Patricia, Matt, & Zon,
I agree with you that when a claim is sent to insurance company A and the claim is then processed and converted into electronic form and paid by Insurance company A, the provider may not be a covered entity based on that. (Except in Texas- my understanding is Texas legislated that any claim, whether on paper or electronic format, makes you a covered entity.) However, when that claim is a forwarded to insurance company B, all bets are off.
I reviewed the definition of a clearinghouse as stated by CMS and my understanding, as meager as it may be, is that any time an insurance company forwards a claim to a 2nd insurance carrier for processing, it is acting as a clearinghouse. Nowhere in the definition of clearinghouse does it rule out insurance companies of any kind.
The point I was trying to make is, as an example, Medicare acts like a clearinghouse when it forwards a claim, whether submitted to them on paper or electronically, to the 2nd insurance carrier for payment. Does it not? Any insurance carrier that forwards information, in electronic form, to a 2nd insurance carrier for processing of the claim, makes the provider a covered entity. The provider is waiting for 2nd insurance carrier to process the claim and receive payment. Medicare is not the only insurance carrier that forwards claims to a 2nd insurance carrier; it was just the most common example I could think of at this time that most offices could relate too.
"ASCA does NOT say that all CE-providers submitting Medicare claims must do so electronically. There are allowances for smaller providers, and there are many of those." ASCA however does require an approved waiver from the Secretary of HHS to send paper claims. I am patiently waiting for the waivers to be posted somewhere so I can get them out to my clients that want to continue submitting claims on paper. I am sure that since the Secretary of HHS must approve them, he will get right on it. Have I missed the application somewhere? Since there is a deadline of months between date of service and when a claim is submitted in order to be paid, when and where I get the waiver approved is an issue.
I made no reference to a claim being faxed to any insurance carrier in my earlier example. Just as a side note, according to conversation I had with a regional head of OCR, fax to fax is not a covered transaction but fax to computer is a covered transaction. The data is converted to electronic format by the receiver and/ or same applies to a computer generated fax. It is our understanding, the reason why, whether or not a computer is involved is an issue, is because of electronic theft, hacking, and recent theft of hard drives from institutions like Tricare in the Southwest where hundreds of thousands of military personnel and dependent personal information was stolen.
I still believe that all physicians should consider themselves covered entities and operate in that manner. With so many state legislatures and now case law approving HIPAA as "Standard of Care", (recent examples have been shared through Wedi Snip list serve), it makes business sense (cents) to be prepared. I have clients that do electronic claims submission and they did not think they were a covered entity. Boy did they have an eye opening experience. Now consider how many physicians out there, who may or may not realize things they are doing are considered covered transactions. That number scares me. These doctors are not getting the right information nor do they believe it affects them.
Thanks,
Susan Bowes
Professional Procedures & Control
Practice Consulting Firm for the Small Practioner
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