William, If you recall, there was discussion about how information is processed prior to the lookup. To solve the routing issues, must we first understand the process that occurs before routing can begin? Should we identify and validate our assumptions about the pre-routing process? It seems the information gathering process that occurs before a transaction set can be submitted via an exchange header will significantly impact the type of information needed in a directory or CPP. Do we need to understand the difference between the major models of insurance - i.e. Employer Sponsored(HMO, PPO), Self-Insured, Medicare/Medicaid, etc. and what type of information is necessary to properly identify the Plan that covers the patient? Do we get input from the provider side as to the typical processes used to gather insurance information? What types of information can you typically rely on from the patient to identify the appropriate Plan? How do you get that plan information today? Which types of plans are the most difficult to collect information about?
What percentage of the 30% non-card carrying patients do the providers simply "Patient bill", and then let the patient deal with the insurance company? Would this be within scope of our initiatives? So many questions, so little time.... -Ronald Bowron >>> "William J. Kammerer" <[EMAIL PROTECTED]> 04/29/02 10:13AM >>> Peter Barry and I presented a session on Identifiers, EDI Addressing and Routing at the Fourth National HIPAA Summit at the Renaissance Marriott in Washington, DC. last Friday. See http://www.hipaasummit.com/ for more information about the HIPAA Summit. The presentation slides themselves are available as a PDF file at http://www.novannet.com/wedi/ , by selecting "Identifiers, EDI Addressing, and Routing Presentation." Like most Powerpoint slides, they are of limited usefulness unless you have the audio tape - which is available from HIPAA Summit for a price. Peter covered the National Plan and Provider IDs, their enumeration, and the database requirements for their maintenance and I followed up with an overview of some of our plans from the Joint WEDI/SNIP and AFEHCT ID & Routing Special Interest Group. Folks did seem to doubt that anything as ambitious as our Healthcare directory and electronic Trading Partner profile could be available by the time H-day rolls around. I emphasized that the registry and electronic profiles will be usable in a manual fashion, where CPPs can be viewed with XSLT style sheets. Most of the value of the registry is just in the ability to locate trading partners' profiles - we don't need to wait for software vendors to update their software for completely automating the "Discovery" process. We've been assuming all along that providers would have no problem "identifying" payers and plans, figuring that each patient carries his insurance card around with him (and that the cards would have the EDI identifier printed on them). But we've been disabused of that notion by comments at the meeting - either patients don't have their insurance cards 30% of the time, or the information that the provider has on file for them is woefully out of date. Pharmacy, according to David Feinberg, maintains a centralized database to solve this problem: apparently, insurance companies load demographic information about their covered subscribers at some clearinghouse for shared access by pharmacies. Of course, this isn't the problem we're trying to solve (of patients not carrying their insurance card). We can make the assumption that the provider has some means of determining some ID of the plan or payer applicable to the particular patient. But to help things along, we may want to add searching by payer name as a requirement - to accommodate the situation where the patient knows the name of his plan or insurance company: refined searches in the registry can locate the actual CPP covering the plan to which eligibility inquiries can be sent. William J. Kammerer Novannet, LLC. +1 (614) 487-0320
