First - I do not recommend that WEDI or WEDI-SNIP
take a position on who pays the costs. I think this is either market driven
(through education, and over time) or something HHS, CMS should
address.
Second - I encourage you to think outside the old provider must
validate/certify box! I am a provider. Before a payer sends me their first 835,
or 271, or 277 etc I want them to prove to me they validated it with a TPT
against types 1-7. This saves both of us TIME and MONEY.
Thinking along
this line might help us determine who should pay for the claim testing. As a
provider I could require it for all payers - then I think I should pay
for it. I can request it of all payers - hoping they agree and thinking
they should pay for it. OR I can decide payer by payer depending on my
past experience with them and their ability to produce compliant transactions -
and negotiate who pays in each case - and also include in this decision on how
we handled the payment of the TPT for my transactions 837, 270, 276,
etc...
I think the bottom line is that we want this industry to get on
the same page. It saves all of us time and money to validate our own outgoing
transactions. I would hope it is such a good idea that any entity would be
willing to perform validation and pay for it themselves. I am not a big
fan of having payers trying to tell me to go to many different vendors to
validate. This would not be administrative simplification or cost savings to
this industry.
Patrice Thaler
Allina Hospitals and
Clinics
-----Original Message-----
From: Susan
Hollabaugh [mailto:[EMAIL PROTECTED]]
Sent:
Tuesday, June 10, 2003 6:33 AM
To: WEDI SNIP Testing Subworkgroup
List
Subject: RE: Meeting Minutes - 5/22/2003 -- who pays cost of
testing
I think the bigger issue is when payors require that
providers test with a
specific TPT against their payer edits. If the model
outlined below (i.e. a
CE tests with the TPT of their choice until their
transaction is certified
then begin testing with another CE) is followed then
the costs are allocated
correctly (the CE producing the transaction pays.)It
also does create a cost
savings for the CE so this would be a value add. If,
however, a provider
tests with a TPT and the transaction is certified on
levels 1-6 but not 7
and it is because the level 7 edits were not available
to the TPT at that
time (for whatever reason,) can the payer require the
provider to re-test
with the TPT? or even worse, require the provider to
re-test with a
different TPT? What cost savings does that give to a provider?
This is
actually not just a cost shift but a work shift, in other words,
nothing is
any different for the provider than always. They still have to
test their
entire transaction set(s) with a large variety of players. The
fees paid to
the TPTs are the smaller cost, it is the resources used to do
the testing
that are the significant expense.
-Susan
-----Original
Message-----
From: Kepa Zubeldia [mailto:[EMAIL PROTECTED]]
Sent:
Tuesday, June 10, 2003 1:37 AM
To: WEDI SNIP Testing Subworkgroup
List
Subject: Re: Meeting Minutes - 5/22/2003 -- who pays cost of
testing
This is an interesting thread and I hope that throwing in my
$.02 will not
generate too many flames.
There are several issues to
consider.
One issue is the difference between trading partner testing and
EDI
compliance
testing. The SNIP white paper recommends that EDI
compliance testing be
completed before trading partner testing starts.
Doing so is for the
benefit
of the covered entity that is testing its own
EDI compliance, and once EDI
compliance testing is complete, further testing
with trading partners is
much
simplified.
When using trading
partner testing in lieu of EDI compliance testing you are
making a
choice. Trading partner testing is, by definition, trading
partner
specific. Most likely it is not portable from one trading
partner to
another. So, a provider that chooses to use trading partner
testing with
payers, without having completed EDI compliance testing first,
is likely to
have to repeat the testing from scratch with each
payer.
Of course, if the provider's EDI compliance testing also includes
a
component
of testing against multiple simultaneous payer specific EDI
companion guides
under one testing umbrella, instead of having to repeat
the entire EDI
testing with each trading partner from scratch, then they get
the best of
both worlds. But that train of though would deviate from the core
of the
discussion, so I will focus back on the problem.
The second
issue is cost shifting. The cost shifting of the EDI testing
occurs in
both directions. Let me explain...
