Regarding 1-2 below:
In my presentation I was
trying to show that testing for types 1-7 is good enough. The industry already
submits most claims electronically. Most providers have figured out business
rules (e.g. that the date of death must not be before date of birth.) There will
be a few new providers to this process and long term it might be good to have
vendors check for business rules - but for now I am approaching this as the
80/20 rule. If I can get my claims or any other transaction through type 1-7
through a vendor tool - then I should be good to go.
Also, WEDI/SNIP is about HIPAA compliance not necessarily about business issues. Here is a sentence from SNIP mission "The WEDI HIPAA SNIP Task Group has been established to meet the immediate need to assess industry-wide HIPAA Administrative Simplification implementation readiness and to bring about the national coordination necessary for successful compliance" I do not believe this group was tasked with solving all health care issues.
Regarding 5 below:
I believe the statements made about "wondering if the CE used real data or did they create them artificially" just takes us down the path of the old paradigm - Don't trust your trading partner. I personally am beyond wondering if my payer REALLY tested a real 835. If they took the time to explain to me that they tested and passed type 1-7 edits then I think they are good to go. What would be a reason for them to lie? To lengthen our testing time? To increase our costs? I don't think so.
Patrice
Allina Hospitals and Clinics
-----Original Message-----
From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]]
Sent: Tuesday, November 26, 2002 12:15 AM
To: WEDI SNIP Testing Subworkgroup List
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
---
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