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[TCS] Health Care Claims Attachments Under HIPAA
Even as health care continues to struggle to effectively implement at a
critical mass level the standard transactions under HIPAA for claims let
alone the other approved standards for eligibility, claim payment and
remittance advice, claim payment status, etc. CMS is working on the NPRM for
health care claims attachments as required under the HIPAA legislation. As
I've examined the existing documentation of what most likely will be part of
the NPRM I am confronted with many questions. Among them are:
1. Given the exponential increase in complexity required to support a 277
request for additional information, the creation of the attachment itself,
the insertion of it into a 275 response and the processing of it by a health
plan, does anyone or the industry have any idea of the costs and benefits
for such an approach?
2. What percentage of claims being submitted currently require further
medical review and result in a request for additional information (the
attachment)? Is this percentage trending up or down? Wouldn't it be folly to
regulate a possibly declining activity?
3. What type of additional information is most often required?
4. How is that additional information made available to the requester? Fax?
Paper via snail mail? Electronically?
5. What about attachments required for DME or home health? Will the NPRM
that most likely will be promulgated cover these?
6. What is the current cost to a health plan and to a provider to process
today's claims attachment?
7. Will the proposed 277/275/HL7 option be able to be cost-effectively
implemented across the entire industry? Over what time frame? At what cost?
Is there a reasonable payback period, say of less than 2 years? Will the
smaller health care providers even be able to implement such an approach?
And can small health plans support it as well?
8. Given that the industry hasn't yet been able to make a full transition to
the current suite of X12-based HIPAA transactions, does it make sense to
perpetuate this approach in light of newer information technologies that are
more suited to today's and tomorrow's needs and which could be substantially
less costly to exploit?
9. Are there "baby steps" that can be taken now to move to electronic claims
attachments that do not require complex systems to be developed at
substantial cost?
And these questions are just the immediate few that jump to mind. I'm sure
there are many more.
I believe that health care now has the benefit of a few years of experience
in its efforts to implement and deploy widely the current suite of HIPAA
standard electronic transactions. What have we learned from this experience
thus far? Before we continue adding to the effort I think it would be much
more productive to go through a post-implementation audit to identify what
worked and why, what didn't work and why, and what would be the optimum path
forward to try to achieve the goals of administrative simplification: taking
unnecessary cost out of the processes required to pay for health care.
Rachel
Rachel Foerster
Rachel Foerster & Associates, Ltd.
Voice: 847-872-8070
email:
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