This problem is so complex from a systems point of view that I do not beleive that WEDi or SNIP or anyother body can take a position on it.
Can a payor require a TP to go through a certain third-party-validation/tesing service for getting validated? This maybe a right of the payer but is it RIGHT? I don't know. Especially when we do not have any body/entity to certify any of the certifiers in the first place. Can the cost of it be forced on the provider by the payer? I don't know. There are situations that this, sometimes one-time, cost sharing makes sense. Covered entities are many but all depend on Vendor suplied systems/software.... Practice Management Systems by provders, Translators and Validators/Third Party Validation (also called certification by WEDi) by all (Payors, providers Clearing Houses etc.,). The connection between payers, providers via clearing houses sometimes, is "many to many" not "any to any". But almost all of them depend on a few vendors for thier transacitons and code sets implementation. So technically, practice management systems and translators from different vendors have to agree with validators from different vendors and adding to the complexity is the business driven implementations (edits kick in here) not forgetting the interpretations of the IGs. I have worked with a few payors and one vendor. Some payors do not require Third-Party-Validation (also called certification by WEDi). Some do require it but do not require it to be from a certain vendor. Some do not require Validation (certification) byond type 4. Some have a policy/process to resolve the Translator/Validator disagreement taking input from their EDI and Business folks to determine how they will reolve it. This may or may not be in favor of either the translator or the validator... as either/neither could be right/wrong but business determines a certain implementation choice. Bottom line... this is not be any easy thing and I do not think if WEDi or anybody can/should offer a recommendation saying a payor can require a TP to go for third-party-testing (also called certification by WEDi, which BTW is not required for transactions and code sets by HIPAA) with a certin vendor, even if we ignore the cost considerations. When we consider the cost it gets uglier. Rama. -- -----Original Message----- From: Marcallee Jackson <[EMAIL PROTECTED]> Sent: Thu, 12 Jun 2003 00:58:14 -0700 To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> Subject: FW: who pays cost of testing Posting this to Testing since I don't believe Leah is part of our List -----Original Message----- From: Leah Hole-Curry [mailto:[EMAIL PROTECTED] Sent: Wednesday, June 11, 2003 9:38 AM To: WEDI Business Issues Subworkgroup List Subject: RE: who pays cost of testing Marcallee, In my opinion, even though folks seem to view this as "just the way the industry works", indeed there is a HIPAA compliance issue. HIPAA Admin. Simp., in part is the government's response to the fact that the industry itself could not agree to make changes to move toward standardization (e.g. the status quo is being changed by mandate). So it is a dangerous argument to make that cost shifting is status quo and therefore OK in the post- HIPAA world, when in fact HIPAA does much to change the status-quo. This is especially true for health plans because the transactions rules do (attempt to) change the balance of power relating to transactions, including a plan's cost-shifting. (E.g. health plans may not require a provider to use DDE, health plans must have capacity to accept all transactions in EDI format, health plans cannot pass on its clearinghouse fees to providers, health plans must accept all valid data elements, even if they don't need them, etc.). These additional transaction requirements are for plans only. I'm surprised that the debate so far has failed to consider one of these key additional requirements for health plans. "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." 162.925(a)(2). This constitutes a broad prohibition on health plan activities as it relates to how plans process standard transactions. CMS has unfortunately not released details on how this provision will be interpreted and enforced. However, given some of the testing scenarios you raise, it is quite plausible that CMS will use this provision to prohibit certain, and especially egregious, cost-shifting (for testing as well as perhaps other transactions related out-sourced activity) by health plans. There are several different criteria (that I can think of off the top of my head) that need to be considered: (a) Comparison of the testing costs and process for electronic "enrollment" before HIPAA and after HIPAA (this is the basic test CMS indicated it would use to determine whether a plan violated this provision with respect to levels of service). (b) If the plan will have other methods to accept transactions, what is the cost and process to submit via other methods compared to the HIPAA standard method. (c) Does