NEMUG Newsletter
August, 2002, Articles
July Meeting: HIPPA
Presentation by Elliot M. Stone, Executive Director and CEO of the HDC, the Massachusetts Health Data Consortium, Inc. (www.mahealthdata.org) July 9, 2002 regarding HIPAA or Health Insurance Portability and Accountability Act
Regional eHealth Collaboration.
HDC, the Massachusetts Health Data Consortium, is a not for profit organization that disseminates health information. One of their main objectives is to provide information and training on HIPAA, The Health Insurance Portability and Accountability Act. They do primary research and act as a clearinghouse for health information. They establish task forces for inter-enterprise projects, for example Mass General with Blue Cross. They organize conferences and educational programs. They enable Chief Information Officers (CIO's) of various employer, health, government, insurance and vendor agencies to collaborate. They provide online information resources and vehicles of communication, but they do not get involved with in-house coordination of individual organizations. HDC webmasters get information out to organizations.
In 1978, the HDC was designated as HIPAA coordinator by the state. At the time there were 132 hospitals sending data in many types of non-standard forms to insurance companies. Each hospital had a different set of forms and the paperwork took weeks or months to send in and process. Often a doctor would submit a second claim because the first was delayed. This created a nightmare of delayed reimbursement, overlaps and non-standard filing. HIPAA is part of a huge effort to standardize the data and the forms. Now, with 80 hospitals to coordinate, the task is still huge. The October 16, 2002 deadline and October 16, 2003 extended deadline loom for institutions to standardize their electronic transactions. The good news is that many of the insurance providers, hospitals and doctors are ahead of the deadline because by standardizing they are finding that they can receive payment for their claim the same much more rapidly than before and, the cost of the filing and processing has been reduced from several dollars to 27 cents per claim. Many organizations are making taking advantage of their allocation of resources towards HIPPA standardization to also re-engineer their IT structure.
Massachusetts is one of the states on the forefront of complying. Medicaid is re-engineering their system aggressively. Partners Health Plans also part of group, they are aggressively moving towards compliance. New England Healthcare EDI Network or NEHEN is a group of several large hospitals that send HIPAA transactions directly to one another via the internet, eliminating the middlemen.
HIPPA does much more than facilitate insurance reimbursement.
- It enables standardizing first screen edits and claims.
- Privacy and security are other aspects of HIPAA. HDC are researching best practices statewide.
- HIPAA is requiring automating testing, transmission and email notification of bio-terrorism lab results for a public health initiative.
HIPAA is a complex bill; this is how HDC is working to help the health industry meet the requirements and reap its benefits. Part C of the bill is aimed at administrative simplification. It is expensive and time consuming to process paper and resubmission of claims by doctors waiting to be paid. HDC works with operations people on getting claims filed more quickly. Some plans did not require a listing of dependents. No one could determine how many people were covered by insurance because dependent information was missing. Formerly, eligibility was determined in many different ways. HIPPA aims to standardize front-end edits and loosen up non-standard requirements so doctors can get paid quicker. All electronic transactions will be required to follow HIPAA standards, but paper transactions will not. Coordination means a lot of people have to be trained in HIPAA and COBRA, which preserves health insurance for people in transition, is a part of that.
Vendors or middlemen need to be standard as well. Examples of middlemen are developers of a software package for a doctor's practice management system or a billing service. They will need to know HIPAA to stay in business because it will be required of doctors.
Transaction aspects of HIPAA impact employers, payers and providers and vendors or clearinghouses between. The ANSI ASC X12-N (Electronic Data Interchange Standards) is the new form, 40-10 version. Secretary of the Department of Health and Human Services Donna Shelela chose the various standards for parts of the regulation. For example she designated X12 for forms. Two of those forms are 270, the Check Eligibility form and 271, the form for the reply. In one organization form 271 came back too fast for front-end employees. There was no procedure in place to deal with an eligibility claim that was rejected while the patient was still in the waiting room. Techs had to be retrained.
Some standards that are not included in the current HIPAA regulations are:
- HL7: Currently the HIPAA requirements are all financial standards. HL7 is a next generation standard for health data transmission, but not included for financial transactions. NEDS, National electronic disease surveillance uses HL7 for reporting lab results.
- ASTM: For standards regarding swipe versus manual keying accuracy, claim filing could be streamlined using the swipe card. ASTM has a standard swipe format. There is nothing in HIPAA yet.
- XML: X12 has a group working on XML, but they are not working on standardization yet.
- Dictionary: There is a dictionary across all transactions to define terms. For example one field name is defined as "Patient Name" rather than "Name of Patient."
- Hardware: Security regulations won't require hardware standards. They may require features, which would mean certain hardware requirements.
For more information on detailed HIPAA requirements see the implementation guide, version 40-10. Washington Publishing (WPC) is only publisher and the HDC web site has a connection to that site. For example, doctors' groups can still send paper, but if you go electronic you must comply with HIPAA as of October 16, 2002 or extended to 2003. There is a companion guide issued by each health plan. Each one details the slight shading of difference on how to submit claims electronically. In HIPAA there is one list of codes for each procedure. The shades of difference between providers might be the list of codes that are acceptable, or required fields. There is a sample guide on web site at www.NEHEN.org. Clarity, Inc. is a company, which certifies transactions for HIPAA. May not be equally acceptable by all providers.
Penalties under law like fines are aimed at the insurance company, not so much the health provider. Insurance companies must accept HIPAA transactions. There are problems that are out of the control of the doctors or insurance companies. Many times doctors don't get paid because the patient or employer has not sent information to insurance company. An employer may not send information on changes in a family or terminations to the insurance company more often than quarterly, which may hold up claim payments.
Privacy regulations required a consent form signed, but Tommy Thompson eliminated them. Protected Health Information PHI, required consent to acknowledgement that you were informed.
HDC research includes claims TAT, or turnaround time and demonstrates that the sending and paying of claims have speeded up. They generate other useful reports like why claims are denied.
HIPAA is an enormous educational opportunity; training is necessary in many areas. Doctors and hospitals will benefit from the improved standardization of electronic communication.
~ submitted by Heidi Pepe-Laird