rachel wrote:
>
> 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.
>
<chris> First, let's be clear that what Rachel is quoting
is not from the rule. It is from a separate discussion
that is attached to the rule. In any event, the loophole
that I was talking about is in that very first paragraph.
The clearinghouses must accept X12, but the providers do
not have to send it. The clearinghouse can continue to
take non-standard formats from providers, and convert them
to non-standard formats for the payers. Status quo.
> <rachel>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.
<chris> The health plan can either *pay* the clearinghouse
to negotiate a new X12 format to send them, and then *pay*
to write an X12 converter at their shop to convert it into
their legacy system, or they can continue to have the data
sent to them in the non-standard format they are currently
getting and not pay anything. Methinks they would choose
do go with the nopay option.>
><rachel> 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.
><chris> Unfortunately, that is not true. The payor can
contract with the clearinghouse to send it to them on paper
if they want to. No provider has to transmit X12 and no
payer has to receive X12 if they use a clearinghouse.
> <rachel> 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.
<chris> Yes, this is what I pointed out in my first mail.
It's ludicrous, but that is the literal read of the rule.
>
> Cheers
Chris Thompson
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