the cost or process of testing create a barrier for the provider to conduct EDI transactions (e.g. is the plan adversely affecting the entity because the entity is conducting or attempting to conduct a standard transaction)? While it is inevitable, and I am sure CMS contemplates that in this massive transition there will be some delay and additional burden for all parties, the question remains valid... how much cost should be borne by each party, and in the case of plans and providers specifically, when and how much, if any, cost shifting is acceptable vs. a violation? Whether WEDI chooses to address this risk and provide some guidance or not, it is in fact a compliance risk that payers need to consider carefully. Leah Hole-Curry, JD FOX Systems, Inc. 602.708.1045 Information transmitted is confidential and may be proprietary to FOX Systems, Inc. It is intended only for the person or entity to which it is addressed. Anyone else is prohibited from disclosing, copying, or disseminating the contents or attachments. If you receive this in error, please notify sender immediately, or us at www.foxsys.com and delete from your system. >>> Marcallee Jackson <[EMAIL PROTECTED]> 06/09/03 20:43 PM >>> I'm going to cross-post this message to the BI SWG because this question involves issues that are related to both testing and business decisions. For those who are new to this message string, the topic being discussed was submitted to the Issues Database. The question is, can a payer require an entity to test and certify through a particular third party tester (TPT) (against 1 - 6 HIPAA guidelines and/or their companion guides) and if so, are there any caveats? I've copied the original question at the bottom of this message along with some of the discussion that took place within the Testing SWG. In the interest of disclosure, I'll say that I was the individual who submitted this question to the Issues Database. Thank you to the Testing SWG for their initial discussion and response. When I posted this question, I was most interested in the caveats. I think for the most part, we're all in agreement that a payer can require that a provider test and certify with a TPT of the payer's choice, but I think there maybe certain conditions to that. Chiefly, can the payer allow the provider to incur the cost for that testing certification? I've discussed this issue with many people now and I'd like to share some of the main points that seem to come up: 1. Transaction testing is just one of the tasks in the implementation process. Completing trading partner agreements and testing communications would be two others and there are likely to be many more as well. If your answer to the question at hand is that yes, a payer can use a TPT(or TPTs) of their choice for testing and require (or not be concerned) that the provider pay for that certification, then my question to you is - can they also outsource other aspects of the implementation process and have the provider pay for that as well? If one of the vendors who has a solution for trading partner agreements and enrollment forms, contracts with a payer to manage the process of completing those forms on the payer's behalf and the payer requires that the provider now go to that vendor and complete those forms before testing, can they then charge the provider for using that service? If the payer couldn't manage the volume of communications testing, could they outsource that too and make the provider pay to test? No? Then why is transaction testing any different? Many different options exist for testing, both for the provider and payer. Why should the payer be allowed to force the provider to use their solution and also pay for it? 2. A health plan can contract with a clearinghouse to receive standard transactions on its behalf but cannot cause the provider to incur fees or costs for that decision. Presumably this requirement is meant to prevent payers from shifting the cost (or a portion of the cost) of using a clearinghouse from themselves over to the provider. Why would the authors of the Final Rule prevent the payer from charging for the clearinghouse but permit the payer to outsource testing to a third party and then allow them to shift the cost of that to the provider? 3. Often when answering this question, folks are looking at the third party testing market and solutions as they exist today and not projecting into the future. When they think of this situation they seem to be thinking that the provider would only have to test with one TPT. But providers who send direct might test with many payers. What if a provider has 20 payers, 15 of which require TPT certification and between those 15 the provider had to test with 7 different TPT vendors who charged fees ranging from $50 - $500? 