Following one of my earlier messages to this list regarding XML/DTDs/SCHEMAS
for the HIPAA covered transactions a gentleman posed the situation that it
would appear the final rule on the HIPAA covered transactions appeared to
provide a loophole for covered entities to opt out of having to comply if
they used/continued to use a clearinghouse to perform the translation from
non-standard to standard formats.
I've been reading the final rule just published to try to see where and how
this could occur, and thus far I haven't seen such a loophole jump out at
me. As a matter of fact, the following language seems to me to remove such a
loophole:
With respect to health plans, a health
plan is required to have the capacity to
accept and/or send (either itself, or by
hiring a health care clearinghouse to
accept and/or send on its behalf) a
standard transaction that it otherwise
conducts but does not currently support
electronically. For example, if a health
plan pays claims electronically but
historically performed enrollment and
disenrollment functions in paper, the
health plan must have the capacity to
electronically perform enrollment and
disenrollment as well as claims
payment as standard transactions by the
applicable compliance date of the
regulation.
Also, in response to the public�s need
for clarification of the applicability of
the HIPAA administrative simplification
provisions (45 CFR subtitle A,
subchapter C) to covered entities, we
revisited the applicability provision
with respect to health care providers. In
the proposed rule, we proposed that the
administrative simplification provisions
would apply to a health care provider
when transmitting an electronic
transaction (63 FR 25305). (We note that
this language differed somewhat from
the statute, which states that the HIPAA
administrative simplification provisions
apply to ��a health care provider who
transmits any health information in
electronic form in connection with a
transaction�� referred to in subchapter
C.)
We phrased the applicability section
in the proposed rule as we did in an
effort to convey the message that these
regulations do not require a health care
provider to transmit transactions
electronically; thus, a health care
provider remains free to use paper
media. These regulations do require,
however, that a health care provider
who uses electronic media to transmit
any health information in connection
with a transaction referred to in 45 CFR
subtitle A, subchapter C, must do so in
compliance with the regulations."
Since the language of the final rule is unambiguous in that it requires ". .
. a health plan is required to have the capacity to accept and/or send
(either itself, or by
hiring a health care clearinghouse to accept and/or send on its behalf) a
standard transaction that it otherwise conducts but does not currently
support electronically."
I would not believe that a health plan would WANT to continue to support
non-standard formats AND the standard formats (which they MUST have the
capacity to accept and/or send) once the mandated compliance date is
reached. At that time I would expect that health plans would pull the plug
on the non-standard stuff so that they can reduce their costs by now
supporting multiple ways of processing the transactions.
Additionally, the final rules requires a health care provider to comply with
the regulations when using electronic media to transmit any health
information in connection a standard transaction. If the provider contracts
with a clearinghouse to perform the translation on its behalf that it
allowable, but the clearinghouse must then transmit the standard transaction
to the health plan.
Now, one could envision a situation in which both the provider and the
health plan contract with the same clearinghouse to perform translation
services on their behalf. The way I would see this working, however, would
be that the provider sends to the clearinghouse a non-standard claim (for
example.) The clearinghouse is required to translate that into the standard
format (the 837.) At that point the health plan wants to get the claim in a
non-standard format and contracts with the same clearinghouse to now perform
the translation from the standard format into the non-standard format. Since
there are no free lunches, the clearinghouse would charge both the provider
and health plan for these services. However, I wouldn't envision this
situation being perpetuated for a long time, but only used for the time
period needed for each of these customers of the clearinghouse to get their
own internal IT capabilities in place for the long term.
On the other hand, since I've been in the health care industry for 30 years
(more or less!!) I've learned not to place bets on when this industry would
move to adopt current mainstream information management technologies in
order to better manage the business of being in the health care business.
Have a good Labor Day weekend all!
Rachel
Rachel Foerster
Principal
Rachel Foerster & Associates
Professionals in EDI & Electronic Commerce
39432 North Avenue
Beach Park, IL 60099
847-872-8070
Fax: 847-872-6860
http://www.rfa-edi.com
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