IMPLEMENTING THE HIPAA TRANSACTIONS AND CODE SETS Presentation to the Coalition of Voluntary Mental Health Agencies April 30, 2002 Prepared By: Robert

IMPLEMENTING THE HIPAA TRANSACTIONS AND CODE SETS

Presentation to the Coalition of Voluntary

Mental Health Agencies

April 30, 2002

Prepared By:Robert BelfortKalkines, Arky, Zall & Bernstein LLP1675 Broadway, Suite 2700New York, New York 10019(212) [email protected]

KALKINES, ARKY, ZALL & BERNSTEIN LLP HIPAA Compliance Presentation – April 30, 2002

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WHAT DO THE RULES MANDATE?

Covered entitiesconducting any of the

HIPAA transactions electronicallymust use standardizedformats and codes.


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Claims submission or encounter data Verification of health plan eligibility Pre-certification and authorization of referrals Claims status Claims payment and remittance advice Coordination of benefits

Plan enrollment and disenrollment Premium payments

WHAT ARE THE HIPAA TRANSACTIONS?

Health plans only


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Claim submissionClaim paymentClaim status inquiryClaim status response

Request for authorizationApproval or denial

Eligibility inquiryEligibility response

TRANSACTION FLOW CHART

Provider

Billing

Pre-authorization

Eligibility

Health Plan

Payment

Pre-authorization

Eligibility


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Claim submission ANSI X12N 837

Claim payment 835

Claim status inquiry 276

Claim status response 277

Request for referral/pre-authorization 278

Response to referral/pre-authorization request 278

Eligibility inquiry 270

Eligibility response 271

ANSI TRANSACTION FORMATS


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MEDICAL CODE SETS

CodeType of Service Code Set Administrator

Physician services CPT-4 American Medical Association

Diagnosis and hospital inpatient services ICD-9-CM Center for Medicare andMedicaid Services

Other health-related services HCFA Common Procedure Center for Medicare and(e.g., DME, labs, pharmacy) Coding System (HCPCS) Medicaid Services

Dental services Code on Dental Procedures American Dental AssociationProcedures and Nomedature


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STATUS OF IDENTIFIERS

Date DateRule Proposed Finalized Comments

Provider Identifier November 3, 1999 Final rule delayed due tolack of funding

Employer Identifier June 16, 1998 Final rule pending

Health Plan Identifier Rule under development

Patient Identifier Suspended due toprivacy concerns


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New versions

Modifications by DSMOs

180-day notice period

MODIFICATION OF STANDARDS


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Cannot use non-standard format even if both parties agree

No local codes Maximum data set Compliance by business associates No cost or time impediments Non-electronic transactions still permitted

KEY ELEMENTS OF TRANSACTION RULES


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A provider under Section 1861(s) or (u) of the Social Security Act

“Any other person or organization who furnishes, bills or is paid for health care in the normal course of business”

“Health care” means care, counseling, service, assessment or procedures related to the physical or mental condition or functional status of an individual - includes case management

ARE YOU A HEALTH CARE PROVIDER?


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Electronic Non-Electronic

Internet Fax

Extranet Telephone

Leased lines Mail

Dial-up lines

Private networks

Tape or disk

Direct data entry*

Telephone voice response*

DO YOU CONDUCT ELECTRONIC TRANSACTIONS?

* Standard content required but not standard format


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Increased labor costs Claims payment lag Demands by payors Medicare electronic billing requirement

CAN YOU AVOID ELECTRONIC TRANSACTIONS?


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Effective October 16, 2003 Exception for “small providers ”

– facilities

– other providers

MEDICARE ELECTRONIC BILLING REQUIREMENT

25 FTEs

10 FTEs


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$100 per violation $25,000 per year cap per violation You won’t get paid!!

PENALTIES FOR NON-COMPLIANCE


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October 16, 2002 ASCA delay until October 16, 2003

COMPLIANCE DATE


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Option to delay to October 16, 2003 Must file compliance plan by October 15,

2002 Must begin testing by April 16, 2003 Medicare exclusion penalty

KEY FEATURES OF ASCA


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Description of covered entity Reason for extension Implementation budget Submission options Electronic form at

www.cms.gov/hipaa/hipaa2/ascaform.asp

ELEMENTS OF ASCA COMPLIANCE PLAN


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Status of your remediation efforts Readiness of your software or billing vendor Readiness of your trading partners Medicare and Medicaid seeking extension

SHOULD YOU FILE FOR AN EXTENSION?