In some cases the providers
expect the payers to provide some sort of "free"
EDI testing as they have
done in the past. In other cases the providers
want
to make sure
their EDI systems are compliant independent of one specific
payer. In some
cases the payers desire to provide a "free" EDI testing
service to their
providers. In other cases the payer does not want to pay
for the
provider's EDI compliance testing. In some cases the payers do not
want
to become the EDI trainers for the providers. In some cases they
do.
In some cases the providers are sending test files that do not meet
basic
X12
syntax requirements. In other cases their files are very
clean and doing
further payer testing is simple, easy, and effective.
In some cases the
providers expect the payers to tell them what to do and how
to fix the EDI
problems. In some cases the payers do not have the
resources to do this. In
other cases they do. In some cases the
payer specifies one payer specific
testing service and pays for it. In
other cases the payer specifies one EDI
compliance verification service
before starting the trading partner testing
and does not pay for it. In
other cases the payer specifies more than one
EDI testing or compliance
service and may or may not pay for it. In some
cases the provider
prefers to test with multiple payers from scratch. In
other cases the
provider prefers compliance testing prior to trading
partner
testing. In some cases the provider can spell HIPAA, WEDI,
SNIP and X12.
In
other cases the provider cannot spell them.
As you
can tell from my tongue in cheek list, there are many tensions and
a
multitude of reasons why the cost shifting is happening. Cost
shifting is,
in theory, unfair. Some times the cost is shifted to the
payer. Other
times
it is shifted to the provider. If there was
no cost shifting, everybody
would pay the share of the resources they
consume. But reality is, cost
shifting is part of the nature of
business. Market forces drive it.
Take the clearinghouse as an
example. Today, most clearinghouses are
looking
at being Business
Associates of both providers and payers. But, are the
costs allocated
proportionately to the services being rendered for each
party? And, I
don't mean to pick on clearinghouses. Ask a smoker and a
non-smoker
what they think about the cigarette taxes and you will get two
different
answers. Cost shifting is common business practice in
free
markets.
Having said all this, is SNIP about to put a response in
the DSMO server
saying that cost shifting in a certain direction is more or
less fair than
in
another direction? Is SNIP about to stick its neck
and say that a certain
kind of cost shifting is not allowed? Or, is
SNIP going to say that a
certain class of trading partner (e.g. payer) should
bear the burden of
testing all the other (e.g. provider) trading
partners?
I doubt it.
But, never say never...
Kepa
Zubeldia
Claredi
On Monday 09 June 2003 09:41 pm,
Marcallee Jackson wrote:
>
> I'm going to cross-post this message to
the BI SWG because this question
> involves issues that are related to
both testing and business decisions.
> For those who are new to this
message string, the topic being discussed
was
> submitted to the Issues
Database. The question is, can a payer require an
> entity to test
and certify through a particular third party tester (TPT)
> (against 1 - 6
HIPAA guidelines and/or their companion guides) and if so,
> are there any
caveats? I've copied the original question at the bottom of
> this
message along with some of the discussion that took place within the
>
Testing SWG.
>
> In the interest of disclosure, I'll say that
I was the individual who
> submitted this question to the Issues
Database. Thank you to the Testing
> SWG for their initial
discussion and response. When I posted this
> question, I was
most interested in the caveats. I think for the most
part,
>
we're all in agreement that a payer can require that a provider test and
>
certify with a TPT of the payer's choice, but I think there maybe
certain
> conditions to that. Chiefly, can the payer allow the
provider to incur
the
> cost for that testing
certification?
>
> I've discussed this issue with many people
now and I'd like to share some
of
> the main points that seem to come
up:
>
> 1. Transaction testing is just one of the tasks in the
implementation
> process. Completing trading partner agreements and
testing communications
> would be two others and there are likely to be
many more as well. If your
> answer to the question at hand is that
yes, a payer can use a TPT(or TPTs)
> of their choice for testing and
require (or not be concerned) that the
> provider pay for that
certification, then my question to you is - can they
> also outsource
other aspects of the implementation process and have the
> provider pay
for that as well?
