Jonathan,
I don't know if you saw a recent ad run by Discover Card. They portrayed a
patient being rolled into an emergency
room (ER) of a hospital, the patient pulls out his discover card, it is
swiped and approved for ER services. The
American Hospital Assoc (AHA) complained to Discover Card that this would
never happen in a US hospital where
pre-approval (270) for ER services would be required. The Discover reply
was basically get a sense of humor. Last year the AHA estimates US hospitals
did about 6% of their business to charity, i.e. non-paying patients. Your
bigger concern should be that many hospitals are closing their ER's because
they are money losers. Most US
cities now only have one Trauma Level 1 hospital that can handle major
trauma like gunshot wounds, usually a
teaching and/or county hospital that is supported with tax dollars.
I was involved in some of the early WEDI efforts at creating what became the
HIPAA guidelines. To say the effort
was intense and difficult given all the parties involved would be an
understatement. Perfection and government
(like military intelligence) may be another oxymoron, look no further than
the proposed missile defense system.
Dave Frenkel
----- Original Message -----
From: Rachel Foerster <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Monday, January 29, 2001 7:38 AM
Subject: Re: Criticalilty & Intent
> Jonathan and William,
>
> Whoa....wait a minute. What on earth are you two quibbling about?????
> Jonathan, you say:
>
> " the worst case is surely not that payment is delayed - if an insurance
> company's computer bounces or delays response to a claim status
enquiry
> until, say, the next working day when a member of staff can pick up
the
> phone to resolve the issue, then someone's emergency treatment or
> surgery
> might be delayed or postponed or a cheaper but less-effective
procedure
> carried out which might leave side-effects. This could in the worst
> case
> prove fatal or result in long-term disability. Then apart from the
> ensuing litigation, there would also be the human trauma and
tragedy."
>
> A claim status query has NOTHING to do with an ELIGIBLITY Inquiry and
> nothing to do with making the decision to render healthcare to an
> individual. Your example above is specious.
>
> Then apparently you quote William as saying::
>
> "> It seems that the NM1 in the Other Payer Patient Information loop
(2330C)
> > has the NM103 (Individual last name or organizational name) marked as
> > "Required," though that makes no sense considering the NM1 in this case
> > is used to provide additional identifiers for an already known entity."
>
> Again, you both have taken something out of what appears to be the 837
claim
> submission and tried to drop it into the 270 Eligiblity Inquiry.
> If either of you had bothered to look at the transaction set for
> eligibility, which is/could be used in the decision making process
> for rendering healthcare, you would have easily seen that no where is
there
> any requirement for "other payer patient information." To wit,
> here's the structure of the 270:
>
> Information Source (Loop 2000A)
> Information Receiver (Loop 2000B)
> Subscriber (Loop 2000C)
> Eligibility or Benefit Inquiry
> Subscriber (Loop 2000C)
> Dependent (Loop 2000D)
> Eligibility or Benefit Inquiry
> Eligibility or Benefit Inquiry
> Information Receiver (Loop 2000B)
> Subscriber (Loop 2000C)
> Eligibility or Benefit Inquiry
> Information Source (Loop 2000A)
> Information Receiver (Loop 2000B)
> Subscriber (Loop 2000C)
> Eligibility or Benefit Inquiry
> Subscriber (Loop 2000C)
> Dependent (Loop 2000D)
> Eligibility or Benefit Inquiry
>
> Now, this doesn't mean that I don't agree with you, Jonathan, that taken
as
> a whole the HIPAA X12 implementation
> guides leave a lot to be desired, are not consistent and cohesive
> throughout, and quite frankly create more questions
> than are answered. This is what you get when you develop stuff by
committee,
> a camel! Each one of these guides
> was developed by a separate work group and they don't hang together as a
> whole as well as they should.
>
> Personally, I think the issue of whether the HIPAA guides comply with the
> X12 technical report is bogus. The real issue
> should be a focus on the standardized DATA content and not on the syntax
for
> formatting the data. Formatting
> date is a walk in the park compared to standardizing/normalizing data, and
> this is where the real issues are in
> health care.
>
> Come on boys, both of you can play in the same sand box without throwing
> sand at each other on this issue. Argue
> about what really counts!
>
> Rachel
>
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