Chris: I wasn't aware that there was an impasse or bottleneck preventing anyone from writing their working papers: I thought the reason we haven't seen anything yet is simply writer's "block." If you're referring to the "problem" of end-points being only payers or providers (or TPAs), I've already given out my opinion that I don't think that is much of a problem. Addressing Clearinghouses can easily be accommodated in our recommendations.
I'd go a step further, and say that supporting aggregation can be made a first-class feature of our CPP EDI Address function. Take an example: a sophisticated provider, like Dave Minch, wants to send standard claim transactions to 20 payers. He looks these payers up in the Healthcare CPP Registry, and finds that 10 of the payers are supported by the same clearinghouse, and that claims for any of the 10 are to be directed to the same "portal" resident at the clearinghouse. Normally, Dave could choose to build 10 interchanges, one for each of the payers, shunting them off to the designated CH portal seriatim. The CPP for an individual payer might even specify an alternate EDI ID to be used in the ISA receiver field - i.e., the proprietary CH-assigned payer ID. Now imagine this: the CPP for the Clearinghouse (which has been referred to by the payers' CPPs) says somehow in the Delivery Channel for claims that claims can be "aggregated," with a special Receiver ID to be used. This could be of benefit to both Dave and the Clearinghouse: Dave now can "aggregate," or combine, the claims for all 10 payers (as described previously by Bob Poiesz) into one standard 837. Maybe there's some obscure advantage to Dave in doing this - as if he'd run out of incremented transaction set control numbers otherwise; I don't know - but it's Dave's option to do this as no one is forcing the provider to perform aggregation. The CH receives Dave's aggregated 837, and assuming it's HIPAA-compliant, can then proceed to split and merge, combining other providers' claims (for the same payer) into consolidated 837s for each of the payers. Apparently, some payers find this to be a big advantage in having multiple providers' claims all munged together in the same 837. In any event, there's nothing that keeps our recommendations from elegantly supporting such "requirements." I'm very "patient" with your "rambling" and "protracted" discussions, as I hope others are: sometimes after reading a ramble, ideas - sometimes unrelated to the original rant - start to jell, leading to breakthroughs. William J. Kammerer Novannet, LLC. +1 (614) 487-0320 ----- Original Message ----- From: "Christopher J. Feahr, OD" <[EMAIL PROTECTED]> To: "William J. Kammerer" <[EMAIL PROTECTED]>; "WEDi/SNIP ID & Routing" <[EMAIL PROTECTED]> Sent: Monday, 15 April, 2002 12:37 PM Subject: Re: A proposed work plan for this group William (and group) I certainly do not want our group to "exclude" anyone's business needs. I agree with other commentors that CHs and VANS will not only be major players for the foreseeable future, but given the nearly non-existent EDI capability of small providers, our CHs and VANs would seem to represent the only way we will even get HIPAA airborne. NEVERTHELESS... HIPAA is a regulation primarily about providers exchanging information with payors. HIPAA addresses the middleman facilitators because they are THERE. Few doctors and insurance companies, however, really want to be in the "EDI business"... most payors and providers appear to want to offload this headache to an AGENT and/or Special Software. Until CPA negotiation and EDI become trivial/transparent, we are going to need a robust layer of "EDI facilitator" businesses to make it all work. Twenty years from now, we will still see massive doctor disinterest in how this "EDI crap" works! Once solid standards are implemented, it's reasonable to expect the big, sophisticated communicators (payors... with actual IT departments) to begin managing their own EDI. Doctors, however, will (we hope) still be primarily interested in medicine... and will always need massive support for B-B communication. The way I see it... far from being on the verge of extinction, the "middleman" industry is likely to swell up over the next decade and SWALLOW up the IT needs of every little player in health care... even providers' "internal" IT needs. This discussion has shown that many communication and addressing models are in actual use today and some of them seem to conflict with "common sense" when applied to a theoretical "point to point" direct-communication model... something that needs to be defined, but is generally individual providers conversing with individual health plans. I think we all can agree that the "CH" or "VAN" industry will be seriously MUTATED over the next 2 or 3 years, and that dozens of variants of the "middleman" business model are likely to emerge in healthcare... mainly around newly-acknowledged PROVIDER needs. So my suggestion to focus our committee's recommendations and proposals on the "point to point" model was intended to give us a clear, common target to fire our recommendations at. I agree that these recommendations should and likely will be useful to CHs and VANs in the near term... ditto for anything resembling a central player-ID and address registry. Once we have agreed on the definition of the COMMUNICATION MODEL that we want our recommendations to support, I believe we will get past this bottleneck and be able to get to work on the papers. Please be patient with this "rambling" discussion. We seem to be close to consensus, but you cannot make something this big "simple"... no matter how much we all wish that it were. I'm actually impressed with this group's patience and willingness to tolerate this useful [if protracted] dialog. Thanks, -Chris Christopher J. Feahr, OD http://visiondatastandard.org [EMAIL PROTECTED] Cell/Pager: 707-529-2268
