Earlier this year I had a fairly detailed exchange with another party on the topic of DDE. It may be pertinent to this discussion as well. I've inserted my comments below.
Rachel Foerster ================ Let's look at the issue of DDE for HIPAA electronic transactions from a different viewpoint. First, the electronic transactions final rule stipulates what a covered entity is required to do. Specifically, they must conduct the identified transactions in compliance with the approved specifications. Some of the transactions are query/response transactions (270/271, 276/277, 278) that can be conducted either in batch or real-time mode. Actually, in my opinion, any of the transactions could be conducted in real-time or near-real-time mode if two willing trading partners wished to do so and architected their respective systems to support that mode. Second, the final rule identifies exceptions for direct data entry and the use of business associates. Specifically, b) Exception for direct data entry transactions. A health care provider electing to use direct data entry offered by a health plan to conduct a transaction for which a standard has been adopted under this part must use the applicable data content and data condition requirements of the standard when conducting the transaction. The health care provider is not required to use the format requirements of the standard. [Note that this exception is identifying the provider is permitted and not permitted to do. In my opinion, this places the burden on the provider to not use a direct data entry system, which is typically developed and made available to the provider by the payer, that fails to meet the data content/condition requirements.] Third, the final rule stipulates additional requirements for health plans: For example, � 162.925 Additional requirements for health plans. (4) A health plan may not offer an incentive for a health care provider to conduct a transaction covered by this part as a transaction described under the exception provided for in � 162.923(b). [ � 162.923 Requirements for covered entities. (b) Exception for direct data entry transactions] In other words, you cannot attempt to induce a provider to use direct data entry by offering incentives. So now, we must define incentive. From the American Heritage Dictionary: in�cen�tive (�n-s�n�t�v) n. 1. Something, such as the fear of punishment or the expectation of reward, that induces action or motivates effort. --in�cen�tive adj. Serving to induce or motivate. I can categorize an incentive (a reward) as being economic (offer monetary reward), performance (provide faster answers than when not using DDE), enriched information (providing more information via a DDE response than what is supported by the corresponding standard transaction.) OK, so if we can agree with the above, then is incentive defined by either the reg or DHHS FAQ, and if it is where and how? This is the tough part!! Here's what I've gleaned from the DHHS FAQs: (I've added the emphasis in the response.) What level of service is required to be provided under HIPAA when an entity implements batch and/or real time submission of a standard transaction? 8/27/2000: 45 CFR 162.925 states "a health plan may not delay or reject a transaction, or attempt to adversely affect the other entity or the transaction, because the transaction is a standard transaction." If the standard transaction (e.g., ASC X12N 270/271) is offered in a batch (non-interactive) mode, the health plan has to offer the same or higher level of service as it did for a batch mode of transaction before the standards were implemented by the plan. If a health plan offers the transaction in a real time (interactive) mode, the level of service has to be at least equal to the previously offered level for a real time mode of transaction. If a transaction is offered through Direct Data Entry (DDE), the level of service, again, has to be at least equal to the level offered for the DDE transaction before implementation of the HIPAA standard. My interpretation of this is that if a health plan currently offers real time (interactive) query/response or DDE query/response TODAY, that the current response time (level of service) under HIPAA must be equal to today's response time before HIPAA. Thus, DHHS views real time and DDE as distinct modes. Here's some insight from the DHHS FAQ into the issue of an incentive taking the form of information enrichment. I use this example since the reference is to a web query, which in my opinion, is a form of DDE. If a covered entity adheres to the data content requirement, can they also provide additional information using other technologies? For example, if a health plan has a Web query solution for claim status, and meets all data content requirements for the 276 request and the 277 response, could they also provide additional information regarding the status of the claim? An example of additional information would be to provide claim resolution instructions for denied claim, or a statement that would better clarify the action taken on the claim. 7/1/2001: A health plan may not add additional information to any of the standard transactions. It may, however, provide additional information through a separate mechanism. For example, the web-based service described in the question could provide additional information on a web page separate from the web page containing the standard data content. The resolution of the standard transaction cannot depend on the additional information. Health care providers and health plans that have a business need for additional information are encouraged to work with the Designated Standard Maintenance Organizations to submit a request to modify the standard(s). Section 162.910 established criteria for the processes to be used for such modifications. But, the unanswered question still remains: if you don't do real time or DDE today, but you plan to do so post HIPAA compliance date, then what level of service must be provided? Health plans are not required by HIPAA to offer real time transactions. Now to your primary question that seems to be, "Can DDE be a faster method for conducting a HIPAA transaction than EDI?" My answer would tend to be yes, based on the above information, specifically the FAQ that states that the level of service for DDE under HIPAA must be equal to DDE pre-HIPAA. I can find no information that would lead to answering the question about level of service post-HIPAA for DDE if you did not provide DDE pre-HIPAA. The implementation guides for the 270/271, 276/277, etc. only describe and compare batch vs real time within that context and give instructions/recommendations about how to conduct the standard transaction in either batch or real time mode. They don't seem to bring in the issue of DDE when conducting the transaction. Does this help? Or is it clear as mud? My concern is that the DHHS FAQs are just that....questions and answers. They are not a formal part of the regulation. At the end of the day, if there is a dispute, I would expect the Court to look first to the language of the regulation. But I would also expect the Court to examine the intent of the payer if it is brought before the bar on a complaint of offering an incentive to do DDE, etc. in violation of the regulation. And keep in mind, I'm not an attorney, so these opinions are just those of a layperson without any standing as an attorney. BTW, I also found a DHHS FAQ about fax and voice response systems. Their conclusion is that 12/28/2000: Fax imaging and voice response transmissions are not subject to the HIPAA transactions standards but may have to meet privacy and security standards. Health plans may continue to offer these services, however, they must still be able to accept and send the HIPAA standard transactions. Personally, I can make a technical argument showing why voice response is functionally equivalent to DDE since both are a human-to-computer interaction, but then again, who am I? And again, this comment is only a FAQ and not an official part of the regulation...so....take care and document why you reached certain decisions and implemented what you did. Remember, under HIPAA, complete and accurate documentation is essential....for everything!!! ================ -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] Sent: Tuesday, March 26, 2002 9:55 AM To: [EMAIL PROTECTED] Subject: RE: Computer-to-computer HTML under the transaction regulation Hmmm. I was reading it differently, but have the same DDE vs. forced realtime 270/271 issue. We have had some similar discussions on a clearing house representing both the payor and the provider...offering both the service of processing in a non-compliant application interface format. They can offer that service but it must be in a hipaa x12 format somewhere, even if just a microsecond. I believe the DDE exemption is eliminated due to the computer to computer activity. A hovering question is what to do with an existing real time transaction (we called a DDE) that doesn't qualify for a DDE exemption because it is computer to computer. Your solution is great to have the payor upgrade the proprietary format enough to have a clearinghouse form a 270/271 for a microsecond. Does that force offering a realtime 270/271? Hopefully not. We really do need an answer because of the sizeable impacts. I'm really not talking about a loophole. I'm suggesting upgrading existing realtime content while forming a batch 270/271 which is a lot before the deadline and a great launching pad for the next round. Peter Barry may be able to weigh in on this fuzzy issue. ********************************************************************** 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.
