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Christopher,
It does matter who "signs up" with whom, since it is really
what determines who pays.
I believe that if the payer has a port available to the
public, the CH would be responsible for any expenses involved with connecting to
the payer's port in excess of the one-time charges the payer charges the
provider (which, in most cases, must be $0), if
it connects to the payer at the
provider's request. It could then distribute the
setup costs amung the provider community desiring access to this
payer.
Don't forget that in this case, the CH is freely chosen by the
provider, since there is a direct path. The payer did not necessarily
choose the CH.
Now, if the payer freely chooses to use the CH as one of the
possible paths to it (independant from any provider's request, or persuing a
request from a provider to the payer), it would be responsible for any CH setup
charges.
The opinions expressed here are my own and not necessarily the opinion of
LCMH.
Douglas M. Webb Computer System Engineer Little Company of Mary
Hospital & Health Care Centers [EMAIL PROTECTED]
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----- Original Message -----
Sent: Wednesday, September 17, 2003 09:42
PM
Subject: RE: clearinghouse/provider
relationship
Richard,
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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of Directors nor WEDI SNIP. If you wish to receive an official opinion, post
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Optiserv Consulting (Vision
Industry)
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Office (707)
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