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Education Gap analysis Remediation Testing Training

FIVE STAGES OF HIPAA COMPLIANCE(Theoretical)


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Denial Anger Grief Acceptance Hope

FIVE STAGES OF HIPAA COMPLIANCE(Actual)


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Oversight by senior management Coordination by CIO or IT staff Participation by affected departments

– Scheduling

– Registration

– Coding

– Clinical

– Billing

– Accounts receivable

BUILDING THE COMPLIANCE TEAM


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ESTABLISING A COMPLIANCE TIMELINE

Education

Gap Analysis

Remediation

Testing

Training

April 2002 December 2002 April, 2003 October 2003

248191


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PERFORMING A GAP ANALYSIS

High

Moderate

Low

STAFFRESOURCES

Low Moderate High COST

Internal Staff

Commercial Self-Assessment

Tool

On-Site Consultant


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Which transactions do you conduct electronically now?

Which transactions would you like to conduct electronically in the future?

Priority considerations– continuity

– complexity

– ROI

– vendor readiness

– partner readiness

DEFINING THE SCOPE OF COMPLIANCE


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Download ANSI implementation guide at www.wpc-edi.com

Prepare HCFA 1500-ANSI 837 crosswalk (see afehct.org/aspire.asp)

Compare data elements and codes

GAP ANALYSIS OF CLAIMS SUBMISSION


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FORMAT GAPS VS. CONTENT GAPS

Format Gaps Content Gaps

• Coding changes • Missing data elements

• Different field sizes

• Different syntax

Remedied by change Remedied by change in businessin technology processes/data capture


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Billing company/clearinghouse

Commercial software package

Home grown system

CURRENT ELECTRONIC BILLING MECHANISM


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Will HIPAA-complaint upgrade be issued? What is timetable? Is there a cost? Will it be tested before distribution? Will it be certified by a third party? What training and support will be provided? How will further upgrades be handled?

QUESTIONS FOR SOFTWARE VENDORS


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Size and financial stability of company

Portion of revenues from health care industry

Level of HIPAA compliance resources

Status of HIPAA compliance efforts

Contractual commitment to future upgrades

SELECTING A NEW SOFTWARE VENDOR


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Will the billing company function as a clearinghouse or subcontract out this function?

Who is in charge of HIPAA compliance?

When will the company be HIPAA compliant?

When will the company be ready to test?

Has the company discussed testing with payors?

Will the company seek third party certification of compliance?

BILLING COMPANY ISSUES


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Medicaid upgrading EMEVS in 2003 Some HMOs using Internet-based systems Significant ROI potential

OTHER TRANSACTIONS


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Remediation Option Pros Cons

Reprogramming Maintains system simplicity High up-front costs Maximum organizational control Need for ongoing revisions No per transaction fees

Translator Software Lower up-front costs Adds complexity to system Vendor responsible for Reliance on vendor for future upgrades future upgrades No per transaction fees

Clearinghouse No up-front costs Per transaction fees Vendor responsibility Maximum reliance on outside for compliance and upgrades entity

SYSTEM REMEDIATION OPTIONS


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Prepare list of trading partners

Obtain HIPAA compliance status report and timeline

Monitor compliance with timeline

Test transactions (April 16, 2003 ASCA target)

Execute trading partner agreements

COORDINATION AND TESTING


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Yes No

TRADING PARTNER AGREEMENTS

Mechanism for connectivity

Responsibility for telecommunication costs

Use of codes not yet specified

Size limitations on batch transactions

Change definition, data condition or use of data

Add data elements or segments to maximum defined data set

Use any code or data elements marked “not used”

Change meaning or intent of implementation specifications


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NYS MEDICAID TIMELINE

In-house testing

External Testing

Upgrade of PACES

Direct electronic interface

Late 2002

Spring 2003

Late 2003/Early 2004??

2005??


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Data capture

Data processing

EMPLOYEE TRAINING


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http://aspe.hhs.gov/admnsimp

www.wpc-edi.com/hipaa

www.wedi.org

www.afehct.org

www.ahima.org

HELPFUL WEB SITES

250527.ppt

Documents

IMPLEMENTING THE HIPAA TRANSACTIONS AND CODE SETS Presentation to the Coalition of Voluntary Mental Health Agencies April 30, 2002 Prepared By: Robert