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Margaret, I don't think the certification vendors are
"self-appointed authorities", I think that they are organizations that focus on
the approved standards - all 6000 pages of them - and develop tools to make
those 6000 pages manageable for covered entities that have
other things to think about, like patient care, or facilitating good health
among insured members...
If covered entities are exchanging notes and agreeing on
resolutions of specification ambiguities, won't we all be best served if
those resolutions are passed to the DSMOs and shared with the certification
vendors? If that doesn't happen, then a few covered entities
will have agreed on things, but the trading partners that weren't in the same
meeting or on the same distribution list will remain out of the loop and
generate more work than is necessary, for themselves and their trading
partners, as they go through the process of hipaa implementation...
imho...
Cynthia Korman
973 394-9529
---- Original Message -----
Sent: Monday, December 02, 2002 5:34
PM
Subject: RE: VALIDATION or
Certification
While I am hesitant to get involved in this
controversy, I would like to add a slightly different perspective on
Certification. While I, as a payer, am open to the concept, it does appear
that certain vendor(s) are "self-appointed authorities" on how to implement
each transaction.
Many in the payer community that are designing
and developing these TCS are exchanging notes and realizing that different
vendors are giving different results, based on their individual
interpretations - maybe even incorrect results. Am I way off base in feeling
there really is no such thing as Certification - i.e. the Govt doesn't require
it, doesn't recognize it, and perhaps most importantly, doesn't regulate
it?
Testing with a third party is always beneficial. And
I do agree there is pressure in the marketplace to "Certify" but where is this
pressure coming from? Vendors?
These opinions are my own and do not represent any
formal position of my employer.
Thank you.
Margaret Murphey
(206)268-2348
Patrice-
I agree that for
the purpose of HIPAA certification, 1 – 7 is sufficient.
Regarding the use
of real or false testing data – there is tremendous pressure on vendors and
clearinghouses to get “certified”. This has nothing to do with the
time saving aspects of testing. It’s done almost solely to satisfy the
demands of a market place that have been led to believe that a vendor’s
certification is crucial to the success of their HIPAA project.
This despite the fact that the market has no idea what certification
actually means. It would be relatively easy for a vendor to run
through the certification exercise without ever actually sending or
receiving a compliant transaction using the software product they’re
supposed to be supporting. It would satisfy the market in a big way to
do so. Now they have months of benefiting from “certification” and
enough time to actually implement the real thing (without
certification). I know most vendors are honest business folk who would
never consider this but one bad apple could give certification a bad
name.
-----Original
Message-----
From: Thaler,
Patrice M [mailto:[EMAIL PROTECTED]]
Sent: Monday, December 02, 2002 10:01
AM
To: WEDI SNIP Testing
Subworkgroup List
Subject:
RE: VALIDATION or Certification
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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