4.06 HIPAA Transactions and Code Sets:

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4.06 HIPAA Transactions and Code Sets
Contingency Planning for the October 2003
Compliance Deadline

• Christine Stahlecker, Principal Consultant
• Computer Task Group Healthcare Solutions
• WEDI SNIP Co-Chair
• HL7 A-SIG Co-Chair

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Contingency Planning for the October 2003
Compliance Deadline

• Industry Readiness
• WEDI Request to HHS
• CMS on Enforcement
• Implementation Checklists
• Other Considerations On Contingency Planning

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Industry Readiness

• How can we really know?
• Self reporting from presenters tells us
• Payers are ready to test
• Vendors are looking for payers to test with
• Clearinghouses are certified
• Providers are waiting for the Addenda release
  from their vendors

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Industry ReadinessWEDI Conference

• The survey says
• Payers (48)
• Providers (21)
• Clearinghouses (6)
• Vendors (12)

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Industry ReadinessWEDI Conference

• A Certification group states current tests show
• Review of straight translation, 0 compliant
• With normal differential, content indicates
  testers are about 60 compliance
• Supplemental (Situational) data shows high
  variances within a batch
• Some payers claims are 96-98 good
• Other payers claims are 3-5 compliant
• Cannot know if the business rules are met until
  end-to-end testing is performed

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Industry ReadinessWEDI Conference

• From Empire BCBS,

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Industry ReadinessWEDI Conference

• From Empire BCBS
• Software and/or Vendors used by their trading
  partners are reportedly not ready
• Submitters who are good to go do not want to
  cut over yet
• Best Practice Recommendation be in production
  with both formats submitters manage their own
  transition by throttling back on UB92/1500,
  throttle up on 837.
• Submitter testing problems traced to starting to
  test before they fully understood and installed
  the Implementation Guides and Companion Guides
  requirements
• Be sure to test the most complex situations
  production problems when test data was limited

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Industry ReadinessWEDI Conference

• From a Clearinghouse,
• 60 of production claims are now on version 4010
• There are 1100 Payers not testing with all yet
• The scope of change was not just new content but
  holding current content to a tighter level
• The regulations were just finalized a few weeks
  ago (i.e., version 4010A)
• The detailed data gap analysis, payer by payer,
  is underway
• The number of clearinghouses that responded to
  the survey was low but their results were
  concerning as 67 reporting in at the early
  stages.

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WEDI Suggests 2 Alternatives to HHS

• Permitting compliant covered entities to utilize
  HIPAA TCS standard transactions that may not
  contain all required data content elements, if
  these transactions can otherwise be processed to
  completion by the receiving entity, until such
  time as compliance is achieved or penalties are
  assessed.
• Permitting compliant covered entities to
  establish a brief transition period to continue
  utilizing their current electronic transactions
  in lieu of reversion to paper transactions.

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WEDI Request to HHS

• WEDI respectfully requests that the Secretary
  provide guidance to the healthcare industry not
  only on these courses of action, but also on what
  is meant by the term compliance, the
  interpretation of which may provide some
  short-term transitional space for attaining a
  successful implementation of HIPAA TCS standards.
  WEDI also would like to emphasize the time
  sensitivity of its request for guidance, and
  respectfully requests that the Secretary provide
  such guidance to the industry within 60 days, by
  June 15, 2003. This timing is necessary for
  effective communication of such guidance to the
  healthcare community.

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AHA Request to CMS

• Adopt a System-wide implementation plan
• The Office of HIPAA Standards would require all
  health plans to maintain current claims
  processing volumes and cash flow cycles for each
  hospital
• No processing slow down after October 16
• End-to-End testing of transactions
• Hospitals are currently having difficulty getting
  health plans to commit to conducting end-to-end
  testing

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AHA Request to CMS

• Identification of Claim Deficiencies
• CMS should recommend the use of adjunct
  transactions to confirm the receipt of a
  transaction (e.g. the acknowledgement
  transaction)
• Any deficiencies in rejected claims should be
  specifically identified so that providers can
  correct and resubmit them timely
• Only deficient claims should be returned, not the
  entire batch remaining claims without
  deficiencies or errors should be processed

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CMS Enforcement

• CMS is getting started with enforcement in 2003
• Lori Davis is CMS Team Lead on Enforcement
• Reasonable differentiation equated to Hapless
  versus Willful non-compliance
• CME will provide Technical Assistance
• Enforcement protocols are yet to be published
  Request for Comments on the Prelude document
  (April 17 Fed Reg)
• Complaint driven enforcement initially
  ultimately market driven enforcement

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Checklist Questions - Payer

• What are your specific LOB requirements? Are
  there Companion Guides?
• Will multiple formats be allowed from a trading
  partner during the transition?
• How long will this dual-path capability be
  available on a need to use basis? Can a
  provider revert prior to October? after October
  2003?

