This is a type of scenario that happens with out of network claims. With today's model there is no a way a CH can be connected to all potential payers. If you live in NY and have an emergency room visit in Seattle what are the chances the hospital CH has connections to a payer in NY? Unfortunately paper is the answer in these cases today. CH's may have to do 'interconnections' to find another CH that has an electronic connection to a particular payer. Dave Frenkel
-----Original Message----- From: Rachel Foerster [mailto:[EMAIL PROTECTED]] Sent: Monday, January 28, 2002 3:02 PM To: [EMAIL PROTECTED] Subject: RE: When is an EDI transaction not? Dave, I can't imagine this practice being valid once HIPAA kicks in. This practice, if it's fairly common, could really put a clearinghouse at risk, especially if they continue this practice but don't advise their customer (i.e., business associate) of it. This is a whole new issue that certainly should be part of the problem/requirement/solution effort of this group. Rachel -----Original Message----- From: Dave Minch [mailto:[EMAIL PROTECTED]] Sent: Monday, January 28, 2002 3:39 PM To: '[EMAIL PROTECTED]' Subject: When is an EDI transaction not? When your CH drops it to paper because they don't have the payer in their TP list.... William, What you have suggested has certainly not escaped our thought process here. While we would eventually like to exchange all of our transactions directly with the payers, the reality of the situation is rather blindingly obvious to those who care to look (and i'm quite frankly amazed at the number of people who should be looking that aren't...). We have created our "top 50" list of payers, which account for about 93% of our total volume, have sent them a questionnaire about 4 months ago, and are just now preparing to send to them RFIs regarding their EDI requirements. For the vast remainder we are certainly hoping to find a VAN willing to take them on, and will be preparing an RFP to that effect in the spring. We presently use 5 different clearing houses for our gov't and commercial claims, and have no idea how many secondary CHs and VANs get into the act now, because the "first-hop" CHs shield us from that information (not that we've asked, which we haven't). The other interesting fact that I learned late last week is that one CH that we use drops many of the "electronic" bills to paper and mails them when we send to a payer not in their database (that should fly well with the HIPAA auditors...). I'm now trying to find out if that is a common practice with the others. With the privacy requirements looming, however, we've certainly got to become more careful, and that means for us a new business model that has many fewer hands playing with the transactions (both directions). I'm actually trying to determine whether or not we can bypass the CH / VAN and have all messages from the payers to us sent directly. It'll be part of the RFP when we get it ready. Dave Minch T&CS Project Manager John Muir / Mt. Diablo Health System Walnut Creek, CA (925) 941-2240
