payer data in the electronic text file – sometimes in a print image file

Paper forms also converted to electronic via optical character recognition (OCR) scanning


Data Element Gaps

Taxonomy Codes and Payer Sequence indicator Codes DO NOT reside on the HCFA 1500

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Ambiguity Within Data Content Crosswalks

Patient Relationship to InsuredHCFA 1500 provides a check box to indicate Self, Spouse, Child, or Other837P lists 25 different Relationships to Insured

CHILD

Child

Stepson or StepdaughterEmancipated MinorAdopted ChildFoster Child

Child where Insured has no financial responsibility

One-to-Many


Data Specificity Gaps

837P makes clear distinctions between Bill-To, Pay-To and Rendering Providers

HCFA 1500 does not

NM1 Segments require the distinction between “individual” and “organization” data types

For example, a Billing Provider may be “John Smith, MD” or “Best Billing Service, Inc.”

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Non-standard Use Of The Paper Claim Format

HCFA 1500 and the UB92 paper claim format contain fields which can be used for a variety of purposes

HCFA 1500, box 19 - “Reserved for Local Use”UB92, field 2 – this untitled field is assigned for use by each individual stateA variety of data (CLIA Numbers, Mammography numbers, procedure descriptors, etc.) can reside in these fields. State and Payer driven


NO ONENO ONE--TOTO--ONE DATA ONE DATA ELEMENT MAPPING ELEMENT MAPPING FROM ANY FORMAT FROM ANY FORMAT TO A HIPAA CLAIMTO A HIPAA CLAIM

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And then there’s the standard code sets . . .

Must be used in all applicable standard transactions Major code sets characterize medical data -diseases, conditions, procedures, health interventions, these include:

ICD-9 -CM - International Classification of Diseases CPT-4 - Physician Current Procedural Terminology HCPCS - HCFA Procedural Coding System for medical equipment, injectable drugs, transportation and other services not in CPT-4 CDT - Current Dental Terminology NDC - National Drug Codes


Supporting Code Sets

In addition to the major code sets, there are dozens of supporting code sets

Medical and non-medical datae.g. those embedded in the more than 500 data elements identified by the standard 837 Professional Claim

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Supporting Code Sets


Code Sets Issues

Most larger plans already use major code sets defined by the HIPAA standardsMany providers and plans use variations or extensions of the basic code sets to serve lines of business and operational work flow issues Typical paper claims process does not easily extend to the use of the supporting code sets

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And then there’s more data elements . . .

That may or may not be supported by your current system


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For all the gory details . . .

http://www.sharpworkgroup.com/getclaim.html

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The Train Wreck


Fall out from the train wreck . . .

Denied claims - Rejected claimsCurrently . . . On average

3% - 5% lost net revenue lost as a result of payment denials

Post 10/16/03 could go much higher – some estimates at 25%

Can you make payroll then?Impact to payers of prompt payment laws in statesThere is not enough time/money left to fix the problemsASCA requires HHS secretary to enforce on 10/16/03

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But … my vendor and clearinghouse told me not to worry!

CMS comments on 4/8/03 meeting in Washington, D.C.Lack of responsiveness and capabilities of

Medicare FI’s and CarriersState Medicaids

164,000 total expected claim submitters7,502 in production as of 2/28/03Only 3.14% Medicare HIPAA claims being submitted as of February ’03

Substantial percentage of provider direct submitters now going to go through a clearinghouse or vendor for HIPAA

All Medicare contractors required to be testing nowVendors experiencing testing turnaround reports taking 2 weeks

Medicare contractors requiring vendors to switch all providers at once or none


Myths & Other Misperceptions

It’s easy & cheap to translate from NSF to HIPAA 837 Claim

NSF is missing data required under HIPAASome NSF data not in HIPAA claim

Most HIPAA 837 claims created from an NSF can be adjudicated today

An assumption not supported by hard data

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The reality . . .

Most providers have not done a data gap analysisChanges needed in data collection backend systems in order to even collect new data required by patient accounting/practice management systems

Providers at substantial risk for not satisfying HIPAA data requirementsSome providers not even filling in data on current systems because claim will be rejected by Medicare

~60% of providers compliant by accident…mostlyNon-specialty physiciansClaims for office visits/surgeries

Some clearinghouses are providing missing dataLarge number of non-compliant encounters


The reality . . .

