Hi All,
Forgive my responding so late... (keeping up with several
listservs can be almost a full time job, in addition to my regular work).
Another reason to advocate more testing rather than less is the
elimination of "local codes". My guess is that there are very few payers
that don't have some local codes, mostly created so that the claims could
be priced appropriately for the benefit (i.e. no deductible for Asthmatics who
participate in a disease management program when they visit their Dr). If
the provider/clearinghouse can not send the codes, business rules must be
devised to serve the same function (somehow). Given that the providers AND
the payers would like to have the process pay the way it did before the
conversion to EDI, you would need to test the new rules.
Put the local codes issue with all the other reasons that have been
mentioned, I don't see how we can't test with the 20-40% of the covered entities
that represent 80-90% of the business transactions.
Jim Moores - HIPAA Team Leader - Privacy
Antares Management Solutions 23700 Commerce Park Road Beachwood, Ohio 44122-5832 [EMAIL PROTECTED]
Phone: (216)292-1605 Fax: (216)292-1619 >>> <[EMAIL PROTECTED]> 05/22/02 09:56AM >>> The problem with saying that a clearinghouse is good enough once they have one line of business working with a payor and trying to apply that as saying that all of the providers coming through that clearinghouse are now tested for that LOB is, there is no way to insure that the business edits of the payer are going to be populated unless the clearinghouse is affiliated with the payer or the payer itself is a customer of the clearinghouse. Each of the clearinghouse customers will have individual situations and data. The payers must require testing with each of their providers. The use of certifying agencies will greatly reduce the testing workload and once certified as HIPAA compliant the payers and providers / clearinghouses can focus on the business edits necessary for ajudication. Dave Lounsberry Translation Analyst Electronic Commerce Blue Cross Blue Shield of Nebraska 402-548-4423 ------------------( Forwarded letter 1 follows )--------------------- Date: Wed, 22 May 2002 09:37:14 -0400 To: [EMAIL PROTECTED] From: Cynthia.Korman[ckorman]@healthcare-systems.com Sender: [EMAIL PROTECTED] Subject: Fw: Full-loop vs Trading Partner Testing Additional comments. (I've kept Wes's e-mail intact, with my additional comments inserted). Wes, thanks for the valuable dialogue! A) Wes wrote: "Agree with (1), map changes. This is pretty close to the white paper, which recommends testing when software has been changed." Cy's response: I would still add some language to subtopic 2 of the white paper, to clarify that changes to files/maps that feed the Clearinghouse would generate the need for business to business testing. Perhaps it's sufficient to extend the first sentence of the last paragraph of subtopic 2 to say "However, IF 1) the Clearinghouse (CH) is creating a custom translation program for each client, OR 2) the CH's client or client vendor is changing the map for the files that feed or are fed by the CH AND the custom programs create or feed the transactions that are sent to the Receiver, THEN testing could be required when the custom programs change. The extent of testing needed will depend on the extent of the custom program changes Too many providers who have not focused on HIPAA TCS would read B-to-B White Paper section 2 as it stands and not realize that they have to worry about the changes to the interface between their legacy systems and the clearinghouse(s). B) Wes continued: "(2) and (3) are problematical. There is no doubt that the best assurance would be achieved by full-loop testing of every healthcare organization with all of its trading partners. But that represents an awful lot of combinations of providers and payers. The real goal for HIPAA implementation has to be to define 'good enough' testing that can be accomplished by the deadline." "One possible definition of 'good enough' is that the error rates are no more than is experienced with current EDI solutions. After the initial rush to implementation is complete, healthcare organizations could raise that bar to achieve some of the business benefits imputed to HIPAA" Cy responds: absolutely agreed - I'd suggest that subtopic 4 of the white paper be expanded to incorporate this and variation on the comments below. B) Wes: " It seems to me that (2), the business perspective, depends on the value that the clearinghouse says it adds. If it does not offer full claims-scrubbing capability, including the business edits that are associated with each line of business for each payer that it services, then there is no real alternative except to do full-loop testing. If it does, then the question remains how accurate is its modeling of the business edits of the payers and will it accept liability if claims are massively delayed or abandoned because of its defects. There is also the issue of testing software that represents unique contract arrangements between a specific provider and payer." "A prudent provider would probably want full-loop testing with its high-dollar-volume trading partners, but might be willing to forego it for the 80 percent of its trading partners that represent twenty percent of its dollar volume (or the seventy that represents 10 percent, or whatever). It can still find and correct low-volume problems when claims are rejected or wrongly denied in production." Cy suggests adding: "A prudent provider may also want to test differing high-dollar-volume contractual arrangements even if they're with one trading partner (e.g. fee-for-service vs. HMO arrangements, both with the same payor) since the info systems used by any one payor to administer different contractual arrangements will vary, as will the changes that must be made to those systems to achieve HIPAA TCS compliance. C) Wes continues: " Health plans will want to select the trading partners with