All
Ruth Tucci-Kaufhold and I are launching a new WEDi/SNIP subwork
group (under the Business Issues WG) that will focus on the issue of
implementation guide selection. That is, for any one service
(e.g., ambulatory surgery) which implementation guide should be used to
submit a
claim/encounter?
This question first came to my attention several years ago when,
during an X12 TG2 WG2 (837) meeting, we did a show of hands for who
billed on
which claim form for a variety of services. The response was
startling. To our consternation, payers are requesting that some (not
all) providers bill
several different ways for identical services.
Why discuss this? One, it appears to be a topic that fits under
the concept of 'administrative simplification'. No, it is not
officially part of HIPAA
(HIPAA states that if you bill a professional claim you must use
the 4010 837 professional implementation guide but it doesn't define
what services or
service sites constitute a professional claim). There seems to be
an opportunity to possibly simplify billing (by agreeing on which claim
form to use for
which kind of service) and save many entities in the industry
unnecessary administrative costs.
Two, who pays this potentially unnecessary cost? Providers of
course, pay. Providers are in the unenviable position of being asking
to submit the
identical service on a variety of claim forms. This forces them to
maintain more than one billing system as well as the supporting xwalk to
move the
information from one form to another (for example, xwalking an
ambulatory surgery claim from a REV code format using treatment,
condition, value,
etc codes to a HCFA 1500 format. For example, we have found that
home health, ambulatory surgery, long term care, many outpatient types
of care
are billed under both the UB (institutional) and HCFA
(professional) formats. Dental surgery is billed using both the HCFA
and the ADA form.
Payers also pay a cost. Here at UHIN we have looked at (and
achieved) standardization of billing forms in the arena of home health.
It was a
fascinating discussion. During the discussion we learned that
payers (our payers anyway) seem to have two approaches to the problem of
receiving a
claim on the 'wrong' form. Either they reject it back and request
it on the 'right' form or they build front-ends that can handle either.
Either strategy
involves considerable costs. If we as an industry, can agree on
reducing the chaos for at least some areas of health care, many will
benefit.
Now that we do have standard billing/reporting formats, this seems
like a good opportuntity to begin discussing the implementation guide
selection
question.
So, I'd like to invite you and any one else you might think is
interested to join our first conference call. It will be held during
the usual WEDi/SNIP
Business Issues call as they are not using the slot that day.
Date: Tuesday, August 21,
Time: 3:30 PM - 5:00 PM EDT (east coast time)
Number: (703) 736-7290
PIN Code: 1315330 (try again if it doesn't work the first time).
Agenda:
Discuss the goals of the WG
Discuss the spreadsheet Ruth has put together and some preliminary
results.
Begin to describe the scope of the issue
Schedule additional conf calls
We are in the process of setting up our own list serve. We'll give
you more information on the call.
I hope you will attend.
Jan Root, Ph.D.
Standards Manager
Utah Health Information Network
voice: 801-466-7705 x202
fax: 801-466-7169
[EMAIL PROTECTED]
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