4. Another thing folks seem to have in mind is that the cost would be one time? What about when a provider initiates new transactions or new connections? Might they have to pay again each time? I do not believe the authors of the TCS Final Rule intended to allow the payer to outsource the tasks involved in exchanging standard transactions and then shift the cost of that outsourcing over to the provider simply because the vendor they've outsourced to doesn't meet the definition of a clearinghouse. In fact, if the entity used for TPT was also a clearinghouse the fee for testing would not be allowed. Before we draft I final response to this issue, I'd like to encourage more discussion. Thanks for you attention to the matter. Marcallee Jackson Director, Healthcare Solutions Edifecs, Inc. (714)865-5059 www.edifecs.com www.hipaadesk.com >From the Testing SWG Minutes: 2) Issue from Issues Database: The following issue was assigned to the Testing SWG and was discussed during the meeting - Can a health plan require that an entity certify with a third party testing service in order for the entity to begin testing with a plan. If so, can the health plan require that certification be obtained from a particular third party and if so, any caveats to that? Along these same lines, can a health plan require that an entity certify against its companion guidelines, with a third party testing service in order for the entity to begin testing with a plan. If so, can the health plan require that certification be obtained from a particular third party? Any caveats to these two items? This issue created a lot of discussion. The HIPAA legislation or ASCA does not mention certification or verification so the issue is pretty much left up to the formation of a best practice. The group agreed that requiring a third party validation/certification would need to be detailed in a Trading Partner Agreement (TPA). If a health plan does require this type of activity, they do have the right to require a particular third party for this purpose because certain business level editing would also probably be built into the software used by the third party that was specific to that particular payer. Not all third party vendors would have that specific editing functionality because they had not been working hand in hand with that specific health plan. The bottom line is that validation and/or certification is not required by the HIPAA legislation although it is recommended by the WEDI Testing white papers. Any requirement that is outside of the scope of the HIPAA legislation would need to be documented and agreed upon in a Trading Partner agreement. -----Original Message----- From: Christopher Feahr [mailto:[EMAIL PROTECTED] ubject: Re: Meeting Minutes - 5/22/2003 -- cost of testing Dear Testing Group, As a provider, I would consider "testing" and any required "certification" to be components of the [necessary] process of "setting up a connection" with my trading partner. The term "enrollment" that is often used by payers or "communities" connotes the true, lop-sided nature of the process, in which the provider "asks" to be "enrolled" in the community and expects to be required to jump through ALL of that community's enrollment hoops... including any testing or certification hoops. All of this hoop-jumping is going to cost the provider $ and would simply be part of his cost of setting up and maintaining each trading partner relationship. I believe that HIPAA is silent on the specific elements of a TP-agreement and is also silent on how the costs [to both parties] of setting it up should be divided. I would not expect many provider complaints about enrollment costs, however... because only the most sophisticated providers will even attempt to manage direct EDI connections. Smaller providers who are not using DDE or dropping to paper will likely be enrolling with ONE clearinghouse... effectively pushing their "testing and certification" concerns onto the CH. If we do experience such provider complaints, they will be handled case-by-case anyway. So I think it's fine for the Testing white paper to remain silent on the ideal/fairest way to parse enrollment costs. ___________________ From: "John Singer" <[EMAIL PROTECTED]> To: "WEDI SNIP Testing Subworkgroup List" <[EMAIL PROTECTED]> > Actually I believe Ellen is correct. A payer cannot pass the cost of testing onto the provider. If a payer designates a testing agency then the payer must also pay for this especially if the testing agency is charging for the testing of payer companion guides. Is there an attorney on this listserve that has reviewed the regulation? I remember reading somewhere that payers cannot pass costs to providers and clearinghouses. > > John > > -- > > --------- Original Message --------- > > DATE: Wed, 28 May 2003 18:38:52 > From: "Falbowski, Ellen" <[EMAIL PROTECTED]> > > > >I have a couple of comments on these minutes. > >1) Regarding the response to the testing issue submitted to the issues > >database, I think that if Party A requires Party B to use a particular > >third party's software for validation, Party A should pick up Party B's > >costs, if any, of using that third party's software. However, if