Dave Minch of John Muir / Mt. Diablo Health System shares a Provider's Perspective in a Q&A:
Q. What do you think about onerous EDI enrollment processes and "certification"? Don't you want all these artificial barriers put up by the payers removed?" A: You can bet that I don't like it one bit. Remember, I have 16 different entities who send bills, and two entities who receive them. Multiply 16 times the 500+ payers we correspond with and you can understand the problem (technically, all entities don't deal with all of the payers, but the subsets are large enough!). Now the other side of my equation is that I receive claims (i & p) into two of my entities (including receiving them from my own senders). As a receiver, I have to ask myself, how much time do I want to spend dealing with paper TPAs and cert testing before allowing a provider to send x12s? The tradeoff is posting my CPP and letting claims flow in, and reject any that aren't HIPAA compliant. Since my chosen software can do a complete HIPAA check (similar to what our friends over at Claredi do), I'm banking on the fact that i'll spend a whole lot less time in auto-rejecting malformed batches/claims, and misdirected claims than if I did the manual TPAs & testing. The one caveat is that i'd like to have my TPs certify with an outside agency such as Claredi before they start sending to me (less rejection processing if they get their act cleaned up ahead of time). We should be able to incorporate a cert_id into the CPP/A. Q. Would you ever be sending claims to insurance companies you normally never dealt with? A: Most of our business is done under some sort of contract - where we have agreed upon certain rate schedules and service lines in advance with the health plan. We do also operate a regional trauma unit through which we get patients from all over the US and abroad, and we do a lot of billing to payers with whom we have no pre-existing relationship. Q. Would you be doing this on behalf of the patient? - if so, would payment usually go to the patient (on the assumption he paid you up front)? A: Technically, all billing done by us is on behalf of the patient. Financial responsibility is the Guarantor's in ALL cases - even with programs such as Medicare, Medicaid, and Champus. This is because the Guarantor can always authorize procedures and other expenditures which go beyond the care covered by any particular plan. We direct bill payers as a service to the patient (and, of course, because the patient could never figure out how to navigate the reimbursement waters by themselves). It also assures us that we will get the bulk of our payment in a somewhat timely manner. If the patient or guarantor cannot provide us with a verifiable plan prior to delivery of service, then we will bill the patient/guarantor for charges. If they pay, then we are generally done with that account - we would not bill after-the-fact on behalf of the patient. What does happen is that the patient will pay some of the bill (or pay deductibles which we later find have already been satisfied), and then present us with a verifiable plan, where upon we will bill that plan (payable to us) and refund any over-payment back to the patient. I think Dave's answers kind of confirm that it is not just my imagination when I reckon there will be (electronic) claims submitted to insurance companies with whom a provider has no pre-existing relationship. That's key: that may never have been possible before HIPAA - and also means the Healthcare Registry's support of Open-EDI (no onerous manual EDI enrollment) is a critical success factor. Compare that to what my "Deep Throat" Big Blue friend says about not even allowing any electronic claims to come in from a provider whom he has never heard of before. Actually "Deep Throat" is not technically with a Blue, but rather with a subsidiary of a Blue. Well, okay. And technically, it's no big deal about his identity, either - he just can't get e-mail posted to the mailing list for some obscure technical reason. We will reveal more about "Deep Throat" in our next installment: "A Payer's Perspective." William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320