Payers feel that Vendors are NOT contacting and working with physicians to level needed to achieve complianceVendors must break provider dependency on them for HIPAA compliance

Results of a detailed analysis 100% of major patient billing and practice management systems

Institutional claims systems~27% of data required by HIPAA not captured in HIPAA-ready system

Practice management systems~60% of required data captured in old system~74% of required data captured in upgraded HIPAA-ready system

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The reality . . .

Providers are the covered entityNot their vendorsVendors can help but the providers will feel the pain of non-compliance

Providers believe they can just drop back to submitting paper claims . . . and escape all of HIPAA!!!!


Dropping claims to paper – Impact

Payers do not have enough staff to manually process claims

Time to process claims will increase exponentially

Providers will experience Severely delayed paymentsNegative cash flow

Costs of doing business will escalate for everyoneThe entire healthcare system will go on life support

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Is there a Bullet Train?


EDI Options: Providers

Replace your current systemsUpgrade your current systemsRemediate all your systemsInstall EDI Management SystemsUse clearinghouse(s)Some combination of all of the above

Understand that there is Understand that there is NO single, simple solution!NO single, simple solution!

DO NOT DO NOT –– REPEAT DO NOT REPEAT DO NOT –– DROP DROP YOUR CLAIMS TO PAPERYOUR CLAIMS TO PAPER

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Questions to ask your vendors

Will your system enable me to create or be able to use and process all the HIPAA transaction sets?

Claims, Remittance, Eligibility, Referrals, etc.If no, is this the time for me to look for another vendor?

Will your system at least have all the data elements in the system to accommodate all the data needed to receive or create all the HIPAA transaction sets?

Does your system have all the data necessary to submit a complete transaction? What fields of information are you adding and/or changing in your system?


Questions to ask your vendors

How will your system handle routing the transaction sets to the health plans and/or clearinghouses?How will your system reconcile submissions and reports to ensure the health plan and/or clearinghouse received everything I transmitted - or - that I received everything I was expecting to receive?Have you conducted any tests of the standard transactions?

With whom?Clearinghouses, my principal payers, third party testing & certification services (which ones)

What happens if a transaction is rejected?How will it show up to me?How will I understand what is wrong with it?

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How will you verify the answers?

Do you understand the new claims sufficiently?Do you understand the new code sets and how you

must use them?Have you contacted your top 10 payers to find out what

they are requiring?


Questions to ask your payers

What will they require in a HIPAA claim in order to successfully adjudicate?What are their testing requirements?

Are you in their testing queue?If you are a direct submitter, will they continue to support that?Do they require a clearinghouse?Do they have a provider support staff ready and trained to help you?How flexible or rigid will they be in accepting HIPAA claims?

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If you are a software vendor . . .What are you doing for your customer?Have you told them in sufficient detail?

Have you documented the detail?Exactly what new fields will be on the screen for claimsExactly what new fields must they fill inExactly what old fields- if any - will be goneExactly what current fields that they may have skipped over mustthey now fill inExactly how will your system support the new code sets

What is the real delivery date of your new HIPAA ready system?What additional customer support

Can you provide?Are willing to provide?Is your staff sufficiently trained for it?

How are you addressing HIPAA security requirements?


So. . . you think you want to be a clearinghouse

Are you ready to be both a covered entity and a business associate?

Federal law & regulations apply to covered entitiesContract law applies to a business associateBoth federal and state exposure if bothWeigh the risks & obligations

Are you ready to support all HIPAA transactions?If not, which ones?If not, why should your customer deal with you versus a full-service clearinghouse?

What are the costs?New IT capabilities

Software, communications, securityAdditional customer support requirementsAdditional policies, procedures, staff trainingLegal advice

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Tick, tock, tick, tock . . .

10/16/2003


HC-415 HIPAA EDI Train Wreck · Title: Microsoft PowerPoint - HC-415 HIPAA EDI Train Wreck.ppt...

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