Rachel,
In my work, I too
am having the same "eyes glazed over" look. A provider I was on faculty with
at the University of Virginia who now is in private practice gave me this
perspective.
"My malpractice
insurance increased 45%, my revenue decreased 12% and has every year for the
last 4. The overhead for employee health benefits increased 24% and my
employees haven't had a raise in 2 years. I am seeing more patients; the
patients themselves are taking longer to pay so I'm not exactly sure why
HIPAA even matters much if I don't have a practice left." He continued," I
honestly don't have much left to deal with this and the only reason I'm even
giving HIPAA Privacy the slightest thought is that I am concerned that a
patient will sue me if I don't, not because I'd go to jail. As far as
Security, I'll take my chances."
I'm paraphrasing a
long conversation, but I thought it was the most succinct assessment that
I've heard a small provider make.
Chris
Christopher
P. Brancato
Compliance
Officer
Director, Client
Development
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-----Original
Message-----
From: Rachel
Foerster [mailto:[EMAIL PROTECTED]
Sent: Friday, May 30, 2003 12:16
AM
To: WEDI SNIP
Transactions Workgroup List
Subject: RE: AHA! An Implementation
Plan, or New, Improved Train Wreck?
Martin, extremely
well analyzed and said.
It's interesting
to me....in the last week and a half I've given a session on The HIPAA EDI
Train Wreck to a group of billing/collection agency/financial management
companies and just today an audio conference to approximately 50+ providers.
While both audiences have been extremely attentive, I came away from both
sessions feeling that this look of attention is rather a "deer in the
headlight" reaction. I will be giving this same presentation at the HIPAA
Summit West in Seattle next week.
Rachel
Foerster
Chief
Executive Officer
Rachel
Foerster & Associates, Ltd.
Ideas
- Promotion - Innovation
Voice:
847-872-8070
email: [EMAIL PROTECTED]
http://www.rfa-edi.com
-----Original
Message-----
From: Jensen,
Martin [mailto:[EMAIL PROTECTED]
Sent: Thursday, May 29, 2003 3:41
PM
To: WEDI SNIP
Transactions Workgroup List
Subject: AHA! An Implementation Plan,
or New, Improved Train Wreck?
I hear that the
AHA "Implementation Plan" is being given consideration by CMS and
NCVHS. As one working to bring several hospitals, medium-large to
small, into compliance, I think it appropriate to
comment.
At first blush,
the articles (there are two, both similar, the better version is linked
below) seem to be a "pro-provider" response to the imminent train
wreck. However, on closer examination, there are some significant
problems. The suggested remedy may be worse than the original
problem.
http://www.hospitalconnect.com/aha/key_issues/hipaa/content/letterjaredadair_transactionsandcodes.pdf
They are called
the American Hospital Association, and thus they direct their remediation
strategy specifically at "the hospital." But I don't know of many
hospitals that are not part of a larger system of physician practices,
clinics and outlying facilities. Such smaller entities are facing a
serious challenge in the transition, with fewer resources to support their
IT conversion and more limited access to capital. Because the smaller
entities and their hospital(s) are fiscally bound, a solution that leaves
those entities out of the loop is certain to affect the
hospital.
Overall, this
paper perpetuates a number of damaging and long-refuted myths regarding
HIPAA compliance:
The Myth of
Understating the Magnitude of the Individual Effects:
"Even a slight
decrease in claims processing...could negatively affect hospitals' ability
to care for their patients." No one who understands the threat is
calling it a "slight decrease" in anything. Except the people who are
trying to downplay the magnitude of the problem to (or at) CMS. The
effects of an unmitigated train wreck will be severe and industry-wide,
effecting even those who have managed to achieve full compliance by the due
date.
The Myth of the
Implementation Plan
"we propose the development of a
system-wide implementation plan....." An Impementation Plan consists
of a set of tasks to achieve identified target objectives and by a series of
well-defined dates. This paper is not about implementation, nor is it
a plan. Instead it is a stopgap contingency measure, and as such it
falls far short of saving providers in general or hospitals in
specific. Though it is probably much more than the payers will be
willing to do voluntarily. The problem is, by calling it an
Implementation Plan, they will again forestall any meaningful planning,
which is what the whole system of payers, providers, clearinghouses, vendors
and government agencies desperately needs.
