Ron, There is no doubt that the patient is "the weakest link" in this discovery process. In vision care, when the patient is unsure of the payor/plan, we routinely query one or two of the largest payors with both the patient's and the presumed subscriber's SSN numbers... just because it's easy to do and we often find them listed. An additional source of confusion in identifying plans is the fact that the patient is often more aware of the name of the general medical plan (possibly a closed-panel HMO that we do not belong to). So the patient calls the eye doctor and states that she has a "vision plan" through "HealthNet". We know that our office is not a member of the HealthNet provider panel, but... avter investigation by my staff, the "vision plan" turns out to be Vision Service Plan (VSP), meaning that re really CAN see the patient after all.
The ONLY reliable info that you can get from the patient is WHO THE PATIENT IS! A central patient plan-membership registry would be VERY helpful. Otherwise, payors will want to essentially "SPAM" every payor in the world with general "type 30" eligibility queries until they get a "hit". The provider is in a tough spot here because many of these "unknown payor" cases can be served in his office, but a few can ONLY be served under the plan in an different office. Patients expect the doctor to magically resolve this at the reception desk... before the services are rendered. A good receptionist might remember that we have seen lots of folks from that particular employer and "worry about who the payor is" later (so as not to waste the appointment)... but occasionally, we get stung and the patient is NEVER happy about having to pay for a bunch of things that were supposed to be "free". -Chris At 12:52 PM 4/29/02 -0600, Ronald Bowron wrote: >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 Christopher J. Feahr, OD http://visiondatastandard.org [EMAIL PROTECTED] Cell/Pager: 707-529-2268
