Jonathan - This is a common, understandable, and extremely dangerous point of view.
First, the concept that a minor formatting error is the sort of "violation" that was meant when the regulators outlawed "nonstandard" transactions is, according to some of those same individuals, incorrect. Second, CMS officials responsible for enforcement said, at the recent WEDI SNIP Summit in Chicago, that they will be initiating enforcement activities on a complaint-driven basis. No one is going to be sifting through your transaction history looking for misplaced situational data elements. They emphasized that they understand the need to maintain cash flow through the transition, and DO NOT want transactions to be suspended due to minor technical inconsistencies. Third, when enforcement is required, CMS will take a "complaint-to-compliant" approach, rather than a fines-and-civil-penalties approach. If one of your trading partners is complying with CMS's enforcement provisions already, sending increasingly compliant transactions, how will you know? Who are you to suspend their transactions when they are already cooperating with CMS? Fourth and finally, we are not talking about two trading partners here -- we are talking about an entire industry that represents 1/7 of the US economy, all transitioning to a new technology at once. Even for a single pair of trading partners, the potential obstacles to sending a transaction that all participants can agree upon as "compliant" are substantial. Take a claims submitted by my hospital to Payer A: 1. Our patient accounting system applies its "HIPAA aware" edits and produces a proprietary claim format, containing all the necessary data content for a standard "HIPAA Compliant" transaction. 2. Our EDI translator converts that proprietary data file into an 837I. It puts the resulting file through its HIPAA compliance maps to ensure the formatting is "HIPAA Compliant." 3. The output file is sent to our clearinghouse, which divides the Payer A content from all the other claims. It combines our Payer A claims with those of other providers and puts the resulting 837 through its "HIPAA Compliant" edits before transmitting it to.... 4. Payer A's clearinghouse, which takes the inbound claims from our clearinghouse, combines it with input from other providers and clearinghouses, runs its compliancy maps, and passes along (in either 837 or proprietary format) to 5. Payer A, which validates the incoming data stream against its compliancy edits (even a proprietary data file must be validated for content, as in Step 1). Now, if, at each step, every participant insists that its and only its interpretation of "HIPAA Compliant" (content and/or format) is correct and rejects all others, how many transactions do you think will go through? Add to this that many are further interpreting that such minor "errors" are grounds for rejecting the entire batch of claims, and you may begin to realize how each time someone else's "HIPAA Compliant" transactions are mingled with yours, you are at risk of losing connectivity with the next step in the line. Furthermore, any subscriber to this list is aware that there continue to be differences of interpretation among informed people -- not counting the 95% of the industry that do not participate in these discussions. As people move their systems into production, unforseen and untested situations arise. Before anyone shouts me down with "that's what standards are for!" arguments, let me offer this up for consideration: There is no greater threat to the success of the conversion to standards than a lock-up of the healthcare financial infrastructure due to overzealous individual interpretations of those standards. I am not advocating disposing of the standards, nor even that strict conformance with the standards -- eventually -- is a bad idea. Just that the scale of this transition needs to be taken into account. We need a pragmatic, reality-based approach to the transition. Several groups are working on this now. In the meantime, please understand the danger that "my way or the highway" compliance strategies pose to our industry. Martin Jensen St. John Health System Tulsa, OK -----Original Message----- From: Jonathan Allen [mailto:[EMAIL PROTECTED] Sent: Thursday, March 27, 2003 03:19 To: WEDI SNIP Transactions Workgroup List Cc: [EMAIL PROTECTED] Subject: Re: Situational segments/elements and payer-specific edits Dave Sell asked: > I'd like to know if any receivers will reject claims that have > unneeded Situational segments or elements. They certainly should. Two principle reasons: a. the old chestnut of HIPAA compliance - sending unneeded situational data would make a transaction non-compliant and both the sender and receiver in breach of the rules (and so liable for fines if caught) [snip] Jonathan ---------------------------------------------------------------------- -------- Jonathan Allen | [EMAIL PROTECTED] | Voice: 01404-823670 Barum Computer Consultants | | Fax: 01404-823671 ---------------------------------------------------------------------- -------- IMPORTANT NOTICE: This message 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 message in error, you are hereby notified that we do not consent to any reading, dissemination, distribution or copying of this message. If you have received this communication in error, please notify the sender immediately and destroy the transmitted information. --- 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-transactions 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
