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

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

1 IMPLEMENTING THE HIPAA TRANSACTIONS AND CODE SETS Presentation to the Coalition of Voluntary Mental Health Agencies April 30, 2002 Prepared By: Robert Belfort Kalkines, Arky, Zall & Bernstein LLP 1675 Broadway, Suite 2700 New York, New York (212)

2 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, WHAT DO THE RULES MANDATE? Covered entities conducting any of the HIPAA transactions electronically must use standardized formats and codes.

3 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Claims submission or encounter data u Verification of health plan eligibility u Pre-certification and authorization of referrals u Claims status u Claims payment and remittance advice u Coordination of benefits u Plan enrollment and disenrollment u Premium payments WHAT ARE THE HIPAA TRANSACTIONS? Health plans only

4 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, Claim submission Claim payment Claim status inquiry Claim status response Request for authorization Approval or denial Eligibility inquiry Eligibility response TRANSACTION FLOW CHART Provider Billing Pre-authorization Eligibility Health Plan Payment Pre-authorization Eligibility

5 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, Claim submissionANSI X12N 837 Claim payment835 Claim status inquiry276 Claim status response277 Request for referral/pre-authorization278 Response to referral/pre-authorization request278 Eligibility inquiry270 Eligibility response271 ANSI TRANSACTION FORMATS

6 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, MEDICAL CODE SETS Code Type of Service Code Set Administrator Physician servicesCPT-4American Medical Association Diagnosis and hospital inpatient servicesICD-9-CMCenter for Medicare and Medicaid Services Other health-related services HCFA Common Procedure Center for Medicare and (e.g., DME, labs, pharmacy) Coding System (HCPCS)Medicaid Services Dental servicesCode on Dental ProceduresAmerican Dental Association Procedures and Nomedature

7 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, STATUS OF IDENTIFIERS Date Rule ProposedFinalizedComments Provider IdentifierNovember 3, 1999Final rule delayed due to lack of funding Employer IdentifierJune 16, 1998Final rule pending Health Plan IdentifierRule under development Patient IdentifierSuspended due to privacy concerns

8 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u New versions u Modifications by DSMOs u 180-day notice period MODIFICATION OF STANDARDS

9 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Cannot use non-standard format even if both parties agree u No local codes u Maximum data set u Compliance by business associates u No cost or time impediments u Non-electronic transactions still permitted KEY ELEMENTS OF TRANSACTION RULES

10 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u A provider under Section 1861(s) or (u) of the Social Security Act u “Any other person or organization who furnishes, bills or is paid for health care in the normal course of business” u “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?

11 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, Electronic Non-Electronic InternetFax ExtranetTelephone Leased linesMail 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

12 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Increased labor costs u Claims payment lag u Demands by payors u Medicare electronic billing requirement CAN YOU AVOID ELECTRONIC TRANSACTIONS?

13 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Effective October 16, 2003 u Exception for “small providers ” –facilities –other providers MEDICARE ELECTRONIC BILLING REQUIREMENT 25 FTEs 10 FTEs

14 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u $100 per violation u $25,000 per year cap per violation u You won’t get paid!! PENALTIES FOR NON-COMPLIANCE

15 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u October 16, 2002 u ASCA delay until October 16, 2003 COMPLIANCE DATE

16 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Option to delay to October 16, 2003 u Must file compliance plan by October 15, 2002 u Must begin testing by April 16, 2003 u Medicare exclusion penalty KEY FEATURES OF ASCA

17 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Description of covered entity u Reason for extension u Implementation budget u Submission options u Electronic form at ELEMENTS OF ASCA COMPLIANCE PLAN

18 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Status of your remediation efforts u Readiness of your software or billing vendor u Readiness of your trading partners u Medicare and Medicaid seeking extension SHOULD YOU FILE FOR AN EXTENSION?

19 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Education u Gap analysis u Remediation u Testing u Training FIVE STAGES OF HIPAA COMPLIANCE (Theoretical)

20 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Denial u Anger u Grief u Acceptance u Hope FIVE STAGES OF HIPAA COMPLIANCE (Actual)

21 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Oversight by senior management u Coordination by CIO or IT staff u Participation by affected departments –Scheduling –Registration –Coding –Clinical –Billing –Accounts receivable BUILDING THE COMPLIANCE TEAM

22 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, ESTABLISING A COMPLIANCE TIMELINE Education Gap Analysis Remediation Testing Training April 2002December 2002April, 2003October

23 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, PERFORMING A GAP ANALYSIS High Moderate Low STAFF RESOURCES LowModerateHigh COST Internal Staff Commercial Self-Assessment Tool On-Site Consultant

24 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Which transactions do you conduct electronically now? u Which transactions would you like to conduct electronically in the future? u Priority considerations –continuity –complexity –ROI –vendor readiness –partner readiness DEFINING THE SCOPE OF COMPLIANCE

25 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Download ANSI implementation guide at u Prepare HCFA 1500-ANSI 837 crosswalk (see afehct.org/aspire.asp) u Compare data elements and codes GAP ANALYSIS OF CLAIMS SUBMISSION

26 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, FORMAT GAPS VS. CONTENT GAPS Format GapsContent Gaps Coding changes Missing data elements Different field sizes Different syntax Remedied by changeRemedied by change in business in technologyprocesses/data capture

27 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Billing company/clearinghouse u Commercial software package u Home grown system CURRENT ELECTRONIC BILLING MECHANISM

28 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Will HIPAA-complaint upgrade be issued? u What is timetable? u Is there a cost? u Will it be tested before distribution? u Will it be certified by a third party? u What training and support will be provided? u How will further upgrades be handled? QUESTIONS FOR SOFTWARE VENDORS

29 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Size and financial stability of company u Portion of revenues from health care industry u Level of HIPAA compliance resources u Status of HIPAA compliance efforts u Contractual commitment to future upgrades SELECTING A NEW SOFTWARE VENDOR

30 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Will the billing company function as a clearinghouse or subcontract out this function? u Who is in charge of HIPAA compliance? u When will the company be HIPAA compliant? u When will the company be ready to test? u Has the company discussed testing with payors? u Will the company seek third party certification of compliance? BILLING COMPANY ISSUES

31 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Medicaid upgrading EMEVS in 2003 u Some HMOs using Internet-based systems u Significant ROI potential OTHER TRANSACTIONS

32 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, 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  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

33 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Prepare list of trading partners u Obtain HIPAA compliance status report and timeline u Monitor compliance with timeline u Test transactions (April 16, 2003 ASCA target) u Execute trading partner agreements COORDINATION AND TESTING

34 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, Yes No TRADING PARTNER AGREEMENTS u Mechanism for connectivity u Responsibility for telecommunication costs u Use of codes not yet specified u Size limitations on batch transactions u Change definition, data condition or use of data u Add data elements or segments to maximum defined data set u Use any code or data elements marked “not used” u Change meaning or intent of implementation specifications

35 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, NYS MEDICAID TIMELINE In-house testing External Testing Upgrade of PACES Direct electronic interface Late 2002 Spring 2003 Late 2003/Early 2004?? 2005??

36 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, u Data capture u Data processing EMPLOYEE TRAINING

37 K ALKINES, A RKY, Z ALL & B ERNSTEIN LLP  HIPAA Compliance Presentation – April 30, HELPFUL WEB SITES ppt


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