Posting this to Testing since I don't believe Leah is part of our List
-----Original Message-----
From: Leah Hole-Curry [mailto:[EMAIL PROTECTED]]
Sent: Wednesday, June 11, 2003 9:38 AM
To: WEDI Business Issues Subworkgroup List
Subject: RE: who pays cost of testing
Marcallee,
In my opinion, even though folks seem to view this as "just the way the
industry works", indeed there is a HIPAA compliance issue.
HIPAA Admin. Simp., in part is the government's response to the fact
that the industry itself could not agree to make changes to move toward
standardization (e.g. the status quo is being changed by mandate). So
it is a dangerous argument to make that cost shifting is status quo and
therefore OK in the post- HIPAA world, when in fact HIPAA does much to
change the status-quo. This is especially true for health plans because
the transactions rules do (attempt to) change the balance of power
relating to transactions, including a plan's cost-shifting. (E.g.
health plans may not require a provider to use DDE, health plans must
have capacity to accept all transactions in EDI format, health plans
cannot pass on its clearinghouse fees to providers, health plans must
accept all valid data elements, even if they don't need them, etc.).
These additional transaction requirements are for plans only.
I'm surprised that the debate so far has failed to consider one of these
key additional requirements for health plans. "A health plan may not
delay or reject a transaction, or attempt to adversely affect the other
entity or the transaction, because the transaction is a standard
transaction." 162.925(a)(2). This constitutes a broad prohibition on
health plan activities as it relates to how plans process standard
transactions. CMS has unfortunately not released details on how this
provision will be interpreted and enforced. However, given some of the
testing scenarios you raise, it is quite plausible that CMS will use
this provision to prohibit certain, and especially egregious,
cost-shifting (for testing as well as perhaps other transactions related
out-sourced activity) by health plans.
There are several different criteria (that I can think of off the top of
my head) that need to be considered:
(a) Comparison of the testing costs and process for electronic
"enrollment" before HIPAA and after HIPAA (this is the basic test CMS
indicated it would use to determine whether a plan violated this
provision with respect to levels of service).
(b) If the plan will have other methods to accept transactions, what
is the cost and process to submit via other methods compared to the
HIPAA standard method.
(c) Does the cost or process of testing create a barrier for the
provider to conduct EDI transactions (e.g. is the plan adversely
affecting the entity because the entity is conducting or attempting to
conduct a standard transaction)?
While it is inevitable, and I am sure CMS contemplates that in this
massive transition there will be some delay and additional burden for
all parties, the question remains valid... how much cost should be borne
by each party, and in the case of plans and providers specifically, when
and how much, if any, cost shifting is acceptable vs. a violation?
Whether WEDI chooses to address this risk and provide some guidance or
not, it is in fact a compliance risk that payers need to consider
carefully.
Leah Hole-Curry, JD
FOX Systems, Inc.
602.708.1045
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>>> Marcallee Jackson <[EMAIL PROTECTED]> 06/09/03 20:43 PM >>>
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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The WEDI SNIP listserv to which you are subscribed is not moderated. The discussions on this listserv therefore represent the views of the individual participants, 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 discussion of specific vendor products and services. They also are not intended to be used as a forum for personal disagreements or unprofessional communication at any time.
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