This makes sense to me and I don't think it conflicts with Catherine's illustration. The problem is that the provider's CH DOES still have to establish and test a connection to the payer. Whether one considers the provider's CH "signing up" with the payer or the payer "signing up" with the CH... either way, a mutual enrollment process must take place and it's possible that the payer would receive a bill from the CH for those costs. There may be transactions fees for the payer too. If the scenario involves a relatively large CH who normally charges hefty set-up and transaction fees to providers, then a small payer may be regarded just another customer.
If I remember correctly, HIPAA prevents the payer or payer's agent from charging the provider or provider's agent over and above the price of a phone call. But I'm not sure that a CH is prevented from levying fees on a direct-connect payer. I'm pretty sure this issue surfaced a couple months ago and was never really settled.
Regards,
-Chris
At 05:46 PM 9/17/2003 -0400, Richard Navaro wrote:
William:
If you are a payer you have two basic options for accepting transactions.
1) You can directly receive standard transactions and open this to everyone at no charge (except cost of call).
2) You can hire a clearinghouse to be your portal and then your customers send the claims to the clearinghouse at no charge and you reimburse the clearinghouse for any clearinghouse fees.
In the example you cited, where you accept claims directly but the hospital chooses to send their claims to their clearinghouse A.
You must offer to accept the claims at no charge from the clearinghouse A. The hospital must pay clearinghouse A their regular fee.
You have no obligation to sign up withor pay clearinghouse A for the claims.
If you hire clearinghouse B as your portal, then clearinghouse A must send the claims to clearinghouse B. As in #2, clearinghouse A would not be charged to send the claims and you would pay clearinghouse B for being your portal.
How you make known how you receive claims is a business decision not covered by HIPAA.
Rick Navaro
Navaro Medical Solutions
-----Original Message-----
From: William Openshaw [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, September 17, 2003 2:05 PM
To: WEDI SNIP Transactions Workgroup List
Subject: RE: clearinghouse/provider relationship
Thank you for the explanation Catherine, we are experiencing the same problems (as a payer) in getting the claims from our providers.
My question is this; who is then responsible for paying the clearinghouse transaction fees? Here is a situation that we are faced with now.
We currently process everything on paper. We are ready to start accepting EDI transactions but are having problems getting our providers to send us the claims. One of our major hospitals has told us that they use Clearinghouse A for their electronic transactions. They refuse to send us the claims directly to our FTP site and insist that we must use their Clearinghouse. Would it then be their responsibility to have their Clearinghouse sign up with us to transfer them to our FTP site and pay the costs, or do we have to sign up with their Clearinghouse to get our files and then we incur the fees? What if we are signed up with Clearinghouse B? Is it the provider's responsibility to contact their Clearinghouse to send our claims to Clearinghouse B and pay the fees, or do we have to do that?
William Openshaw
ASR Corporation
-----Original Message-----
From: Catherine Lohmeier [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, September 17, 2003 12:15 PM
To: WEDI SNIP Transactions Workgroup List
Subject: RE: clearinghouse/provider relationship
I'll take a stab at this one...it will be hard to describe all the possible combinations. I have some background in this having worked for a clearinghouse and a payer in the past, but this is still just one perspective on how this all might, or should work.
The issue that will have the most influence on the use of a clearinghouse, in my opinion, is going to be who has contracted with the clearinghouse to act on the covered entity's behalf (become a Business Associate).
If a payer contracted with the clearinghouse, then the payer will decide which transactions will go through that Business Associate. For example, a payer may contract with one clearinghouse for the 837 and another for the 270/271. It would be the payer's responsibility to tell providers how and when to use these resources, AND give some kind of direction as to what type of provider paperwork will need to be in place with the clearinghouse. I'll call this "signing up" and it can include trading partner agreements and/or contracts. Part of the clearinghouse's agreement with the payer may include doing this paperwork and communication for the payer, or the payer may choose to have this "sign up" function remain in house. Either way, the provider must receive directions directly or indirectly from the payer.
