162.930, the clearinghouse financial rule, says that if a health plan requires a provider to go through a clearinghouse to reach it to send or receive standard transactions, then the plan must pay for the clearinghouse. (That's a paraphrase of course).
So on the surface it would seem that health plans who are telling providers to reach them only through a clearinghouse would not be adding cost to the providers but would be absorbing the cost themselves. However, counsel for some plans are thinking that if the plan offers to receive, say, diskettes, that would mean they are not requiring the clearinghouse but are offering the clearinghouse as an option. And if they are not requiring the clearinghouse, the plan would not have to pay for it. We are looking at this problem. I doubt this is very sound reasoning and it goes in the face of the basic concept that each party should pay its own way. Say, however, it is in fact a loophole. We might then expect the loophole to be closed quickly in a future rule. So regardless of the conclusion of the legal review, it seems to be imprudent policy to assume that a diskette path will get around the fundamental purpose in 162.930 that a provider should not be forced to pay for basic services it does not want. Peter Peter Barry Peter T Barry Company Ozaukee Bank Building 1425 West Mequon Road Mequon Wisconsin 53092 (414) 732 5000 (national cell) [EMAIL PROTECTED] --------------------------- In a message dated 11/1/2001 12:14:26 PM Central Standard Time, [EMAIL PROTECTED] writes: > Subj: RE: Provider Confusion > Date: 11/1/2001 12:14:26 PM Central Standard Time > From: [EMAIL PROTECTED] (Johnson, Barbara) > Reply-to: <A HREF="mailto:[EMAIL PROTECTED]";>[EMAIL PROTECTED] </A> > To: [EMAIL PROTECTED] ('[EMAIL PROTECTED]') > > I think an interesting question is raised here regarding the business > purposes of using clearinghouses in the new HIPAA world. By rule, a > clearinghouse is an entity that receives proprietary format information, > translates it into X12 standard format, and sends off a standard compliant > transaction; or, a clearinghouse receives a standard x12 transaction, > translates it into a proprietary format, and sends it off as a transaction > to whatever entity needs to receive it in that proprietary format. The key > role of said clearinghouse is to do a translation from/to > standard/non-standard. In my mind, if the provider billing entity can > create and send a standard transaction itself, then I do not see a business > purpose in the provider billing entity using a clearinghouse. However, on > the payer side, it would be beneficial to deal with the least amout of > incoming transaction files as possible, and this might be achieved if all > senders used the same clearinghouse. I can not imagine what it will be like > to get a daily file of transactions from every possible provider billing > entity. Who is going to keep track of all that stuff? > > Barb Johnson, Director of Compliance, Audit, Data Management > MercyCare Insurance Co, Janesville, WI > > -----Original Message----- > From: Jonathan Fox [mailto:[EMAIL PROTECTED]] > Sent: Thursday, November 01, 2001 8:54 AM > To: [EMAIL PROTECTED] > Subject: Provider Confusion > > > In response to your comments: > > "I am trying to get a sense of what providers are > encountering when they contact payers. I am hearing > that payers are trying to coerce providers into using > clearinghouses instead of going point to point - the > problem is many providers are investing in advanced > connectivity tools like SeeBeyond, Vitria etc...and > can support point to point so why would they want to > spend over 500K to integrate and enable an EAI tool > for X12 to just send a compliant message to a > clearinghouse and be charged an access or transaction > fee. It does not make sense and I feel it is not > HIPAA's intent. > > Are you aware of what others are doing and/or can we > pose this to a broader audience to get feedback?" > > > I would like to go on record by saying that we prefer the exact opposite. > We do not currently have ANY cost associated with clearinghouses. We would > prefer to deal direct or with any service that does not charge a fee. > There is absolutely no coercion coming from this payer!!!! > > > Jonathan Fox > eCommerce Analyst > Independent Health > ********************************************************************** To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=business and enter your email address.