>
> If one of the vendors who has a solution
for trading partner agreements
and
> enrollment forms, contracts with a
payer to manage the process of
completing
> those forms on the payer's
behalf and the payer requires that the provider
> now go to that vendor
and complete those forms before testing, can they
then
> charge the
provider for using that service? If the payer couldn't manage
> the
volume of communications testing, could they outsource that too
and
make
> the provider pay to test? No? Then why is
transaction testing any
> different? Many different options exist
for testing, both for the
provider
> and payer. Why should the
payer be allowed to force the provider to use
> their solution and also
pay for it?
>
> 2. A health plan can contract with a
clearinghouse to receive standard
> transactions on its behalf but cannot
cause the provider to incur fees or
> costs for that decision.
Presumably this requirement is meant to prevent
> payers from shifting the
cost (or a portion of the cost) of using a
> clearinghouse from themselves
over to the provider. Why would the authors
> of the Final Rule
prevent the payer from charging for the clearinghouse
but
> permit the
payer to outsource testing to a third party and then allow them
> to shift
the cost of that to the provider?
>
> 3. Often when answering
this question, folks are looking at the third
party
> testing market
and solutions as they exist today and not projecting into
the
>
future. When they think of this situation they seem to be thinking
that
the
> provider would only have to test with one TPT. But
providers who send
> direct might test with many payers. What
if a provider has 20 payers, 15
> of which require TPT certification and
between those 15 the provider had
to
> test with 7 different TPT
vendors who charged fees ranging from $50 -
$500?
>
>
>
4. Another thing folks seem to have in mind is that the cost would be
one
> time? What about when a provider initiates new transactions or
new
> connections? Might they have to pay again each
time?
>
> I do not believe the authors of the TCS Final Rule
intended to allow the
> payer to outsource the tasks involved in
exchanging standard transactions
> and then shift the cost of that
outsourcing over to the provider simply
> because the vendor they've
outsourced to doesn't meet the definition of a
> clearinghouse. In
fact, if the entity used for TPT was also a
clearinghouse
> the fee for
testing would not be allowed.
>
> Before we draft I
final response to this issue, I'd like to encourage more
>
discussion.
>
> Thanks for you attention to the
matter.
>
>
> Marcallee Jackson
> Director, Healthcare
Solutions
> Edifecs, Inc.
> (714)865-5059
>
www.edifecs.com
> www.hipaadesk.com
>
>
>
> From
the Testing SWG Minutes:
>
>
> 2) Issue from Issues
Database:
>
> The following issue was assigned to the Testing SWG
and was discussed
during
> the meeting -
>
> Can a health
plan require that an entity certify with a third party
testing
>
service in order for the entity to begin testing with a plan. If so,
can
the
> health plan require that certification be obtained from a
particular third
> party and if so, any caveats to that? Along these same
lines, can a health
> plan require that an entity certify against its
companion guidelines, with
a
> third party testing service in order for
the entity to begin testing with
a
> plan. If so, can the health plan
require that certification be obtained
from
> a particular third party?
Any caveats to these two items?
>
> This issue created a lot of
discussion. The HIPAA legislation or ASCA
does
> not mention
certification or verification so the issue is pretty much left
> up to the
formation of a best practice. The group agreed that requiring a
>
third party validation/certification would need to be detailed in
a
Trading
> Partner Agreement (TPA). If a health plan does
require this type of
> activity, they do have the right to require
>
a particular third party for this purpose because certain business level
>
editing would also probably be built into the software used by the third
>
party that was specific to that particular payer. Not all third
party
> vendors would have that specific editing functionality because
they had
not
> been working hand in hand with that specific health
plan. The bottom
line
> is that validation and/or
certification is not required by the HIPAA
> legislation although it is
recommended by the WEDI Testing white papers.
> Any requirement that is
outside of the scope of the HIPAA legislation
would
> need to be
documented and agreed upon in a Trading Partner
agreement.