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Checklist Questions - Payer

• Are there recommended phase in strategies?
• Do you offer test support (e.g. Help Desk)?
• Will the same telecommunication methods be used
  for all transactions?
• Are there new connectivity protocols available or
  required?
• If there are reports today affected by
  standardized code sets, will source databases be
  converted? How will they be tested and reviewed
  (e.g. clinical pathways, Decision Support,
  Formulary)?

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Checklist Questions - Provider

• Have you done a detailed data gap analysis (using
  the 4010A requirements) for each inbound and
  outbound transaction you will be performing?
• Have you resolved all source and destination data
  locations?
• Has each affected application vendor (Patient
  Reg, Clinical, HIM, Billing Office, Patient
  Accts, etc.) responded to your inquiry regarding
  their remediated software?

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Checklist Questions - Provider

• Do you have the latest software that was
  remediated for HIPAA version 4010A? Do you have
  unapplied updates that must preceed the HIPAA
  version?
• Has your vendor, clearinghouse, BA certified this
  version? If not certified, who have they tested
  with? Who supplied the data for these tests?
• Are the payers that your vendor tested with, the
  same payers that are important to you? Consider
  the various Lines Of Business.

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Checklist Questions - Provider

• Will your vendor, clearinghouse, BA
  enable/support your testing with payers? If not,
  are they guaranteeing reimbursement?
• Exactly what does the HIPAA compliant version NOT
  include? What are your options to implement these
  other transactions?
• Are there more releases or versions required from
  your vendor to supply all of the capabilities of
  the standard transactions (e.g. is COB included
  now or another release)?
• Have you established a HIPAA test environment,
  team, coordinator, plan?

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Checklist Questions - Vendor

• What version is your customer really using? Are
  backlogged updates required?
• What installation check are you requiring to
  assure upgrades are successfully installed?
• Have you certified your products?
• Are you recommending that your customers certify?
• Are you supporting your customers need to perform
  interface tests? Tests with their mission
  critical partners?

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Checklist Questions - Clearinghouse

• Are you testing with each Payer?
• Are you testing with each Provider?
• Are you testing with other Clearinghouses?
• How many must be tested How many have been
  tested?
• How long does each take? (Figure out if there
  will be a pathway for your claims).
• Are you supporting your customers need to test
  with their mission critical partners?
• What observations can you share with those
  yet-to-test from approaches taken that are
  successful?

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Best Practices

• Certify. Test with one of the certification
  services.
• Complete internal testing and certification
  before testing with your trading partner.
• Plan and prepare to test follow your plan.
• Using current production data is not sufficient.
• Use selective, specific Test cases
• Consider production parallel (if supported) to
  really be able to compare future results

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Best Practices

• Certification Facilitates Unit Testing of key
  Inputs and Outputs
• Unit Testing should focus on controlled test
  cases, scenarios and predicted results
• Unit Test is limited in the volume of
  transactions
• Certification Facilitates System Testing
• May be used to stress test with large volumes
  of transactions
• Certification Facilitates User Acceptance Testing
• Cases address Companion Guide edit criteria
• Certification Does Not Replace Provider-Payer
  testing

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Best Practices Considerations

• Hands off testing made available between CEs
• Use of production programs in test cycles for
  actual results
• Migrate the workload to new TCS rather than
  cut-over
• Business processes need to be addressed, it is
  not just the computer
• Streamlined error correction, not just the
  original submission
• Build test systems to last (internal thru
  external) we will need them annually
• Provider Identifier is expected next

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Cash Flow Brown-Out

• Even if youre on the right track, youll get run
  over if you just sit there.
• Will Rogers, Humorist
• Bad news early is good news. On early problem
  detection.
• Shamelessly stolen from Empire BCBS
• Assure yourselves know your performance
  baseline anticipate changes monitor closely

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Dependencies

• Dont be the weakest link
• Communicate openly, honestly, often
• Collaborate
• Failure will not be a singular event.
• We are in this together.

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4.06 HIPAA Transactions and Code Sets
Contingency Planning for the October 2003
Compliance Deadline

• Chris.Stahlecker_at_ctghs.com
• [phone] voice
• [phone] fax
• [phone] cell