I would suggest, for the purpose of our discussion, we call a claim each of the 2300 loops and a transaction each ST-SE segment. Don't know if I did that in previous messages or not. Anyone on the list object?
-----Original Message----- From: "Marcallee Jackson" <[EMAIL PROTECTED]> Sent: Mon, 25 Nov 2002 22:57:00 -0800 To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Subject: RE: VALIDATION or Certification OK so if I understand correctly: Certification services should go beyond certification of HIPAA compliance and move into business use of the transaction; analyzing errors more likely due to data entry errors than to programming or file production issues. An interesting exercise but unless the submitter was planning on using an editor in their front end, is this helpful in terms of compliance in the production environment? Does a failure to produce a Date Last Seen when the procedure involves a diabetic foot exam result in a failed test or a failed certification? If it is up to the industry to set their own thresholds for compliance, does that mean all certified entities should be required to publish the statistics on their certification in terms of number of transactions certified, percentage of pass/fail, etc? If the number of claims should reach one week's worth of data, how do we decide what that volume is for a particular entity? The press announcements I see related to certification are most often vendor related, not provider or payer. Since a mechanism for certification exists and "certification" has been recommended by SNIP, there is an expectation that a vendor will certify, even if in the end this certification is nearly meaningless. Is a clearinghouse that certifies itself as compliant assuring its non-standard submitters of anything other than its ability to hand a certification authority a file the authority deems to be compliant? More questions to come, I'm certain. -----Original Message----- From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]] Sent: Monday, November 25, 2002 10:15 PM To: WEDI SNIP Testing Subworkgroup List; Marcallee Jackson Subject: Re: VALIDATION or Certification Marcallee, Thank you. Now we are getting back on track. Let me address your points. 1. and 2. There are a number of good reasons why transactions that are correct from the EDI perspective and from the HIPAA IG perspective will fail the business use of the transaction. For instance, if the dates are out of "sequence", there will be no HIPAA errors detected (HIPAA does not require that the date of birth be before the date of death) but the transaction could very well fail the business logic. A transaction without HIPAA errors is not necessarily a good business transaction. If you are interested, I can get you more specifics out of band. The example was just that, an example, but you get the feel, right? 3. What is a claim? Is it the entire 837 with hundreds of 2300 loops, or is it each one of the 2300 loops? From the business perspective of healthcare, it is each one of the 2300 loops. From the EDI perspective, it could well be the entire 837. It would be nice to get a clarification from HHS on this, as it could very well affect the penalties. I believe the covered entities are required to have perfect claims, but we need to know the scope of a claim. See point #4. As for the certification, both should be measured, how many 2300 loops are good and how many ST-SE transactions are good. The number of 2300 loops per ST-SE is another important metric. Of course, I am assuming that all transactions must at least be compliant with X12 syntax or the whole ST-SE would be bad. But, will a bad ZIP code cause an entire 837 to be bad even if it only happens in one out of 10,000 claims? I say that is too drastic a position. 4. Excellent point. What is the threshold to claim "compliance" ? Can I claim compliance because 1% of my claims are correct? How high should it get? Can I claim compliance if my correct claim percentage is 50%, 75%, 85%, 90%, 95%, 97%, 99%? I just picked some numbers. Who has the answer to this one? Currently the industry operates at around 95% - 97% correct claims. In fact, when a provider tests with Medicare they are supposed to be at least 95% clean before going to production. So, is that the threshold? Or has HIPAA become 100% clean or nothing? I would like to suggest that SNIP makes some consensus recommendations in this area. Lacking an industry consensus, it will be left up to the trading partners to set their own thresholds. 5. How do we know the certified entity used real data? First they should be required to only use real data by contract. Then the certification should disclose how they obtained the certification. How many transactions they certified? Was it only a handful, or was it a real substantial number of transactions. It is very difficult to create large numbers of test claims (large being a relative measure, depending on the entity) My gut feeling (not very scientific) tells me that the number of claims certified should correspond to about one week worth of business or more. Then, if the tested transactions were artificially created, they will probably be monotonous, and that should be reflected in the details of the certification. The details of the certification should represent a real live situation for that provider, including the quantity and types of claims (quality) that represents that specific provider. If the certification discloses these facts, then cheating the system by certifying concocted data becomes self defeating. Do we have other assertions? Kepa On Monday 25 November 2002 10:16 pm, Marcallee Jackson wrote: > Rachel - My first message was my way of saying "cool it". I know that > you know there are few on the list that enjoy a good debate the way I > do, so I'm not going to take your comments on that personally. I'm also > not going to beat a dead horse so let's move on to the issue of > "certification". Separating product from process, if I understand the > assertion being made for certification, it is that: > > 1. Certification summarizes for the tester the results of the business > scenarios included in the test. > 2. Certification allows an aggregate report of capabilities, thereby > protecting PHI. > 3. Certification assumes a less than 100% compliant file is to be > expected and so the pass rate should be identified and clients should be > certified if even one transaction proves to be compliant. > > But I don't understand a few things: > > 1. In the example given earlier, the provider was able to produce HIPAA > compliant primary claims but not secondary claims. Shouldn't the > secondary claims have failed the test? > 2. 89% of consultations failed certification. Shouldn't those have > failed the test? > 3. Is it OK to be compliant with some of the transactions you send, or > are CE's required under the law to be fully compliant? > 4. If in fact an entity with a less than 1% pass rate can announce to > the > World that it has met "certification" requirements through a third party > testing and certification authority, what does that mean for the > industry? > 5. Doesn't certification imply some independent analysis and > verification of validity? If so, how do we know that the certifying > entity used real data? What's to stop a vendor, provider or payer from > building rather than producing a compliant transaction and certifying > it? > > Hope this sets an example of vendor free jargon and assists in the > discussion on this topic. > > Marcallee --- The WEDI SNIP listserv to which you are subscribed is not moderated. 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They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time. You are currently subscribed to wedi-testing as: [EMAIL PROTECTED] To unsubscribe from this list, go to the Subscribe/Unsubscribe form at http://subscribe.wedi.org or send a blank email to [EMAIL PROTECTED] If you need to unsubscribe but your current email address is not the same as the address subscribed to the list, please use the Subscribe/Unsubscribe form at http://subscribe.wedi.org --- 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/. 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