Rachel, You make an excellent point. For the non-par provider, however, the first hurdle is still going to be finding an "address" for the payor... even if that is an 800 phone #. Once a connection is established with the payor (can be time-consuming today) the provider can make a reasonably good guess regarding whether/when he'll get paid. Obviously, the bigger the "ticket", the more assurance the provider will need.
I could be wrong, but I still think the main reason for a provider's refusal to submit non-par claims for patients would be related to the hassle of "learning the insurance dance" for one small claim. Not doing this dance "correctly" is why many non-par claims do not get paid. So even if the doctor articulates the problem as "non-par = lower chance of getting paid", I would still tend to believe that the problem is non-standard claim-submission requirements and difficulty knowing where/how to transmit claims and status requests. Regards, Chris At 10:59 AM 6/30/02 -0500, Rachel Foerster wrote: >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 > >-----Original Message----- >From: William J. Kammerer [mailto:[EMAIL PROTECTED]] >Sent: Saturday, June 29, 2002 5:24 PM >To: WEDi/SNIP ID & Routing >Subject: Re: Non-participating/out of network providers > > >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. > > >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. Christopher J. Feahr, OD http://visiondatastandard.org [EMAIL PROTECTED] Cell/Pager: 707-529-2268 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.
