Today providers who use a CH complete 3 - 5 TPA/Enrollment forms - Medicare, Medicaid, BCBS and Champus are payers that almost always require agreements. In my experience it takes an average of 2 - 3 weeks for a CH to receive completed paperwork from the provider and an additional 6 - 8 weeks for approval from the payer (though BCBS often approves in 2 - 3). It takes providers as long to complete their part of the enrollment paper work for these payers as it does for most to complete testing, implementation, training and full production for payers who don't require it. That's if the enrollment process goes well.
Many payers are very particular when it comes to their agreements. Some require the signature of every physician in a group (imagine that if you have 50+ physicians), most require a listing of every group number and provider ID, some require social security numbers, some that the agreement be sent in on a particular color of paper, others that only a particular color of ink may be used and most will reject the agreement for any error. Each agreement is proprietary. It often takes 2 or more attempts before the provider gets it right. The whole process is an incredible hassle. In other situations, the payer does not require a written agreement between the provider and payer but does require the CH to obtain authorization. This process, while still time consuming, is far easier than the one described above. I am strongly in support of TPA's combined with COT's and entered into only by the parties directly exchanging data. It also seems that some sort of power of attorney between the provider and CH should be sufficient to allow the CH to auto-enroll its clients with the payer, particularly for the simple exchange of data. More complicated data exchanges, such as EFT or split routing, may require a more manual process but those exchanges are not common today and not likely to be in the near future. I stress that the vast majority of payers today do not require any TPA or enrollment process between themselves and physicians who bill through a CH. These include payers such as Aetna, Cigna, United Healthcare, Coventry Healthcare, Humana and Prudential. I'd suggest we look at their current model and find ways to keep it. AFEHCT is very interested in this issue and I believe is also planning on a work group. Marcallee Jackson Long Beach, CA 562-438-6613 -----Original Message----- From: Ronald Bowron [mailto:[EMAIL PROTECTED]] Sent: Wednesday, February 20, 2002 7:33 AM To: [EMAIL PROTECTED] Subject: Re: Electronic Trading Partner Agreements William, I agree with your assessment that manual TPA's would render any automated routing methodology moot. I had previously raised the question as to why the TPA cannot be transitive like the COT? Better yet, why not combine the COT with the TPA? Then the COT/TPA assumes the Payer trusts the Clearinghouse or Repricer to ensure the validity of the Provider (Each CE carries the trust from the previous entity). Not being a legal person, I don't know if this would be advisable or not. There are Provider Credentialing services out there that will substantiate the licensing of an individual provider, as well. I believe the infrastructure exists today, although it is not coupled with the electronic transaction processing, and most likely not well supported by the electronic processing systems. If we could define the methodology for verifying the identity of a CE as part of the TPA process, then the TPA may be able to be automated. I've always advocated, if a manual processing works then consider automation. If it's broken and you automate - you exacerbate the problem 10,000 times more often. So, is the current manual TPA process working well enough that it is possible to introduce automation and standards? Have any of the larger payers moved to a Web Based TPA process? Would a notary model like Thawte (www.thawte.com) is using for certificates be acceptable, or overly complicated? So many questions, so little time. I believe Kepa has the appropriate approach to solving the lower level routing issues, but now we need to walk that back into the business process level and see what falls apart. If business requirements dictate a TPA between CE's before routing can occur, then we must address how TPA's can support our efforts to automate routing. Regards, Ronald Bowron
