RE: clearinghouse/provider relationship

[William Openshaw]

Thank you Cathy and I agree in part with what you are saying.   Obviously, if we offer the direct submission, we will be providing a great service to our providers who aren't large enough or simply can't afford to absorb the high costs of utilizing a clearinghouse (provided their PMS can output compliant transactions).    What I don't understand is the justification used by the larger provider organizations that automatically mandate the CH fees to be paid by the payer, regardless of whatever deal they struck with their CH.  Albeit, a good business decision would dictate an agreement from the payer to incur, or share CH fees in order to facilitate larger numbers of EDI transactions, which potentially eliminates all of the paper mess.  But as Richard Navaro expressed, the CH holding the claims for ransom doesn't seem to be a good way to persuade payers to do business with them electronically, especially when the payer has proven means to interact with the providers using free, Internet based applications.  The providers are choosing to utilize a CH instead of transmitting directly to us, so I say again; should they then be obligated to pay the fees that are associated with their own decision?  Using your banking example below, I can walk into a local branch and withdrawal cash for free, but if I choose to use an ATM, I pay a fee for those transactions.  It's my choice at my expense.  Not the expense of the institution operating the ATM.  Exaggerated?  Yes, but completely fitting.   -----Original Message----- From: Catherine Lohmeier [mailto:[EMAIL PROTECTED] Sent: Thursday, September 18, 2003 12:19 PM To: WEDI SNIP Transactions Workgroup List Subject: RE: clearinghouse/provider relationship   I always find myself looking to the intent of what HIPAA is trying to accomplish.   The intent is a set of standards for information passing electronically between entities involved in the healthcare industry.  EDI has proven very cost effective in other industries, and it will in healthcare as well.  But there are some growing pains involved and that also has happened in every other industry.   We all agree that HIPAA put a mandatory responsibility of having the capability to send and receive all the HIPAA standard transactions on the payer and gave providers the option of choosing which ones they want to use.   We all agree that if a payer provides a direct or indirect (clearinghouse) means for providers to send and receive their transactions without a premium attached then that is following the letter of the rule.  But for a payer to say, "I did my part. Now, providers, the rest is up to you", is not following the intent of the rule, in my humble opinion.   That's like a bank saying, "OK, I have an electronic funds and bill paying network setup, but you the customer have to figure out your own way to access it.  What ever costs you incur figuring it out is on you."  I know it's an exaggerated example but I'm trying to make a point.   HIPAA does not prohibit a payer from having as many direct AND indirect methods as they want for getting transactions into and out of their systems.  It seems to me the easier a payer makes this for the provider or the agent of the provider (clearinghouse), the more the provider will use it, and isn't that the intent?  Getting rid of this endless stream of inefficient paper, retyping, scanning?  Historically, offering better customer service and reliability makes a business more competitive in the marketplace.   Payers are businesses just like a bank, or a retail store or an architectural firm, and they must do their own cost benefit business analysis to decide how much to offer their clients-the members and the provider community.  The choices they make may differentiate them in the healthcare marketplace of the future.   Again, this is just my own personal opinion.     Catherine Lohmeier Implementations Project Lead OD Professional(tm) Team   --- The WEDI SNIP listserv to which you are subscribed is not moderated. 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