The "sign up" paperwork may include the clearinghouse's standard contract/trading partner agreement. Maybe the payer negotiated something custom for providers working with them. Again, if the payer initiated this contract with the clearinghouse, this information must come from them either directly or indirectly.
In my mind, at this point it doesn't matter if the provider has HIPAA transaction capability or not. But it will matter to the clearinghouse what data format is coming from the providers. The clearinghouse will most likely have some data formats that they are familiar with and can accept easily. This should all be defined in the "Sign up" paperwork. Testing the data moving back and forth will be necessary and should also be defined in the "sign up" paperwork, don't forget that. Once testing is complete and everyone goes live, then the data is received by the clearinghouse, and the translation to HIPAA formats and possible re-translation into a format the payer can receive will occur.
Now the provider gets to choose which transactions they want to do and they follow directions to get set up. The next question is: how does the provider get the data to the clearinghouse?
Here's where it most likely will get confusing....
The provider may be able to directly create and send all HIPAA transactions related to a provider's practice, or it may only be able to do the some transactions, like the 837, directly from the practice management system in the business office. In this case, the properly formatted HIPAA transaction will be sent to the clearinghouse and then sent off to the payer in whatever format the payer contracted to receive. The clearinghouse has to be able to receive a HIPAA format, but not necessarily all of them. Remember, the payer may have chosen a different clearinghouse for some of the other transactions.
(Also, clearinghouses that do the 270/271 today usually include a way for the provider to send the 270 request and receive the 271 response all though the system of the clearinghouse. I frankly don't see this changing much in the near future. But if a payer contracts with a clearinghouse to do this for them, then instructions on how to do this must come from the payer either directly or indirectly. Others more informed are welcome to chime in on this issue.)
But what if the provider CANNOT send their data in a HIPAA transaction format?
It looks to me like the provider now has to have their own contract with the clearinghouse above and beyond, or in concert with, the paperwork required to send transactions to the payer. The provider, in fact may already have a relationship with a different clearinghouse (call it clearinghouse "B") than the one the payer has designated as their Business Associate(call it clearinghouse "A").
So this becomes the picture, the provider sends data to his/her Business Associate in whatever format is agreed to in the "sign up" paperwork with clearinghouse "B". -OR-- the provider decides to contract with the same clearinghouse (clearinghouse "A") that the payer is using and sends the data in the format named in those "sign up" agreements.
If the provider initiates the contract, the provider is responsible for organizing this connection and sign up information with which ever clearinghouse they picked.
It is possible for clearinghouse "B" to receive the provider's data and then send it to clearinghouse "A" who in turn gets it to the payer. It is possible for clearinghouse "A" to be the business associate of both the payer and the provider.
In response to your question of who's responsibility is it to provide access to the information to the provider, the summary of all this is: if the provider has initiated the business associate agreement with a clearinghouse then the clearinghouse will give detailed instructions of how to send and receive the information. If the payer has contracted with the clearinghouse then I see the two of them working together to relay to affected providers the appropriate instructions on how to send and receive information.
In the event that two different clearinghouses are involved, a third set of agreements may be required for getting data back and forth between clearinghouse "A" and "B". This third set would not affect the provider or the payer as it would be between the clearinghouses. I just don't know how likely this scenario will be. But it is possible.
Does this even remotely answer your question? If not please feel free to give me a call.
If I made an absolute mess of this, please feel free to correct me. This is just my personal opinion.
Catherine Lohmeier
Implementations Project Lead
OD Professional(tm) Team
402.423.6509 x 15
-----Original Message-----
From: Martin, Catherine A [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, September 17, 2003 7:02 AM
To: WEDI SNIP Transactions Workgroup List
Subject: clearinghouse/provider relationship
Please help me understand the relationship & responsibilities of providers, clearinghouses & payers as it relates to ensuring that providers have the authority to request information via a clearinghouse.
For instance, if there is a trading partner agreement between a payer and a clearinghouse and the payer receives 270 transactions from the clearinghouse, but does not have a trading partner agreement with the provider actually seeking the information, is it the clearinghouse's responsibility to ensure that the provider has the authority to make the 270 request for information?
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