RE: Covered Entity or not

[Matthew Rosenblum]

Doug and Susan,   Not so fast, please:   1) ASCA does NOT say that all CE-providers submitting Medicare claims must do so electronically.  There are allowances for smaller providers, and there are many of those.   2) What follows is a quote in an e-mail that I received on November 27, 2003 from Stanley Nachimson from the CMS Office of HIPAA Standards.  Mr. Nachimson and I were discussing this exact topic of whether or not a provider faxing a paper-claim directly to a health plan (or its clearinghouse or TPA) would define the provider as a covered entity:   “If a provider is faxing a claim to the business associate of the health plan (whether that is a clearinghouse or TPA), the provider has conducted the transaction entirely thru fax, and is not a covered entity.  If the provider contracts with someone (which then becomes the provider's business associate) to translate the claim from fax to electronic standard before submission to the health plan (or the health plan's business associate), then the provider becomes a covered entity.  Again, what matters is where in the transaction does the translation take place - before or after submission to the health plan (or its BA).”   I hope that this helps.   Your questions are always welcome.   Matt   Matthew Rosenblum Chief Operations Officer Privacy, Quality Management & Regulatory Affairs http://www.CPIdirections.com   CPI Directions, Inc. 10 West 15th Street, Suite 1922 New York, NY 10011   (212) 675-6367 [EMAIL PROTECTED]   CONFIDENTIALITY NOTICE: This E-Mail is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you have received this communication in error, please do not distribute it.  Please notify the sender by E-Mail at the address shown and delete the original message. Thank you.   AVISO DEL CONFIDENCIALIDAD: Este email es solamente para el uso del individuo o la entidad a la cual se dirige y puede contener información privilegiada, confidencial y exenta de acceso bajo la ley aplicable. Si usted ha recibido esta comunicación por error, por favor no lo distribuya.  Favor notificar al remitente del E-Mail a la dirección mostrada y elimine el mensaje original. Gracias.   -----Original Message----- From: Doug Webb [mailto:[EMAIL PROTECTED]] Sent: Monday, February 03, 2003 11:57 AM To: WEDI SNIP Privacy Workgroup List Subject: Re: Covered Entity or not   Susan, Well said.   Still another kink -- come October, you will have to file your Medicare claims electronically, which makes the loopholes even smaller.   IMHO, this makes just about anyoune who does "Health Care" a CE, except for those few providers who do a strictly cash business, and never file a claim with anyone.   I kind of expect that in another few years, large numbers of payors other than Medicare will be rejecting paper claims.   The opinions expressed here are my own and not necessarily the opinion of LCMH.   Douglas M. Webb Computer System Engineer Little Company of Mary Hospital & Health Care Centers [EMAIL PROTECTED]   "This electronic message may contain information that is confidential and/or legally privileged. It is intended only for the use of the individual(s) and entity(s)  named as recipients in the message. If you are not an intended recipient of the message, please notify the sender immediately,  delete the material from any computer, do not deliver, distribute, or copy this message, and do not disclose its contents or take action in reliance on the information it contains. Thank you."     ----- Original Message ----- From: [EMAIL PROTECTED] To: WEDI SNIP Privacy Workgroup List Sent: Monday, February 03, 2003 09:19 AM Subject: Covered Entity or not   Everyone, We can argue all day long whether or not we are a covered entity, but I think it makes good business decision to agree that you are if you send in claims and be done with it. Look at this situation, I don't know if many doctors or support staff realize this:  Anytime a claim is sent to Medicare, paper or electronic, it is coverted into an electronic transaction because Medicare forwards it to 2nd insurance companies.  So now you are a covered entity.  The only way to get out of sending claims to Medicare is not to treat anyone who may have Medicare.  Who can afford to refuse to treat a large portion of our society.  Another kink- Medicare requires the doctor to file the claim for the patient so don't think you can give the claim to the patient and he files it for you.  The loop holes for not being a covered entity is so small, you almost have to practicing in the dark ages to not be a covered entity.  I think you just have to resign yourself that if you practice and treat patient whether cash practice or not, you ARE A COVERED ENTITY.  At least that is what I am advising our clients, better safe than sorry. Thanks, Susan Bowes Professional Procedures & Control Practice Consulting Firm for the Small Practioner Contact info: 211 Turner Drive Reidsville, NC  27320 Phone- 336-578-7461 Fax-  336-578-7461 or 336-342-2030 --- The WEDI SNIP listserv to which you are subscribed is not moderated. The 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/. These listservs should not be used for commercial marketing purposes or discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. 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