Dave, I think you have described the most sensible (and perfectly legal, as far as I can see) rollout scenario for the small providers. As attractive as this model is for the OMS vendor, however, I don't think very many of them realize that it's almost the ONLY option, other than putting EDI translator capability right on the doctor's desktop. I'm afraid that the majority of OMS vendors are assuming that if their existing software can produce NSF or a CMS1500 "print image", all they will have to do for HIPAA is have their doctor-customers contract with "a clearinghouse" to magically transform claims into the "HIPAA format". For eligibility transactions, doctors will simply be pointed to a website with some lame DDE implementation. I predict that payment advice will stay on paper for several more years... and if the doctor is dreaming about "auto-posting" payments to his accounts/receivable any time soon... fuggetaboutit.
Things are even worse in vision-land. The lack of suitable eyewear device codes actually has our software community and most payors in a state of near paralysis. OMS program development has ground to a virtual halt. At this moment, no one has a clue how to handle eyewear device claims under HIPAA... about 80% of the typical optometrists' claim volume. Wiring up X12 messaging ability for the remaining 20% of the claims that do fit the standard, will NOT be cost-effective for eye doctors in the short term... causing most of this "regular medical claim" traffic to drop back to paper... where the CMS 1500 standard works fine. Should be interesting! -Chris At 01:20 PM 4/12/02 -0700, Dave Minch wrote: >If, as Rachel has suggested, many of the payers are actually going to >contract with CHs as their "front door" for EDI (whether the CHs are >subsidiaries or otherwise), then that CH's identifier could, in fact, be the >identifier that the payer tells us (via the CPP or other manual method) to >place on the claim (in the ISA). It would be assumed, in that situation, >that the CH is acting on behalf of (is the agent for) the payer, and >therefor represents "the financially responsible party" in its dealings with >the provider. > >In that case, the CH would have specific arrangements with the payer (a >TPA), that could, in fact, specify conversion to a proprietary format (such >as NSF) for transfer of the claim to the payer. As long as the claim is >transferred from provider to the CH as an 837, the law is satisfied (as I >read it), because the CH would be operating as the payer's agent. > >This is also true in reverse for the providers. Some billing software will >be used by smaller providers to enter claims data, and will then transfer >that data to a central location in a proprietary format (say, a "flat print >image file"). The central location is the billing software's "hub" - just >another CH in our view, but one with a special relation to the provider - it >is the provider's "billing agent"). Again, the law is satisfied because the >CH is the agent of the provider, and it communicates to payers via the >mandated transaction set. One of the largest provider software suppliers in >the country is planning on doing just that as their "answer" to making the >software HIPAA compliant - and they are licking their chops at the millions >of $$ to be made sending all those claims on behalf of the provider in that >really difficult electronic format (and for only $.25 per claim - what a >deal...). > >Have I misinterpreted the regulations? Anyone want to bet that these won't >be the most common scenarios initially? > >Dave Minch >T&CS Project Manager >John Muir / Mt. Diablo Health System >Walnut Creek, CA >(925) 941-2240 Christopher J. Feahr, OD http://visiondatastandard.org [EMAIL PROTECTED] Cell/Pager: 707-529-2268
