Ron, I would agree that a CH may drop an electronic claim it received from a provider to paper **only** if the provider is aware that this will occur, under what circumstances it will occur, and agrees to it. If the CH does not disclose its practice to do this, then I believe it is acting, at a minimum, unethically, and perhaps dishonestly....especially if the provider has a reasonable presumption to believe that the CH will retain the claim it received electronically in electronic form.
Rachel Foerster Rachel Foerster & Associates, Ltd. Phone: 847-872-8070 -----Original Message----- From: Ronald Bowron [mailto:[EMAIL PROTECTED]] Sent: Tuesday, January 29, 2002 6:15 AM To: [EMAIL PROTECTED] Subject: Re: When is an EDI transaction not? Rachel, Since according to the pre-able of the CRF 45 Page 50314, and example is given where "a health care provider may send an electronic health care claim or equivalant encounter information standard transaction for Patient A to health plan Z, and may send paper claim for Patient B to health plan Z." It then goes on and states on page 50315, "we interpret HIPAA to mean that a health plan cannot refuse to conduct a transaction because it is a standard transaction, we do not believe that use of the standard transactions can create a relationship or liability that does not exist." Therefore, when a CH prints a claim to paper on behalf of the provider, are they not acting as a BA (similar to a Billing agent) in this regard and therefore paper claims are permitted? (Assuming the TP defines the relationship as such and the Provider is informed of the means of deliver, electronic vs. paper?) -RB ----- Original Message ----- From: "Marcallee Jackson" <[EMAIL PROTECTED]> To: "David Frenkel" <[EMAIL PROTECTED]>; <[EMAIL PROTECTED]> Sent: Monday, January 28, 2002 7:17 PM Subject: RE: When is an EDI transaction not? > Today's CH's routinely trade claims with other CH's. In fact, it would not > be unusual for a CH not to trade claims with others. These so called > "gateway" agreements can be a significant source of revenue. I know of > several clearinghouses that can support a claim for a NY resident treated in > Seattle, if the payer uses a CH of any significant size. Out of network > claims do not necessarily have to be dropped to paper. Most health plans > today do not require provider enrollment or network participation in order > to receive electronic claims. As long as the CH has connectivity (directly > or through a gateway), providers are free to bill. > > Though dropping claims to paper is routine, in my experience its often done > as part of an "all payer" solution. This solution enables the provider to > send all claims to the CH. The CH sorts through the claims file, routes > those with a valid payer ID electronically and drops the rest to paper. The > cost averages from about .39 to .49 a claim. For most providers this is a > cost effective method of processing claims. Often providers send claims > that are missing payer ID's. As a value add service CH will drop these > claims to paper rather than reject them. When either service exists CH's > normally provide summary reporting back to the provider giving claim totals > by payer ID and indicating the number dropped to paper. It's important for > submitters to audit these reports periodically to ensure maximum EDI volume. > Few do. > > In the "good ol' days" CH's dropped claims to paper for "non-par" payers > (payers who do not pay for claims) in order to give the payer an incentive > to contract for services. The thinking was that if a CH could show a high > enough volume of paper, the payer would pay the CH to receive them > electronically. The advantage to the provider was that in the end, the > payer cost shared for EDI. This worked. But today's incentive more often > comes from matching payer listings of network providers against a CH's list > of submitters and showing the potential for volume. > > If you have a CH dropping claims to paper for a payer who they show they are > billing electronically, I would check your agreement for a possible > violation and ask for a refund. > > Marcallee Jackson > Long Beach, CA > 562-438-6613 > > > > -----Original Message----- > From: David Frenkel [mailto:[EMAIL PROTECTED]] > Sent: Monday, January 28, 2002 3:40 PM > To: [EMAIL PROTECTED] > Subject: RE: When is an EDI transaction not? > > > 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 > > >