>
>
> -----Original Message-----
> From:
Christopher Feahr [mailto:[EMAIL PROTECTED]]
> ubject:
Re: Meeting Minutes - 5/22/2003 -- cost of testing
>
> Dear Testing
Group,
> As a provider, I would consider "testing" and any
required
> "certification" to be components of the [necessary] process of
"setting
> up a connection" with my trading partner. The term
"enrollment" that is
> often used by payers or "communities" connotes the
true, lop-sided
> nature of the process, in which the provider "asks" to
be "enrolled" in
> the community and expects to be required to jump
through ALL of that
> community's enrollment hoops... including any
testing or certification
> hoops. All of this hoop-jumping is going
to cost the provider $ and
> would simply be part of his cost of setting
up and maintaining each
> trading partner relationship. I believe
that HIPAA is silent on the
> specific elements of a TP-agreement and is
also silent on how the costs
> [to both parties] of setting it up should
be divided.
>
> I would not expect many provider complaints about
enrollment costs,
> however... because only the most sophisticated
providers will even
> attempt to manage direct EDI connections.
Smaller providers who are not
> using DDE or dropping to paper will likely
be enrolling with ONE
> clearinghouse... effectively pushing their
"testing and certification"
> concerns onto the CH. If we do
experience such provider complaints,
> they will be handled case-by-case
anyway. So I think it's fine for the
> Testing white paper to remain
silent on the ideal/fairest way to parse
> enrollment
costs.
>
>
> ___________________
> From: "John Singer"
<[EMAIL PROTECTED]>
> To: "WEDI SNIP Testing Subworkgroup List"
<[EMAIL PROTECTED]>
>
>
> > Actually I
believe Ellen is correct. A payer cannot pass the cost of
> testing onto
the provider. If a payer designates a testing agency then
> the payer must
also pay for this especially if the testing agency is
> charging for the
testing of payer companion guides. Is there an attorney
> on this
listserve that has reviewed the regulation? I remember reading
> somewhere
that payers cannot pass costs to providers and clearinghouses.
>
>
> > John
> >
> > --
> >
> >
--------- Original Message ---------
> >
> > DATE: Wed, 28 May
2003 18:38:52
> > From: "Falbowski, Ellen"
<[EMAIL PROTECTED]>
> > >
> > >I have a couple
of comments on these minutes.
> > >1) Regarding the response to the
testing issue submitted to the
> issues > >database, I think that if
Party A requires Party B to use a
> particular
> > >third
party's software for validation, Party A should pick up Party
>
B's
> > >costs, if any, of using that third party's software.
However, if
> Party
> > >A allows Party B to choose the
validation software, Party A would not
> > >need to pay for the
validation costs.
> > >
> > >2) X12N/TG2/SPWG2 (the work
group that created the 824 Implementation
> > >Guide Reporting IG)
was notified at the February X12 meeting that
> > >X12N/TG3 would be
drafting a Type 1 Technical Report on which
> responses
> >
>to use when. Not sure of the status of that work.
> >
>
> > >-----Original Message-----
> > >From:
[EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
>
> >Sent: Wednesday, May 28, 2003 3:14 PM
> > >
> >
>Attendees:
> > >
> > >Brandi Wyatt - EDIFECS
>
> >Ed Hafner - Foresight
> > >Miriam Paramore - PCI
>
> >Kerry - EPIC Systems
> > >Lou Oliver - Advent
Software
> > >Patrick Edwards - Arkansas Blue Cross
> >
>Tim Collins - Kentucky Medicaid
> > >Dave Frankel -
EDIFEG
> > >Suzan Ryder - Empire Blue Cross Blue Shield
> >
>John Lilleston - Verizon
> > >
> > >Agenda
Items:
> > >
> > >1) Review of Washington D.C.
Conference:
> > >
> > > Ed
Hafner reported that the Testing breakout session went very
> >
>well. There were over 100 people in the room for the session and
over
> 40
> > >surveys were completed and returned to Ed after
the session. Brandi
> > >also said she overheard several
positive comments about the session
> > >after it was over. Many
people liked that we were presenting actual
> > >testing experiences
and statistics but some felt that there was not
> > >enough time
provided in the session to allow the attendees to digest
> the
>
> >information and ask questions.
