Roy,
I can see you are pretty upset. Knowing that you are in the midst of
the debate over NCPDP "optional" data elements explains somewhat why you
are so upset. The X12 HIPAA implementation guides have avoided the
"optional" elements to a great extent, by defining "conditions" that
force certain data elements to be used or not used. I would urge NCPDP
to agree on the 5.1 conditional data elements and eliminate the optional
elements.
But even in the X12 HIPAA guides there are some elements that are at the
option of the provider (and thus subject to the "minimum necessary"
determination by the provider) and some other elements that at the
option of the payer (if required for adjudication) and thus cause great
variability from payer to payer.
The problem is striking a balance between what the payers really need
for adjudication of a claim versus what they would like to have for
other reasons. Personally, I think that any data element that is
constant (name, address, taxID, phone number, etc.) probably is best
collected once through some sort of enrollment process or the NPI/PlanID
directory (when available) rather than transmitted in every single
claim. Of course, this becomes a directory maintenance problem, and it
seems like HHS is still struggling with these directories.
But, until we get to the ideal minimalist data stream, we are going to
have to live with differences. Keep in mind that what some people see
as annoying differences, other people see as a competitive advantage.
Or perhaps the only technical means to deal with a legacy system. Or
"needed" by some State law dating from the era of carbon paper.
How do we live with the differences without too much interference with
the daily operations? We can discuss this off line.
I will stop here. Enough said today.
Kepa
> Roy Bussewitz wrote:
>
> 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]
> >
> > This message has been prepared on resources owned by Kent County,
> MI. It is
> > subject to the Acceptable Use Policy of Kent County. Candice Craig,
> CMH,
> > 616-336-8930.
> >
> >
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