With the advent of standard transactions, the marginal cost to large providers (or their billing service or clearinghouse agent) of using EDI with any "new" payer that comes along (i.e, their first encounter with a patient insured by that payer) will drop significantly. Regardless of the payer, the provider can now be reasonably sure the payer should "understand" any standard HIPAA transaction thrown at it, say an 837. Would it be possible that the cost of mapping to any particular payer's EDI guidelines was the real barrier to providers (institutional, at least) doing electronic billing on behalf of their patients in the past?
But now individual EDI guidelines dictated by the payer are a thing of the past. As an aside, I do suspect that some payers will try to use "companion" guides in much the same way, thinking they're just renamed implementation guides. Except now, they will find that most of the (arbitrary) restrictions they place in these "companion" guides are unenforceable: I've even seen these guides say what particular X12 delimiters to use! A payer (or provider, or clearinghouse for that matter) must take a standard transaction as long as it conforms to the HIPAA IG: if the sender's delimiters are acceptable by the X12 application syntax rules and the HIPAA IG, the recipient should be the one doing the adapting. So now the only thing standing in the way of providers sending standard transactions to any old payer is the ugly, old, manual and onerous EDI enrollment process. As some of our correspondents have told us in the past, this is one area where clearinghouses have an advantage (over point to point). Generally, when a provider is signed up with a clearinghouse, she can send electronic transactions to any payer advertised by that clearinghouse, with the few exceptions of Medicare and some commercial payers. Kepa's and Marcallee's Clearinghouse Power-of-Attorney concept was meant to break down that remaining barrier. Presumably, most payers "trust" any provider to send electronic transactions to them via the clearinghouse for some reason: maybe they think the CH will scrape the viruses and cooties off the claims; who knows? Or perhaps the payers know that the CH will do some kind of front-end edits to make sure the claims are reasonably coherent. Certainly hospitals do courtesy billing with insurance companies they do not "participate" with; their ability to do eligibility inquiries, claims and COB electronically (as opposed to telephone calls, faxes and paper) should increase their operating efficiency. Unlike a physician provider, hospitals can't generally rely on the patient to pony up the cost of a heart transplant ahead of time; if they want the "business," they have to help the patient navigate the insurance waters - even though the patient is ultimately "responsible" in a meta-physical sense. But the issue of identification and routing of transactions to payers from non-participating or out-of-network providers isn't one that requires too much more analysis and discussion. I suspect that it will eventually fall out of the bigger "trust" problem that comes along with the Healthcare CPP Registry. If payers know they can "trust" a provider - coming in out of the blue - they're more likely to commence electronic "trading" with them. And that trust might be conferred by digital IDs and signatures that, in effect, says the AMA "knows" the provider, or the ADA "knows" the dentist, or some accreditation body "knows" the hospital. Or even that any other "known" commercial insurance company "knows" the provider, thus building on a "Web" of trust concept. William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 discussions on this listserv therefore represent the views of the individual participants, and do not necessarily represent the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an official opinion, post your question to the WEDI SNIP Issues Database at http://snip.wedi.org/tracking/. Posting of advertisements or other commercial use of this listserv is specifically prohibited.