Party > >A allows Party B to choose the validation software, Party A would not > >need to pay for the validation costs. > > > >2) X12N/TG2/SPWG2 (the work group that created the 824 Implementation > >Guide Reporting IG) was notified at the February X12 meeting that > >X12N/TG3 would be drafting a Type 1 Technical Report on which responses > >to use when. Not sure of the status of that work. > > > >-----Original Message----- > >From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] > >Sent: Wednesday, May 28, 2003 3:14 PM > > > >Attendees: > > > >Brandi Wyatt - EDIFECS > >Ed Hafner - Foresight > >Miriam Paramore - PCI > >Kerry - EPIC Systems > >Lou Oliver - Advent Software > >Patrick Edwards - Arkansas Blue Cross > >Tim Collins - Kentucky Medicaid > >Dave Frankel - EDIFEG > >Suzan Ryder - Empire Blue Cross Blue Shield > >John Lilleston - Verizon > > > >Agenda Items: > > > >1) Review of Washington D.C. Conference: > > > > Ed Hafner reported that the Testing breakout session went very > >well. There were over 100 people in the room for the session and over 40 > >surveys were completed and returned to Ed after the session. Brandi > >also said she overheard several positive comments about the session > >after it was over. Many people liked that we were presenting actual > >testing experiences and statistics but some felt that there was not > >enough time provided in the session to allow the attendees to digest the > >information and ask questions. > > > >2) Issue from Issues Database: > > > > The following issue was assigned to the Testing SWG and was > >discussed during the meeting - > > > > Can a health plan require that an entity > > certify with a third party testing service > > in order for the entity to begin testing > > with a plan. If so, can the health plan > > require that certification be obtained from > > a particular third party and if so, any > > caveats to that? Along these same lines, can > > a health plan require that an entity certify > > against its companion guidelines, with a > > third party testing service in order for the > > entity to begin testing with a plan. If so, > > can the health plan require that > > certification be obtained from a particular > > third party? Any caveats to these two items? > > > > This issue created a lot of discussion. The HIPAA legislation or > >ASCA does not mention certification or verification so the issue is > >pretty much left up to the formation of a best practice. The group > >agreed that requiring a third party validation/certification would need > >to be detailed in a Trading Partner Agreement (TPA). If a health plan > >does require this type of activity, they do have the right to require a > >particular third party for this purpose because certain business level > >editing would also probably be built into the software used by the third > >party that was specific to that particular payer. Not all third party > >vendors would have that specific editing functionality because they had > >not been working hand in hand with that specific health plan. The > >bottom line is that validation and/or certification is not required by > >the HIPAA legislation although it is recommended by the WEDI Testing > >white papers. Any requirement that is outside of the scope of the HIPAA > >legislation would need to be documented and agreed upon in a Trading > >Partner agreement. > > > >Please review the verbiage above as we would like to draft a final > >response to this issue during the next meeting and enter it on the SNIP > >website. > > > >4) Next Steps for Testing SWG: > > > > Sue and John had discussed a couple of topics that the Testing SWG > >may want to undertake as our next steps. One idea was to develop a > >white > >paper as to business scenarios when the 997, TA1, 824, etc. transactions > >would be used. Also, document the advantages and disadvantages of using > >standard transactions versus proprietary ones until the standards are > >mandated. > > > >Brandi Wyatt also came up with another testing idea and will document > >that idea to the group prior to the next meeting. We will devote an > >agenda item to this subject for the next meeting and try to make some > >decisions as a group. > > > >Thanks!! > > > >____________________________________________ > >John D. Lilleston > >Section Manager - Healthcare EDI > >Verizon Information Technologies, Inc. > >Phone - (813)979-3225 > >Fax - (813)978-5570 > >[EMAIL PROTECTED] > >www.VerizonIT.com > >____________________________________________ > > > > --- 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. You are currently subscribed to wedi-business 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/. 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. You are currently subscribed to wedi-business 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/. 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. 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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