We have actually made a decision within the
Testing SWG that we will not take a position on who pays the costs, for reasons
already stated on the listserv.
Larry Watkins
Executive Vice President
Claredi Corporation
Office: 801-444-0339 x204
Fax: 770-419-5295
Mobile: 678-463-0885
Email: [EMAIL PROTECTED]
-----Original Message-----
From: [EMAIL PROTECTED]
[mailto:[EMAIL PROTECTED]
Sent: Tuesday, June 10, 2003 1:26
PM
To: WEDI SNIP Testing Subworkgroup
List
Subject: RE: Meeting Minutes -
5/22/2003 -- who pays cost of testing
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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discussions on this listserv therefore represent the views of the individual
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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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