William, Noticed that I never answered your questions below, so I thought I'd take a minute & do so. When everything was fee-for-service, the world was simple - then HCFA decided to contract for certain services from certain providers, and to only pay "schedule" rates for other services. The flood gates are now wide open, and we have nearly as many health plans as we do employers represented in our databases. The carriers offer "specialized" plans and there are no guidelines on how these coverage agreements are structured - its truly a boutique business. The carriers sell the plans to employers, who turn around and offer the coverage to their employees - larger employers offer several different coverages, depending on the employee's needs. They (carriers, large self-insured employers, HMOs) then come to our front door (some thru the back door) and negotiate with us to be a contracted provider to perform some or all of the services they are selling at the other end.
Along with these plans came another cottage industry - third party administrators (TPAs) - who sell their services to employers and carriers - they contract to perform lots of different services including claims review, claims repricing (taking the provider's charges and "re-pricing" them to reflect contract agreed charges), eligibility & benefits checking, etc. Further, if the plan is capitated, they perform other services related to lifetime benefits and adjudication on behalf of the plans. There are numerous situations where more than one TPA can be in the mix - e.g. a professional repricer before the plan administrator, and even a separate reviewer. They can be in any sequence, though the repricer is usually the first stop for claims if one is present. The only good news is that usually (but not always) the TPAs can figure out amongst themselves where to send the claim next in the sequence because they only deal with a limited set of contracts. The kicker is that these "third parties" usually get inserted into the mix because neither the employer nor carrier want to be burdened with figuring out the nuances of the ridiculous contracts they are negotiating. So they contract with the third party, and then tell us that "for plan INS-xxxx, send the claim to RPCyyy, and request eligibility & benefits from TPAzzz". So, it ends up being our problem to determine where to send claims and address inquiries. I have no doubt that this situation will continue with EDI, so having a separate set of addresses by plan and transaction makes a lot of sense to me. This assignment is somewhat dynamic, however, and needs to be kept up to date by whoever is contracting for the coverage. These contracts are usually not long-term, and when they change, often the claim destination can change along with other contract terms. I'm still not sure I understand how we would ever go about determination that re-discovery is necessary, but i'm learning more every day... Hope this helps to explain some of it. Dave Minch T&CS Project Manager John Muir / Mt. Diablo Health System Walnut Creek, CA (925) 941-2240 -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Friday, February 15, 2002 12:42 PM To: Dave Minch Subject: Re: I hope you don't mind me "volunteering you" to do the 838 IG Thanks a lot, you're a trooper!! Also thanks for looking into the digital ID. I was gonna ask the list, but I'll ask you now: why do providers have to send their claims to repricers? Why don't they send them to the TPA or the Payer, who then in turn can send them to the repricer? Why does the provider have to keep track where to send claims? Actually, what's re-pricing? DO they set the maximum customary allowable fees based on a geographical area, or something like that? Why isn't that something TPAs or payers do themselves? If there're any interesting points here, you can answer to the listserve! William J. Kammerer Novannet, LLC. +1 (614) 487-0320 +1 (614) 638-4384 (c) +1 (928) 396-6310 (FAX) ----- Original Message ----- From: "Dave Minch" <[EMAIL PROTECTED]> To: "'William J. Kammerer'" <[EMAIL PROTECTED]> Sent: Friday, 15 February, 2002 01:41 PM Subject: RE: I hope you don't mind me "volunteering you" to do the 838 IG William, Don't know if i'm ready to tackle writing an entire IG, but what i am doing is trying to map data elements needed for our transaction generator into the present draft definition. I've already hit a couple of snags, and expect that the ENE loop, as well as a couple of others will need some expansion if the 838 is to be a viable candidate. The 838 seems much more suited to materials management EDI, and the only loops that are particularly helpful are LX-TPD and ENE-TXN. I haven't looked at the ebXML CPP/CPA that Rachel had suggested a couple of days back, thought I'd finish my mapping to 838 first then look at that one. Give me a week or so to look at these and then we can decide if its worth pursuit. I'll look into getting the digital id next week & see if I can take the plunge into those murky waters - i'm not particularly fond of Alpo, but what the heck... Dave Minch T&CS Project Manager John Muir / Mt. Diablo Health System Walnut Creek, CA (925) 941-2240
