If I've read providers, like Mimi Hart, correctly, they would indeed like to send electronic transactions to payers, even those with whom they do not "participate." It's generally the payers who are resistant to taking in transactions from out-of-network providers - or at least providers who haven't been "enrolled." Providers, especially hospitals, take in out-of-network patients all the time. Today, I assume that telephone calls, faxes and mail are the norm to determine "will I get paid?" The "vision" is that HIPAA standard electronic transactions will be the norm tomorrow.
The issue of trust in cyberspace goes both ways: not only does the payer need to "trust" the provider, but the provider also needs to "trust" the payer. The payer wants to make sure that a transaction really came from the provider it purports to have come from, and - at the very least - that he provides services which make sense in the context of the claim (via certificates and Provider Taxonomy Codes); this the Healthcare CPP Registry and other technology can solve. The issue of whether the provider actually saw the patient, or really rendered the services stated, exists whether the claim is paper or electronic. On the other hand, the provider wants to make sure the eligibility inquiry goes to the real payer, and that the answers come back from the same place; we can solve this problem. The issue of payer viability - if that's what the provider is worried about - exists whether the eligibility response comes back on fax, phone or electronically. If it's a worrisome concern, go to A.M. Best for the answer. Obviously (or hopefully) a provider will not cut into a patient until the proper referrals are in hand; whether this can be done practically with the 278 is beyond me. Regardless, if standard transactions are available to the provider for communicating with the payer, why wouldn't he prefer to use them rather than the smile-and-dial rigmarole? Even payers are champing at the bit, wanting to conduct eligibility inquiries electronically with out-of-network or non-participating providers; take a look at the posting on the Transactions listserve entitled "Re: Question: Rejecting a transaction" (28 Aug 2001) at http://www.mail-archive.com/[email protected]/msg00075.html. In it Don Bechtel answers Jim Griffin, a payer, who really, really wants to do 270/271s with out-of-network providers, but at the same time wants to make sure he can reject providers whom he suspects of fraud: "We are a national payer with contracted providers in every state, but only 50% or 60%/40% of our claims volume is with PPO providers, the rest is with providers where we have no agreements. Therefore the ability to perform a 270/271 is a great benefit for us, however the ability to reject such requests is also a business need. Similar situations could also exist with a claims status transaction." William J. Kammerer Novannet, LLC. Columbus, US-OH 43221-3859 +1 (614) 487-0320 ----- Original Message ----- From: "Rachel Foerster" <[EMAIL PROTECTED]> To: "'WEDi/SNIP ID & Routing'" <[EMAIL PROTECTED]> Sent: Sunday, 30 June, 2002 11:59 AM Subject: RE: Non-participating/out of network providers I'm not so sure that the issues of trust, a standard claim format, or anything other than will I/when will I get paid, is the major reason why a provider would not be willing to send a claim to a payer with which it does not participate. As for major procedures, such as cardiac procedures, services from a specialist, etc., I can't imagine any of these being performed by a provider without all of the appropriate referrals/authorizations, etc. Thus, the obstacle is not a technical one, but a financial one: if the provider is not participating in a given payer's network, then the concern is one of payment for health care services rendered, not what clearinghouse, what claim format, or what payer id to use. Therefore, if this is the typical case rather than a technical barrier, I would suggest that it might be worthwhile to move on to identifying other requirements/issues that would be within the realm of solution by an automated health care registry. Rachel Foerster 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.