The Myth of the
Achievable Testing Objective
"we believe that a successful
implementation of the transaction and code set standards will
require...complete end-to-end testing...well in advance of the October 16
deadline." At the WEDI conference last week, one of the Blue Cross
payers said that in order to do end to end testing with all of their
submitters, they would need to complete over 300 successful tests per
day. As of now it is taking an average of 6 weeks and many hands-on
hours per submitter. Some payers have rightly concluded that
end-to-end testing, especially under the mandated "100% complete and
error-free" transaction standard, is unworkable, and have abandoned that
approach for all but their largest providers and direct submitters. On
an individual basis, direct testing is clearly the best way to assure
business continuity; but from an industry perspective, it is entirely
unworkable.
The Myth that the
Payer Is Always Right
"Advance testing would give
providers the time to identify and correct reporting and formatting
deficiencies...." The subtle assumption is that all errors are caused
by provider deficiencies. This assumption is belied by many providers'
experiences in testing with payers. What about when the payer needs to
identify and correct *their* deficiencies in interpreting the
standards? What about when one of the clearinghouses (there are often
two in a transaction chain) has reformatted the original submission
incorrectly, or rejected a submission unjustifiably? One payer I
talked to said his biggest problem was that he had no idea how many claims
his clearinghouse had rejected "on his behalf." And thus he has no way
of contacting the submitter and working out their mutual needs, much less
knowing how far he has gotten in trading partner testing.
The Myth of the
Error Message
"We...urge CMS to recommend the
routine use of the various X12 acknowledgement messages...." X12's 997 and
TA1 acknowledgements carry almost no useful information in terms of decoding
problems with claims. In fact, someone pointed out at the conference
that even a denial in an 835 won't give providers much of a clue about the
reason a claim or line item was rejected. This person said much more
meaningful information is carried in the claim status response (277), which
adds another transaction to the priority list for providers. And the
status codes that are "approved" are much less detailed than most
proprietary reports payers are sending now.
The "Bad Providers
Deserve to Die" Myth
I can't believe they really say
this, but they do: "The proposed implementation plan does not help covered
entities -- providers or health plans -- that are unprepared to generate a
standard transaction." What about the providers who are waiting in
line for their vendors to install, who have been waiting in line for the
payers to test, who were waiting for CMS to approve an Addenda that
works? Do those "bad providers" deserve to die? More to the
point, do their patients?
Also, in the final
analysis, the "plan" itself is nearly unintelligible. Roman Numeral
III on page 7 is where I expected to find the calculation for the value of
an estimated payment. The rest of the letter seems to imply that the
payment would be based on an estimate of claims revenue (presumably after
subtracting any claims that could actually be processed).
But instead, item
III does no such thing, and the steps it suggests make no sense. In
fact, if followed, they would make matters far worse.
�
In step III.1, it implies that the
claims are getting through. Providers who need the most relief will be
those whose transactions are rejected immediately for syntactical
discrepencies -- a "full bounce" of a batch of claims -- followed
immediately by those who cannot get their system (i.e. their software vendor
or clearinghouse) to produce a compliant transaction.
�
In step III.2, they assert that
these claims can somehow be adjudicated. But the contingency payments
were supposed to be for the claims that could NOT be adjudicated.
�
Finally, and worst of all, Step
III.3 requires that the provider submit the missing elements -- the
unavailability of which are the cause of the errors in the first place -- on
a paper "statement." If my system has not given me a way to send, for example, subscriber
date-of-birth, it is likely that it gives me no place to store such information. How am
I supposed to send a "statement" of information that I don't have?
More to the point, how does sending this data in a completely nonstandard
format (presumably on paper) reduce the impact of the train wreck? Any
payer with sense would deliver such reports immediately to their shredder,
so as not to waste the scarce personnel resources already processing a
mountain of paper claims, which at least are in a recognizable format.
What's more, the provider would be far better off sending a paper claim,
which doesn't REQUIRE the unavailable information.
And so this
avalanche of paper claims, the much-feared root cause of the trainwreck,
becomes the logical consequence of adapting this purported "implementation
plan."
Next...an analysis
of the unexamined effect of the train wreck on financial markets, and a
possible alternative to perserve financial stability.
Martin
Jensen
Project
Manager
St.
John Health System
918-744-3234
