NJ SHORE September 25, 2003 HIPAA Transactions

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NJ SHORE September 25, 2003HIPAA Transactions
YouVendor Panel

• Pat Hewitt
• Siemens Medical Solutions
• Siemens Confidential

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Objectives

• Provider Readiness Status
• Siemens Readiness Initiatives Status
• Challenges
• Recommendations

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Providers are Ready

• We received our first remittance within two
  weeks of submitting our first live claim to
  Medicaid, said Peter Courtway, CIO, Danbury
  Hospital. Our claims were adjudicated as
  expected and the entire process was smooth and
  seamless. Quicker payment on those claims means
  major improvements to our revenue cycle, so were
  pleased to be up and running ahead of the game.
• Hartford hasnt experienced one denied claim
  since we went into production with the 837, adds
  John Matakaetis, Director of Patient Accounting,
  Hartford Healthcare.
• Receiving payment so quickly is almost a miracle
  in this line of work, adds Donna Small, MSO
  Systems Administrator at Health First. We have
  some very happy people around here and its
  nice to see the fruits of our collective labor
  paying off with such positive outcomes.

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Agenda

• Data Gap Analysis
• Remediation
• Testing
• Implementation

We're All in This Together!!
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Data Gap Analysis (DGA)

• The Claim DGA, Two pre-requisites
• Comprehensive understanding of how your current
  processes work that provide data to and support
  your billing process
• Comprehensive understanding of the relevant
  Implementation Guides 837I 837P
• Purpose of each transaction
• How each transaction works
• Required situational data elements
• Required code sets/values

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Data Gap Analysis

• The DGA Identifies
• New required situational data elements based on
  the services you provide (continues after 10/16)
• Current processing flow gaps
• Identification of NEW workflows, procedures,
  and/or data collection processes
• Masterfile changes (new code sets, charge master
  changes)
• System set up requirements decision tables,
  master files, billing options

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Data Gap Analysis

• About Payer Companion Guides
• Most Companion Guides are available now. They
  contain
• Additional Payer specific requirements
• Edits that will ease claims adjudication with
  that payer
• Additional Payer billing instructions
• All their requirements must conform to the
  National Guides they cant require anything
  beyond the National Guides and they cant reject
  a claim if it has more data than they want.

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Data Gap Analysis

• Deliverables
• A customized spreadsheet identifying if/how you
  currently populate required and situational
  fields, which fields, based on your business, you
  will need to populate and how these will need to
  be set up to bill properly
• A Remediation Plan identifying the specific work
  that will be needed to build HIPAA compliant
  claims
• Average time to complete a DGA for either the
  837I or 837P is between two and three weeks

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Agenda

• Data Gap Analysis
• Remediation
• Testing
• Implementation

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Remediation

• Remediation is the work of addressing your data
  gaps
• Set up new, needed data elements in the system
• Implement procedures for capturing the data,
  including identifying where data will be captured
  and training staff to obtain and enter new data
• Master file changes
• System set up based on payer Companion Guides

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Agenda

• Data Gap Analysis
• Remediation
• Testing
• Implementation

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Testing

• Status
• Most providers appear to be either testing 837
  transactions internally or externally with third
  party testing tools, clearinghouses or with
  payers
• Certification Agency testing a good idea if
  Payers arent ready when you are.
• Providers that have used third party testing
  tools and have done DGA appear to be further
  along in the process

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Prepare for Testing

• Create Test Plans and prepare for testing
• Identify business functions and billing scenarios
• Understand Payer requirements (volume, scenarios,
  real or test data)
• Create test patients or identify accounts for
  re-bill
• Success in prep work will reduce rework in
  testing phase
• If using your Test system make every effort to
  Simulate Productiondecision tables, master
  files, patient data
• Document all Test system changes made while
  testing
• Plan to update Production with all Test system
  updates

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Testing Options

• Through Testing Certification Organization
• Through HIS Vendor
• Through Claims Clearinghouse
• Directly to Payer

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Vendor Initiatives
HIPAA Support

• HIPAA Central (1Q00) HIPAA Central-Customers
  Only (4Q00)
• HIPAA Readiness National Kickoff w/CMS, BCBSA
  (3Q00)
• Statement of Direction, HIPAA U (1Q00, ongoing)
• Planning bulletins, Customer memos (4Q99,
  ongoing)
• HIPAA Security Summit (4Q99), Seminars (1Q00),
  Webcasts (4Q00, ongoing)
• Transaction support Claredi Certified (2Q02,
  ongoing)
• Successful customer/payer tests (4Q02, ongoing)

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Vendor Initiatives
HIPAA Support

• HIPAA Ask The eXperts RadioShow
• Payer Testing Status Updates
• HIPAA Readiness Executive Briefing Kit (
  Website)
• Product-specific Readiness Report Cards
• Product-specific Readiness Checklists
• Customer Success Bulletins
• "Putting it all Together" Transactions Workshops
• Refreshed HIPAA Central
• HIPAA ExcelerateTM (including payer testing
  help!!!)

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Agenda

• Data Gap Analysis
• Remediation
• Testing
• Implementation

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Implementation

• Cutover and Review acceptance/rejection reports
• Re-adjust process, system decision tables
• Divide and conquer
• CMS Guidance on Compliance

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Implementation
Contingency Planning

• CMS Guidance, Complaint driven process (dont
  tell, dont ask)
• Trading partner mutually agreeable solutions,
  okay for transition
• Must finish the transition
• Contingency plans to ensure payment during
  transition are okay
• Demonstrate Good Faith efforts you will need
  evidence
• Testing with some trading partners
• Implementation with some trading partners
• Testing and Certification evidence
• Testing payer requirements in absence of direct
  payer testing
• Third party testing can accelerate implementation
  - show due diligence
• Certification will reduce testing requirements
  with many payers
• Be prepared to run dual solutions, best approach
  least impact
• Claims 837 and Legacy formats e.g. NSF, 1500,
  UB92

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Implementation

• Our Best Guesses about Oct. 16, 2003
• Very few payers will have more than 837s, 835s
  and 270/271 supported day 1. There are lots and
  lots of transactions
• Some Medicaids will still rely on local codes and
  may require current processes for some time after
  October 16.
• Payers will be committed to paying every claim
  possible even if its not completely compliant.
• Cash flow impact minimized if you are making
  good faith efforts!

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Siemens Status

• Claims837P, 837I, COB GA
• Claims Dental GA
• Claim Status TBD
• Remittance GA
• Eligibility GA
• Referrals Authorizations GA

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