IMPLEMENTING THE HIPAA TRANSACTIONS AND CODE SETS
Presentation to the Coalition of Voluntary
Mental Health Agencies
April 30, 2002
Prepared By:Robert BelfortKalkines, Arky, Zall & Bernstein LLP1675 Broadway, Suite 2700New York, New York 10019(212) [email protected]
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
2
WHAT DO THE RULES MANDATE?
Covered entitiesconducting any of the
HIPAA transactions electronicallymust use standardizedformats and codes.
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
3
Claims submission or encounter data Verification of health plan eligibility Pre-certification and authorization of referrals Claims status Claims payment and remittance advice Coordination of benefits
Plan enrollment and disenrollment Premium payments
WHAT ARE THE HIPAA TRANSACTIONS?
Health plans only
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
4
Claim submissionClaim paymentClaim status inquiryClaim status response
Request for authorizationApproval or denial
Eligibility inquiryEligibility response
TRANSACTION FLOW CHART
Provider
Billing
Pre-authorization
Eligibility
Health Plan
Payment
Pre-authorization
Eligibility
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
5
Claim submission ANSI X12N 837
Claim payment 835
Claim status inquiry 276
Claim status response 277
Request for referral/pre-authorization 278
Response to referral/pre-authorization request 278
Eligibility inquiry 270
Eligibility response 271
ANSI TRANSACTION FORMATS
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
6
MEDICAL CODE SETS
CodeType of Service Code Set Administrator
Physician services CPT-4 American Medical Association
Diagnosis and hospital inpatient services ICD-9-CM Center for Medicare andMedicaid Services
Other health-related services HCFA Common Procedure Center for Medicare and(e.g., DME, labs, pharmacy) Coding System (HCPCS) Medicaid Services
Dental services Code on Dental Procedures American Dental AssociationProcedures and Nomedature
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
7
STATUS OF IDENTIFIERS
Date DateRule Proposed Finalized Comments
Provider Identifier November 3, 1999 Final rule delayed due tolack of funding
Employer Identifier June 16, 1998 Final rule pending
Health Plan Identifier Rule under development
Patient Identifier Suspended due toprivacy concerns
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
8
New versions
Modifications by DSMOs
180-day notice period
MODIFICATION OF STANDARDS
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
9
Cannot use non-standard format even if both parties agree
No local codes Maximum data set Compliance by business associates No cost or time impediments Non-electronic transactions still permitted
KEY ELEMENTS OF TRANSACTION RULES
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
10
A provider under Section 1861(s) or (u) of the Social Security Act
“Any other person or organization who furnishes, bills or is paid for health care in the normal course of business”
“Health care” means care, counseling, service, assessment or procedures related to the physical or mental condition or functional status of an individual - includes case management
ARE YOU A HEALTH CARE PROVIDER?
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
11
Electronic Non-Electronic
Internet Fax
Extranet Telephone
Leased lines Mail
Dial-up lines
Private networks
Tape or disk
Direct data entry*
Telephone voice response*
DO YOU CONDUCT ELECTRONIC TRANSACTIONS?
* Standard content required but not standard format
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
12
Increased labor costs Claims payment lag Demands by payors Medicare electronic billing requirement
CAN YOU AVOID ELECTRONIC TRANSACTIONS?
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
13
Effective October 16, 2003 Exception for “small providers ”
– facilities
– other providers
MEDICARE ELECTRONIC BILLING REQUIREMENT
25 FTEs
10 FTEs
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
14
$100 per violation $25,000 per year cap per violation You won’t get paid!!
PENALTIES FOR NON-COMPLIANCE
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
15
October 16, 2002 ASCA delay until October 16, 2003
COMPLIANCE DATE
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
16
Option to delay to October 16, 2003 Must file compliance plan by October 15,
2002 Must begin testing by April 16, 2003 Medicare exclusion penalty
KEY FEATURES OF ASCA
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
17
Description of covered entity Reason for extension Implementation budget Submission options Electronic form at
www.cms.gov/hipaa/hipaa2/ascaform.asp
ELEMENTS OF ASCA COMPLIANCE PLAN
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
18
Status of your remediation efforts Readiness of your software or billing vendor Readiness of your trading partners Medicare and Medicaid seeking extension
SHOULD YOU FILE FOR AN EXTENSION?
