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?
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Can a HCFA1500 - UB92 – NSF form translate successfully into HIPAA 837 Claim?
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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Can a HCFA1500 - UB92 – NSF form translate successfully into HIPAA 837 Claim?
Short Answer:Short Answer:NO!NO!
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Data Element Gaps
Taxonomy Codes and Payer Sequence indicator Codes DO NOT reside on the HCFA 1500
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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Supporting Code Sets
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
And then there’s more data elements . . .
That may or may not be supported by your current system
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
For all the gory details . . .
http://www.sharpworkgroup.com/getclaim.html
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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
The Train Wreck
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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!!!!
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Is there a Bullet Train?
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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?
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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?
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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?
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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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Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
Tick, tock, tick, tock . . .
10/16/2003
Copyright 2003, Rachel Foerster & Associates, Ltd., Beach Park, IL 60099. All rights reserved. www.rfa-edi.com
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