To my knowledge, the operative for the trading partner decisions is not the
IGs. It is the Privacy Rule and the security NPRM (and expected security
rule).
These have caused our lawyers to decide that we need agreements with our
direct trading partners - the clearinghouses, billing services and direct
submit providers, as well as with the ultimate business partners - the
providers.
I agree with other comments that it might be better if providers and payers
were communicating directly. That is my ultimate vision with the Internet,
encryption, NPI and National PayerID - as long as we can find that illusive
database for the information (general and encrytpion keys).
Until then, we have to find our path through this muck.
So for now, I see the sender as the entity that creates the ISA, and the
receiver as the one that opens the ISA.
I suggest that we include in the discussions all of the functions that the
sender and receiver IDs in the ISA can fulfill, or enhance. We should at
least identify those functions and state their inclusion or exclusion from
the conclusions of the final document. (too many 'clusion's there - sorry)
Bob
"Rachel
Foerster" To: <[EMAIL PROTECTED]>
<[EMAIL PROTECTED] cc:
tcom.com> Subject: RE: Time-out for terminology
question(s)
01/25/2002
03:55 PM
Please respond
to rachelf
Bob,
I think you've made some very interesting observations vis a vis an
agreement between provider and payer. But, I would suspect that if your
legal counsel requires that an agreement be in place between a payer and
its
providers before they do business, couldn't this be construed as a network
provider agreement that are typically employed today? I would suspect that
payers do not do business with all "comers" without first agreeing to the
rules of engagement.
If in fact, the industry does coalesce around establishing such an
agreement
between each provider and the payers to whom they submit claims, this could
in fact help solve of the addressing issues in the ISA, since in that case,
the provider would then be the originator of the business transaction,
regardless of the format at the point of origination. Clearinghouses would
then clearly become intermediaries in the actual exchange of business
transactions between the provider and the payer. This whole issue of
trading partner agreements is also fraught with ambiguity, inconsistency,
and uncertainty, and the HIPAA IG's don't really serve to clear any of that
up. But, if in fact, your opinion that HIPAA will end up forcing agreements
between each provider and its payers, then the questions about who should
be
identified on the ISA becomes moot.
A separate agreement relative to the 835 makes sense for a lot of reasons,
not the lease of which is that in many cases, the provider may wish to
receive payment electronically, in which case the financial institution
gets
involved. As you no doubt know, in the early 1990's the Science and
Technology Division of the American Bar Association developed two model EDI
trading partner agreements: one addressing EDI transaction exchanges in
general and the other specific to electronic payments. These two model
agreements contained extensive commentary useful to an organization's legal
counsel. I would certainly recommend that these two model agreements be
examined as a potential starting point.
On the other hand, I do wish to point out that when the federal government,
most notably the Department of Defense, went full bore into EDI in the
early
to mid 1990's they initially required that each supplier to the government
execute an EDI trading partner agreement. This was a huge failure and in
fact, became a major barrier for getting the hundreds of thousands of
suppliers willing to engage in EDI with the feds. Within 6 months the feds
abandoned the requirement for an EDI trading partner agreement. Other
industries also recognized the barrier an EDI trading partner agreement
became when trying to establish EDI information exchanges. So, I would just
urge health care to not rush into a business model that clearly didn't work
for other industries, including our beloved federal government, without
fully examining and understanding the impact and issues that will
result....this is a prime example of beware of unintended results!
Rachel Foerster
Rachel Foerster & Associates, Ltd.
Phone: 847-872-8070
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Friday, January 25, 2002 1:10 PM
To: [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Subject: RE: Time-out for terminology question(s)
Rachel,
Our legal area is not on the same page with the people that say we can do
business without an agreement between the provider and the payer. In fact,
this is a topic that has had EXTENSIVE debate here. The reigning opinion
is that HIPAA will be forcing all payers toward agreements with the
provider, not eliminate them.
What I (and others) have been advocating here is that there is a need for
only two authorizations from the provider. One as a general trading partner
to cover legal and other issues for all transactions except the 835, and a
separate contact for authorization for the 835 (this does not necessarily
mean a hardcopy document). There are people (legal types mostly) that want
separate authorization for each transaction.
An initial authorization is necessary to start the relationship. That will
include an agreement and reference guide that identifies all items about
the payer that are allowed by section 1.1.1 of the HIPAA guides. At that
point, all of the HIPAA transactions to date except the 835 are provider
initiated. If the provider sends 837s, then the provider wants to do
claims. So, once the electronic relationship is setup, the use of the
transaction identifies the request to use the transaction.
The 835 is payer initiated, but only at the request of the provider. To
send it out automatically would not be appropriate. The provider can even
want the 835 without sending an 837, so we don't have any 'trigger' except
the provider's request for the 835. Since the 835 route to the provider is
not a given (it could be a bank that does dollars to data reconciliation
for the provider), only the provider can tell the payer where the 835
should be sent.
Bob
"Rachel
Foerster" To: <[EMAIL PROTECTED]>
<[EMAIL PROTECTED] cc:
tcom.com> Subject: RE: Time-out for
terminology question(s)
01/25/2002
12:11 PM
Please respond
to rachelf
Bob,
I agree. But does this need only belong to the 835 transaction. One could
make this assumption based on other messages to this list that the provider
doesn't get that directly involved with the payer for claims submissions. I
find it difficult to assert that the provider and payer must interact
directly for the 835 but then stay at arm's length for claims and other
HIPAA transactions. This doesn't hang together from an overall process
basis.
So, a question to be answered is the relationship between the provider and
the payer when exchanging HIPAA transactions - the IG's are focused only
very narrowly on a discrete information exchange and the entire process
doesn't seem to be addressed appropriately.
In my opinion, this whole effort is crying for a good process analysis
effort rather than just discrete and disjointed message exchanges.
Rachel
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
Sent: Friday, January 25, 2002 7:25 AM
To: [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Subject: RE: Time-out for terminology question(s)
There are additional issues with the 835.
HIPAA does not link the 835 with the 837. A provider can ask for the 835
without sending electronic claims.
Providers sometimes send claims through multiple routes. They can even
want to the 835 to return through a different route (like a bank). The
payer must be told when a provider wants an 835 and which route to use.
Sending information down the wrong route can be a privacy problem.
To keep it short - there is NO substitute for provider to payer
communications for the 835.
Bob
Dave Minch
<dave.minch@jm To: [EMAIL PROTECTED]
mdhs.com> cc: [EMAIL PROTECTED]
Subject: RE: Time-out for
terminology question(s)
01/24/2002
06:43 PM
William,
I would guess that, following the pattern that appears to be present for
claim submission which i just finished commenting on, routing of the 835 or
277 would not depend so much on the ISA sender as it would on the 1000A
submitter. The 1000B receiver would have to have my "first-hop" address to
put into the ISA to respond to me.
If that is true, does it imply that i actually need to have a TPA with
every
payer i send information to? (yuck..!!) or if I use a CH, is it their job
to
update the next hop's routing tables (same question that you just asked),
and so forth until the payer's routing tables are eventually updated with
my
submitter id & route information? How does it work today when the paths
are:
Claim: provider ---> prov's CH ---> payer's CH ---> payer
Remittance: payer ---> prov's CH ---> provider (note the omission
of the
payer's CH)
Dave Minch
T&CS Project Manager
John Muir / Mt. Diablo Health System
Walnut Creek, CA
(925) 941-2240