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
19
Education Gap analysis Remediation Testing Training
FIVE STAGES OF HIPAA COMPLIANCE(Theoretical)
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
20
Denial Anger Grief Acceptance Hope
FIVE STAGES OF HIPAA COMPLIANCE(Actual)
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
21
Oversight by senior management Coordination by CIO or IT staff Participation by affected departments
– Scheduling
– Registration
– Coding
– Clinical
– Billing
– Accounts receivable
BUILDING THE COMPLIANCE TEAM
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
22
ESTABLISING A COMPLIANCE TIMELINE
Education
Gap Analysis
Remediation
Testing
Training
April 2002 December 2002 April, 2003 October 2003
248191
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
23
PERFORMING A GAP ANALYSIS
High
Moderate
Low
STAFFRESOURCES
Low Moderate High COST
Internal Staff
Commercial Self-Assessment
Tool
On-Site Consultant
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
24
Which transactions do you conduct electronically now?
Which transactions would you like to conduct electronically in the future?
Priority considerations– continuity
– complexity
– ROI
– vendor readiness
– partner readiness
DEFINING THE SCOPE OF COMPLIANCE
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
25
Download ANSI implementation guide at www.wpc-edi.com
Prepare HCFA 1500-ANSI 837 crosswalk (see afehct.org/aspire.asp)
Compare data elements and codes
GAP ANALYSIS OF CLAIMS SUBMISSION
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
26
FORMAT GAPS VS. CONTENT GAPS
Format Gaps Content Gaps
• Coding changes • Missing data elements
• Different field sizes
• Different syntax
Remedied by change Remedied by change in businessin technology processes/data capture
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
27
Billing company/clearinghouse
Commercial software package
Home grown system
CURRENT ELECTRONIC BILLING MECHANISM
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
28
Will HIPAA-complaint upgrade be issued? What is timetable? Is there a cost? Will it be tested before distribution? Will it be certified by a third party? What training and support will be provided? How will further upgrades be handled?
QUESTIONS FOR SOFTWARE VENDORS
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
29
Size and financial stability of company
Portion of revenues from health care industry
Level of HIPAA compliance resources
Status of HIPAA compliance efforts
Contractual commitment to future upgrades
SELECTING A NEW SOFTWARE VENDOR
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
30
Will the billing company function as a clearinghouse or subcontract out this function?
Who is in charge of HIPAA compliance?
When will the company be HIPAA compliant?
When will the company be ready to test?
Has the company discussed testing with payors?
Will the company seek third party certification of compliance?
BILLING COMPANY ISSUES
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
31
Medicaid upgrading EMEVS in 2003 Some HMOs using Internet-based systems Significant ROI potential
OTHER TRANSACTIONS
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
32
Remediation Option Pros Cons
Reprogramming Maintains system simplicity High up-front costs Maximum organizational control Need for ongoing revisions No per transaction fees
Translator Software Lower up-front costs Adds complexity to system Vendor responsible for Reliance on vendor for future upgrades future upgrades No per transaction fees
Clearinghouse No up-front costs Per transaction fees Vendor responsibility Maximum reliance on outside for compliance and upgrades entity
SYSTEM REMEDIATION OPTIONS
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
33
Prepare list of trading partners
Obtain HIPAA compliance status report and timeline
Monitor compliance with timeline
Test transactions (April 16, 2003 ASCA target)
Execute trading partner agreements
COORDINATION AND TESTING
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
34
Yes No
TRADING PARTNER AGREEMENTS
Mechanism for connectivity
Responsibility for telecommunication costs
Use of codes not yet specified
Size limitations on batch transactions
Change definition, data condition or use of data
Add data elements or segments to maximum defined data set
Use any code or data elements marked “not used”
Change meaning or intent of implementation specifications
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
35
NYS MEDICAID TIMELINE
In-house testing
External Testing
Upgrade of PACES
Direct electronic interface
Late 2002
Spring 2003
Late 2003/Early 2004??
2005??
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
36
Data capture
Data processing
EMPLOYEE TRAINING
KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002
37
http://aspe.hhs.gov/admnsimp
www.wpc-edi.com/hipaa
www.wedi.org
www.afehct.org
www.ahima.org
HELPFUL WEB SITES
250527.ppt
Top Related