> > >
> >
>2) Issue from Issues Database:
> > >
> >
> The following issue was assigned to the
Testing SWG and was
> > >discussed during the meeting -
> >
>
> > > Can a health plan require
that an entity
> > > certify with a third party testing
service
> > > in order for the entity to begin testing
> >
> with a plan. If so, can the health plan
> > > require that
certification be obtained from
> > > a particular third party and if
so, any
> > > caveats to that? Along these same lines, can
>
> > a health plan require that an entity certify
> > > against
its companion guidelines, with a
> > > third party testing service
in order for the
> > > entity to begin testing with a plan. If
so,
> > > can the health plan require that
> > >
certification be obtained from a particular
> > > third party? Any
caveats to these two items?
> > >
> >
> This issue created a lot of discussion.
The HIPAA legislation
> or
> > >ASCA does not mention
certification or verification so the issue is
> > >pretty much left
up to the formation of a best practice. The group
> > >agreed
that requiring a third party validation/certification would
> need
>
> >to be detailed in a Trading Partner Agreement (TPA). If a
health
> plan
> > >does require this type of activity, they do
have the right to require
> a
> > >particular third party for
this purpose because certain business
> level
> > >editing
would also probably be built into the software used by the
> third
>
> >party that was specific to that particular payer. Not all
third
> party
> > >vendors would have that specific editing
functionality because they
> had
> > >not been working hand in
hand with that specific health plan. The
> > >bottom line is
that validation and/or certification is not required
> by
> >
>the HIPAA legislation although it is recommended by the WEDI Testing
>
> >white papers. Any requirement that is outside of the scope of
the
> HIPAA
> > >legislation would need to be documented and
agreed upon in a Trading
> > >Partner agreement.
> >
>
> > >Please review the verbiage above as we would like to draft
a final
> > >response to this issue during the next meeting and
enter it on the
> SNIP
> > >website.
> > >
>
> >4) Next Steps for Testing SWG:
> > >
> >
> Sue and John had discussed a couple of topics
that the Testing
> SWG
> > >may want to undertake as our next
steps. One idea was to develop a
> > >white
> >
>paper as to business scenarios when the 997, TA1, 824, etc.
>
transactions
> > >would be used. Also, document the advantages
and disadvantages of
> using
> > >standard transactions versus
proprietary ones until the standards are
> > >mandated.
> >
>
> > >Brandi Wyatt also came up with another testing idea and
will document
> > >that idea to the group prior to the next
meeting. We will devote an
> > >agenda item to this subject
for the next meeting and try to make some
> > >decisions as a
group.
> > >
> > >Thanks!!
> > >
>
> >____________________________________________
> > >John D.
Lilleston
> > >Section Manager - Healthcare EDI
> >
>Verizon Information Technologies, Inc.
> > >Phone -
(813)979-3225
> > >Fax - (813)978-5570
> >
>[EMAIL PROTECTED]
> > >www.VerizonIT.com
> >
>____________________________________________
---
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and do not necessarily represent the views of the WEDI Board of Directors nor
WEDI SNIP. If you wish to receive an official opinion, post your question to the
WEDI SNIP Issues Database at http://snip.wedi.org/tracking/.
These listservs should not be used for commercial marketing purposes or
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- RE: Meeting Minutes - 5/22/2003 -- who pays cos... Susan Hollabaugh
- FW: Meeting Minutes - 5/22/2003 -- who pay... <[EMAIL PROTECTED]>
- FW: Meeting Minutes - 5/22/2003 -- who pay... Marcallee Jackson
- RE: Meeting Minutes - 5/22/2003 -- who pay... Larry Watkins
- RE: Meeting Minutes - 5/22/2003 -- who pay... Marcallee Jackson
- RE: Meeting Minutes - 5/22/2003 -- who pay... Marcallee Jackson
- RE: Meeting Minutes - 5/22/2003 -- who pay... Herb Larsen
