I've read the last few responses in this
thread with a mixture of amusement and frustration. The parts about doing "what
makes sense," and taking "logical action" are right on. Unfortunately, because
we have gotten the federal government (further) involved in our business, logic
and sense are no longer part of the equation.
I wholeheartedly agree that it makes perfect sense to process all claims from a given 837 transaction that are possible, regardless if whether or not other claims in the transaction are compliant. (IMO, it makes sense even to process a non-compliant claim, if the compliance violation itself doesn't preclude it.) However, that's not the way most of the folks participating seem to read the regulation.
If I had to defend my actions in court, I think I'd be more successful defending them on the grounds that I was simply following the (stupid) law, than I would be in explaining that I was doing what made sense and/or seemed logical. After all, I don't think it would be successful defense to explain that you were speeding because the speed limit in the area didn't make sense.
Regarding "coming into conflict with state...laws;" while I completely concur that the states should have overriding jurisdiction in these - and any other - conflicts between state and federal laws and regulations, the Fourteenth Amendment did away with that concept in practice long ago.
And as for what Congress intended; if even 1% of the Congresscritters (outside of its sponsors) who voted on this thing actually read any of it, I'd be amazed. In my estimation, their main "intent" was to be able to go back home and tell their constituents that they "did something about <fill-in-the-blank>."
-----Original Message-----
From: Price, Carolyn [mailto:[EMAIL PROTECTED]]
Sent: Monday, July 22, 2002 12:01 PM
To: [EMAIL PROTECTED]; William J. Kammerer; [EMAIL PROTECTED]
Subject: RE: When is a claim a standard claim?
Kepa: I cannot believe that Congress or HHS intended for ALL claims to be
denied if one was "bad"--the "Business of Health Care" would slow down to
unbelievable porportions! Payers will accept the claims, and deny the bad
one!! That's the only LOGICAL action!
Carolyn Price
-----Original Message-----
From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]]
Sent: Monday, July 22, 2002 7:01 AM
To: William J. Kammerer; [EMAIL PROTECTED]
Subject: Re: When is a claim a standard claim?
William,
When a provider sends 3,654 claims, and one of them is bad... I don't think
the providers are going to agree with the idea that it is OK to reject all
of
them because the one bad claim in the file. If the other 3,653 claims are
HIPAA compliant, can the payer refuse them? Isn't the payer required to
conduct the standard transactions?
Here is where the world of EDI and the world of business collide. It may be
an invalid 837 because it is tainted by a bad claim... but is that what was
intended when the Secretary adopted the 837?
Kepa
On Sunday 21 July 2002 10:32 am, William J. Kammerer wrote:
> May I suggest that this thread be moved to just one or the other of the
> WEDI/SNIP Business Issues or Transactions listserves? Cross-posting (on
> the WEDI/SNIP listserves) runs counter to Zon Owen's SNIP Listserv Usage
> & Etiquette Guidelines (2002-04-01) at
> http://www.mail-archive.com/business%40wedi.org/msg00311.html.
>
> A recipient *may* reject an entire 837 transaction set if even only one
> claim within is "tainted," but I doubt the law forbids more
> "fine-grained" rejection. As Kepa noted, many of the semantic issues
> may not be discovered until well into the back-end, long after the
> transaction set has been translated. It may be difficult to "rollback"
> thousands of correct "claims" within a single 837, for example, just
> because the 3654th claim had a semantic inconsistency of the type Ellen
> Falbowski mentioned: e.g., data from the CR1 Ambulance Transport
> Information segment is missing when the payer finally discovers, deep in
> the back-end, that an ambulance type Procedure Code was used.
>
> Since the 824 (004050X166) allows for selective rejection, the payer, if
> she prefers, could accept all but the erroneous claim (items), or all
> claims for the particular patient which contained the erroneous claim
> line item, or the entire 837 - depending on what floats her boat
> (technically and business-issue wise). The provider (or billing service
> or CH) would have no call to complain if the payer were to reject the
> entire 837 since it is, in effect, non-compliant; but at the same time,
> he certainly would not object to the selective rejection of erroneous
> claims - which obviously allows him to get paid for the clean claims,
> however.
>
> The payer is not refusing to accept the standard transaction - the most
> important part of the law, strongly emphasized throughout the TCS Rule.
> And the provider still has not been given an artificial incentive to not
> use the standard transaction, because he still hasn't gotten paid (for
> the one invalid claim) even if the payer adjudicates the remainder of
> the 837 (not because she is necessarily generous, but probably because
> it's actually simpler for her). Everyone's happy: why should the HIPAA
> Stasi get involved?
>
> William J. Kammerer
> Novannet, LLC.
> Columbus, US-OH 43221-3859
> +1 (614) 487-0320
>
> ----- Original Message -----
> From: "Rachel Foerster" <[EMAIL PROTECTED]>
> To: <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]>;
> <[EMAIL PROTECTED]>
> Sent: Saturday, 20 July, 2002 11:30 AM
> Subject: RE: When is a claim a standard claim?
>
> Ok Kepa....here's my take. Hopefully others will chime in.
>
> First, no where in the law or the regs is either the UB92 or HCFA-1500
> mentioned. Thus, I think we need to abandon thinking that DHHS was
> looking for an equivalent in another standard format. If DHHS just
> wanted a simple (!!!???) claim transaction, then why not just adopt
> these two formats and be done with it.
>
> Second, since DHHS adopted the X12 837 "transaction set" as the
> standard, I would have to assume (I know...that's a risky thing to
> do!!!) that it did so knowing that the 837 is actually a container for
> one or more claims.
>
> Thus, if any portion of what's in the container fails compliance, the
> entire container is "tainted" as you say and must be rejected. This is
> the position I've maintained for quite some time and I still believe
> it's the appropriate way to go. For example, if the 837 container holds
> only one claim that fails compliance, the entire 837 must be rejected -
> container and all. The same would be true for a 270 containing inquiries
> for multiple individuals, and also the 276 and a 278. I don't think we
> can have one rule for the 837 transaction set and a different one for
> the others. Furthermore, it's my opinion that any covered entity
> conducting a non-complying transaction is subject to penalties under the
> law, there needs to be much more black/white decision points (after all,
> computers only think in terms of on/off, true/false) that can then be
> embodied in program logic. It's all of this interpretative stuff that
> causing all the heartburn now as it is.
>
> Rachel
> RFA, Ltd.
>
>
>
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