which they do full-loop testing based on similar considerations. They will decide based on their confidence in a specific clearinghouse, the dollar volume of specific providers (and hence their potential liability in case of a huge, unjustified increase in rejections or denials), and the existence of specific contractual provisions with the providers." "One additional comment with respect to (3). There are limits on the assurance that is created by having a vendor test its system with a clearinghouse or trading partner. Most patient accounting systems, for example, are highly configured to the specifics of the provider's organization. Vendor-testing can help to ensure that the basic software is operational, and to handle the generic code set changes such as claims-adjustment reason codes. But it cannot replace testing of the software as configured with the clearinghouse or ultimate trading partner." D) Cy: I'd suggest adding something somewhere in the white paper, for expectation-setting purposes, regarding the following. It will be important to avoid beating up on test planners/testers/HIT vendors/clearinghouses/executives charged with HIPAA TCS testing. During testing, these brave souls will find many glitches and facilitate fixes. But they will not find all of the glitches. Testers must be like mature and well-rooted trees in a hurricane - they are blown around but remain firmly rooted, and do not break. They may lose a branch or two from the winds alone. It'll be nice if the folks depending on them keep chain saws out of sight both during and after the hurricane. :^> - C Cynthia Korman, CHE, MS, MBA Principal Strategic System Solutions, LLC 973 394-9529 [EMAIL PROTECTED] www.healthcare-systems.com ----- Original Message----- > From: Cynthia Korman [mailto:[EMAIL PROTECTED]] > Sent: Tuesday, May 21, 2002 7:50 PM > To: [EMAIL PROTECTED] > Subject: Fw: Full-loop vs Trading Partner Testing > > > Business-to-business White Paper V2 subtopic 2 should be revised. After > clearinghouse software has been proven to successfully process a particular > line of business, provider-to-payer or payer-to-provider testing would still > be required in many instances, including the following: > 1) when clearinghouse files come from "upstream" systems or go to > "downstream" systems and there's a new or significantly-changed map > associating the up- or downstream legacy files to the clearinghouse files > 2) to confirm that the content of transactions is accurate from the busine ss > perspective; for example > a) to confirm that, on a particular claim, the different providers > (billing, pay-to, rendering, referring, attending etc.) are properly passed > through the clearinghouse and into the target system of the trading partner; > where payors use referral data to analyze provider practice patterns, this > can become especially of concern... > b) to confirm that, for PPO claims, contracted disounts are not being > applied twice because of an error in the way billing data is picked up by > the clearinghouse > NOTE: a and b are only examples; what is important to test will vary based > on the character of each covered entity. > 3) When HIPAA-ready legacy systems are newly installed and those systems > have required significant change, for example to accomodate > newly-standardized claim adjustment reason codes (Hopefully the legacy > system vendors will be open regarding the extent of changes to accommodate > HIPAA) > > At least one of the above items 1, 2, and 3 applies for just about every > covered entity, right? So trading partner testing will be more of a rule > than an exception - it will require less manpower to test as more partners > are tested. But it'd be foolhardy for trading partners to not do any > trading partner-to-trading partner testing... > > Cynthia Korman, Principal > Strategic System Solutions, LLC > 973 394-9529 > [EMAIL PROTECTED] > www.healthcare-systems.com > ----- Original Message ----- > > From: "Rishel,Wes" <[EMAIL PROTECTED]> > > To: <[EMAIL PROTECTED]> > > Sent: Tuesday, May 21, 2002 5:05 PM > > Subject: Full-loop vs Trading Partner Testing > > > > > > > My reading of subtopic 2 in the Business to Business Transaction Set > > Testing > > > Version 2 white paper is that there is no need for provider-to-payer > > testing > > > where a clearinghouse is involved provided that the clearinghouse is not > > > using modified software to handle the provider and has previously > > > demonstrated that it can handle the lines of business that will be > > proffered > > > by the provider. > > > > > > Is that a correct interpretation? Is it pretty much the consensus? > > > > > > ********************************************************************** > > > To be removed from this list, send a message to: [EMAIL PROTECTED] > > > Please note that it may take up to 72 hours to process your request. > > > > > > > > ********************************************************************** > To be removed from this list, send a message to: [EMAIL PROTECTED] > Please note that it may take up to 72 hours to process your request. > > ********************************************************************** > To be removed from this list, send a message to: [EMAIL PROTECTED] > Please note that it may take up to 72 hours to process your request. > ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ********************************************************************** To be removed from this list, send a message to: [EMAIL PROTECTED] Please note that it may take up to 72 hours to process your request. ------------------------------------------------------------------------------ |
- Full-loop vs Trading Partner Testing Rishel,Wes
- Fw: Full-loop vs Trading Partner Testing Cynthia Korman
- RE: Full-loop vs Trading Partner Testing Rishel,Wes
- Fw: Full-loop vs Trading Partner Testing Cynthia Korman
- RE:Fw: Full-loop vs Trading Partner Testing DAVE . LOUNSBERRY
- RE: Fw: Full-loop vs Trading Partner Testing Rishel,Wes
- Jim Moores
