I thought the whole idea was you could fill out a claim without paying
attention to who the payer is and, except for the payer ID, you could send
the same claim to anyone. It seems to me situational elements should depend
on the medical encounter, not what a payer wants.
Peter
Peter Barry
Peter T Barry Company
Ozaukee Bank Building
1425 West Mequon Road
Mequon Wisconsin 53092
(414) 732 5000 (national cell)
[EMAIL PROTECTED]
-------------------------
In a message dated 9/10/2001 11:22:20 AM Central Daylight Time,
[EMAIL PROTECTED] writes:
> Subj: RE: Situational Data Elements
> Date: 9/10/2001 11:22:20 AM Central Daylight Time
> From: [EMAIL PROTECTED] (Roy Bussewitz)
> Reply-to: <A HREF="mailto:[EMAIL PROTECTED]";>[EMAIL PROTECTED]
</A>
> To: [EMAIL PROTECTED] ('[EMAIL PROTECTED]')
> CC: [EMAIL PROTECTED] (Roy Bussewitz)
>
> Why can't the payor obtain the SSN from the patient? Or, when the
> payor/state & fed. governments use an agent, why can't the payor's agent
> obtain the SSN from the governments or other payors?
>
> Since I work for the National Association of Chain Drug Stores (NACDS) I am
> getting very concerned that every time a payor or payor's agent needs any
> type of information, their first thought is to get it from the providers.
>
> I can only speak for chain pharmacies, but I must remind you that there is
a
> severe pharmacist shortage and the last thing pharmacists have the time to
> do is to be the source for every little bit of information that a payor or
> the payor's agent could obtain from other sources.
>
> Electronic transaction standards where supposed to reduce time and costs...
> I am beginning to wonder if that's true. Prior to electronic payment claim
> standards, pharmacies filled out a one page paper claim form and submitted
> it for payment. Now, the pharmacy electronic payment claim form v 5.1 is
> 100s of pages long and still growing.
>
> One of the problems with electronic payment claims standards is that they
> have become the catch all for every bit of information a payor things it
> might need. The payor, because they can pretty much tell a provider what
> patient information that provider needs to submit if they want to be in the
> payors' limited provider networks, is not concerned about the providers
time
> or cost of obtaining and transmitting this information. These payor's
> requests are huge cost shifters to providers.
>
> Are there any other providers out there who believe a lot of their time is
> being wasted by being used as the most convenient source of
> administrative/financial information? If there is, I would like to ask what
> should we do about this... we may need to change the entire way health care
> information is obtained, used, and disclosed.
>
> I might as well put another concern out for your consideration (and this is
> only Monday morning so I'm not fully revved up yet), I am becoming VERY
> concerned about the state and federal governments role in privacy. There
> may be a conflict of interest since both these governments are big payors
of
> health care and they seem to want a lot of information... information which
> patients' may not want to provide them IF given the choice. That's where
> the privacy regs etc come in... they should give the patient the choice,
but
> do they really?
>
> The government payors can get all this information in a number of ways: 1)
> Broadly define what a health care provider is... to include them; 2)
Broadly
> define what health care operations are; and 3) Say in the laws they create
> that no real patient INFORMED consent is required for both 1 & 2... or that
> only a very general (read this as meaningless) consent is required.
>
> Also the Trading Partner Agreement is often a take it or leave it situation
> for the provider who does not usually have as much bargaining power as the
> payor. "Agreements" or contracts often carry the impression of
mutuality...
> of a more equal bargaining power, which in health care is very often a
myth.
> Payor's can say, "If you want to be a provider in our limited provider
> network you have to play by my rules and that includes sending me the
> patient information I want."
>
> I have heard at least one government employee say that (and no, I'm not
> going to identify him or her), "You know, payors have other leverage to get
> what ever information they want." There was no response when I asked, "Do
> you mean withholding the providers payment, because if you do you are
making
> a mockery of the HIPAA privacy regs and the protections they supposedly
> provide for patients."
>
> If I sound like an angry provider... I am, and I think there are plenty of
> other angry providers out there that you will hear from. If there are
> health care providers out there who have the same frustrations and
concerns,
> I sure would like to hear from you. You've got my email address IF you
don't
> want to share with everyone.
>
> -----Original Message-----
> From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]]
> Sent: Monday, September 10, 2001 10:44 AM
> To: [EMAIL PROTECTED]
> Subject: Re: Situational Data Elements
>
>
> Candice,
>
> It seems to me that a payer that needs the SSN in the REF segment can
> have as part of the Trading Partner Agreement the specific requirement,
> that according to the Implementation Guide, the REF with the SSN must be
> sent in all claims to this payer.
>
> Kepa
>
>
> Candice Craig wrote:
> >
> > The 837 Professional IG states (page 49) if no rule appears in the notes
> for
> > a situational element, the item should be sent if available to the
sender.
> > As a payer (receiver) can we require the provider (sender) to collect and
> > therefore transmit the information? For example, using Loop 2010CA -
> > Patient Secondary Identification (page 166). This loop is situational if
> > additional information is required to adjudicate the claim/encounter. If
> we
> > require social security numbers for reporting to the state, can we
require
> > that this loop be always used to collect social security numbers? It is
> not
> > necessary to process the claim, but we must use it when reporting
> encounters
> > to the state.
> >
> > Thanks for any input!
> >
> > Candice Craig
> > GUI Designer/HIPAA Implementation Team
> > Kent County Community Mental Health
> > [EMAIL PROTECTED]
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