Y'all!
This is not a case of what someone thinks is "common sense", or what any of
us think "they" should have meant.
The Rule states:
Section 162.925 makes it clear that a health plan may not offer an
incentive for a health care provider to conduct a transaction covered by
this part under the direct data entry exception.
(4) A health plan may not offer an incentive for a health care
provider
to conduct a transaction covered by this part as a transaction
described under the exception provided for in � 162.923(b).
They also may not provide incentives that will discourage (i.e., adversely
affect) the use of standard transactions.
Marsha
Verizon Information Technologies Inc.
Managed Care Division
Phoenix, AZ
HOME OF THE WORLD CHAMPION ARIZONA DIAMONDBACKS
Phone - 602.678.6042
Fax - 602.678.6331
E-mail - [EMAIL PROTECTED]
Confidentiality Notice: This e-mail message, including any attachments, is
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"Todd Leeders"
<tleeders@claimtempsol To: <[EMAIL PROTECTED]>,
<[EMAIL PROTECTED]>,
utions.com> <[EMAIL PROTECTED]>,
<[EMAIL PROTECTED]>
cc:
06/24/02 09:23 AM Subject: RE: Online Authorization
/ Referrals
Please respond to
transactions
So we all agree, incentives from the payor to the provider should be
allowed.
Especially if you think about it in the following light. Industry experts
estimate it costs a payor $5-$15 to take a paper bill and turn it into a
check. If a provider uses edi correctly, these costs are brought down to
maybe $1 per successful EDI submission.
In fact, I beleive there are payor sponsored programs at least in
California
that allow the payor to pick up the $0.25 EDI Clearinghouse Costs on behalf
of the providers. Doesn't this count as an incentive program?
-----Original Message-----
From: Mimi Hart [mailto:[EMAIL PROTECTED]]
Sent: Monday, June 24, 2002 8:46 AM
To: [EMAIL PROTECTED]; [EMAIL PROTECTED];
[EMAIL PROTECTED]; [EMAIL PROTECTED]
Subject: RE: Online Authorization / Referrals
I am not Martin, but I believe there are times we agree..and I will
provide a "provider" side view of this issue...
In my personal opinion, if as a Provider, I upgrade my technology
appopriately, after entering patient demographic/clinical data once, I
should be able to push "send"..and a real time/batch
authorization/referral request will be sent to ANY payer I have taken
the time to set up EDI technical specs with..and their answer should
come back to me real time/batch - directly into my app, without retyping
it...
If I use a payers proprietary front end....be it web or otherwise..I
must "type in or do a search of somekind"...taking me out of my
app..then, once the response is received...I must enter it into my
app...you are talking at least three entries of data vs one the "HIPAA
compliant" way...
So why would I use their front end? Only if they provide
"incentive/disincentive"...only giving me a yes/no answer....not making
"enrollment" in their EDI system easy..or providing more information on
their proprietary system then they provide via EDI...all of which I
think are blurring the line..but which some may well do.......
Hope this helps..
Mimi Hart
Research Analyst, HIPAA
Iowa Health System
319-369-7767 (phone)
319-369-8365 (fax)
319-490-0637 (pager)
[EMAIL PROTECTED]
>>> "Todd Leeders" <[EMAIL PROTECTED]> 06/20/02 02:15PM
>>>
Martin,
I'm very new to the industry, in that I am returning to it after 8
years of
being away, so please excuse the simpleton inquiries. I do however
possess
15+ years of IT Experience, so feel free to be technical in your
response.
Simpleton Inquiry:
Regarding the "You must not give incentives of any kind to make
partners use
Inet Solutions".
If one of the end in mind goals of Administration Simplification via
Inet &
EDI solutions is to lower the overall cost of health insurance and the
provision of health services. Why would "government" prohibit a payor
form
incenting a provider?
Taking a common sense approach there are only two ways to get a
provider to
use such a system and lower overall industry costs:
1. Payor or Government (Incentives)
2. Government Non-Compliance (Punishment)
If you have insight into the reasoning, would you please pass it
along?
Sincerely,
Todd Leeders
-----Original Message-----
From: Martin Scholl [mailto:[EMAIL PROTECTED]]
Sent: Thursday, June 20, 2002 10:45 AM
To: Scott Barley; [EMAIL PROTECTED]
Subject: Re: Online Authorization / Referrals
NO,
You don't have to convert to X12. but.....
1.) you have to provide and process the same data content that the
standard
transaction has
2.) you still have to provide a standard system, even though your
internet
solution may be faster, more elegant and well appreciated.
3.) You must not give incentives of any kind to make your partners use
the
Internet solution over the standard one.
Hope this helps
Martin Scholl
Scholl Consulting Group, Inc.
301-924-5537 Tel
301-570-0139 Fax
[EMAIL PROTECTED]
www.SchollConsulting.com
----- Original Message -----
From: "Scott Barley" <[EMAIL PROTECTED]>
To: <[EMAIL PROTECTED]>
Sent: Thursday, June 20, 2002 11:17 AM
Subject: Online Authorization / Referrals
> Question:
>
> A payor is providing an internet based product to their providers for
the
> submission of referral/authorization requests directly into the
payor's
> system. The provider manually enters a request for an authorization
within
> the web application and the info is inserted directly into the
database
from
> the web application. Since this is an extension to the payor's
system
> application and is not a system to system transaction, is their any
need
to
> convert to ANSI 278 before placing into the system?
>
>
> Thanks in advance for any info on this!
>
> Scott Barley
>
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the views of the WEDI Board of Directors nor WEDI SNIP. If you wish to receive an
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