Slide 0 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Slide 1 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Chapter 8 Electronic Data Interchange: Transactions and Security

Slide 2 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Learning Objectives  Summarize HIPAA requirements for electronic claims.  Identify the transactions and code sets to use for insurance claims transmission.  Create a successful insurance claim for submission and reimbursement.  List HIPAA compliance guidelines for electronic protected health information.  Describe necessary components when adopting a practice management system.  Explain the difference between carrier- direct and clearinghouse electronically transmitted claims.

Slide 3 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Learning Objectives (cont’d.)  State measures used to secure privacy of electronic mail, Internet, and instant messaging.  Describe the use of patient encounter forms, crib sheets, and scannable encounter forms in electronic claims submission.  List computer transmission problems that can occur.  Name some types of interactive computer transactions.

Slide 4 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Chapter 8 Lesson 8.1

Slide 5 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Electronic Data Interchange (EDI)  Used for transmission of health insurance claims  Transmitted data is encrypted  Improves efficiency of claims submissions

Slide 6 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Advantages of Electronic Claim Submission  No signatures or stamps  No searching for an insurance carrier’s address  No postage costs or trips to post office  No need to store or file claim forms  Electronic claims leave an audit trail  Improved cash flow  Quicker processing time and payment  Reduced overhead and labor costs

Slide 7 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Clearinghouses  Claims are checked electronically  Claims with missing/incorrect information are rejected  Rejected claims are sent back to the provider with a report  Batches of acceptable claims are sent to the appropriate payer  Corrected claims are reprocessed

Slide 8 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Advantages of a Clearinghouse  Translation of various formats to the HIPAA-compliant standard format  Reduction in time of claims preparation  Cost-effective method through loss prevention  Fewer claims rejections  Fewer delays in processing and quicker response time  More accurate coding with claims edits  Consistent reimbursement

Slide 9 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. HIPAA Transaction and Code Set (TCS) Benefits  More reliable and timely processing  Improved data accuracy  Easier and more efficient information access  Better tracking of transactions  Reduction of data entry/manual labor  Reduction of office expenses

Slide 10 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. HIPAA Required Code and Data Sets  ICD-9-CM codes  CPT-4 codes  CDT codes  NDC codes  ICD-10-CM/ICD-10-PCS codes  Taxonomy codes  Patient account number  Relationship to patient  Facility code value  Patient signature source code

Slide 11 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Electronic Formats  Specialist authorization  Reimbursement claims  Request and respond to additional information  Health care claims/attachments/claims status  Coordination of benefits  Health care payment and remittance advice  Plan enrollment/disenrollment/eligibility  Premium payments  Referrals  First report of injury

Slide 12 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Standard Unique Identifiers  Standard unique employer identifier  Standard unique health care provider identifier  Standard unique health plan identifier  Standard unique patient identifier

Slide 13 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Practice Management System  Should be able to prepare, send, receive, and process HIPAA standard electronic transactions  Can help track receipt of Notice of Privacy Practices (NPP), patient treatment consents or authorization, and mapping disclosures

Slide 14 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. HIPAA-Ready PMS  Set security access to patient files in the software  Indicate date of receipt and signing of NPP  Insert date of patient’s authorization  Maintain files of practice’s authorization and notification forms  Track requests for amendments, restrictions on disclosure of PHI, and physician response to request  Track expiration dates

Slide 15 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Encounter or Multipurpose Billing Forms  Also called charge slip, multipurpose billing form, patient service slip, routing form, super bill, transaction slip  Customized to meet the needs of the health care office  May include preprinted procedural or diagnostic codes  Scannable encounter forms save time

Slide 16 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. DO: Use the patient account numbers to differentiate between patients with similar names. DO: Use correct numeric locations of service codes, current, valid CPT or HCPCS procedures codes DO: Print an insurance billing worksheet or perform a front-end edit to look for and correct all errors before the claim is transmitted to the third-party payer. DO: Request electronic-error reports from the third-party payer to make corrections to the system. DO: Obtain and cross-check the electronic status report against all claims transmitted. DON’T: Use special characters. DON’T: Bill codes using modifiers -21 or -22 electronically unless the carrier receives documents to justify more payment. Do’s and Don’ts for Keying Insurance Data for Claims Submission

Slide 17 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Encoder  Signature requirements  Physician  Patient

Slide 18 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Clean Electronic Claims Submission  Claim scrubber software  Encoder software  Electronic clearinghouse  Single and batch claims review

Slide 19 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Chapter 8 Lesson 8.2

Slide 20 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Interactive Transactions  Back-and-forth communication between two computer systems  Real time communication allows instant information transfer  Electronic funds transfer (EFT) can speed up reimbursement

Slide 21 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Electronic Remittance Advice (ERA)  ERA: Online transaction about the status of a claim  Medicare ERA  formerly called Medicare explanation of benefits (EOMB or EOB)  based on American National Standards Institute (ANSI) Accredited Standards Committee X12 (ASC X12) Health Care Claim Payment/Advice (835) or ANSI 835

Slide 22 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Procedures for Claim Transmission 1. Set up the database. 2. Enter data. 3. Batch or compile a group of claims. 4. Connect the computerized database with the clearinghouse or direct to the payer. 5. Transmit the claims. 6. Review the clearinghouse reports.

Slide 23 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Methods for Sending Claims  Cable modem  Digital subscriber line (DSL)  T-1  Direct data entry (DDE)  Application service provider (ASP)

Slide 24 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Computer Claims Systems  Carrier-direct  The medical practice has its own computer and software to process claims.  The insurer sometimes leases a dedicated terminal to the physician.  Clearinghouse  The doctor’s office sends paper claims or a disk or tape to the clearinghouse, which forwards a batch of claims to the insurer.

Slide 25 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Transmission Reports  Send and receive files reports  Scrubber report  Transaction transmission summary  Rejection analysis report  Electronic inquiry or claims status review

Slide 26 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Administrative Simplification Enforcement Tool (ASET)  Online tool  Assists health care providers, payers, clearinghouses, and others to submit complaints regarding the HIPAA TCS rule

Slide 27 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. The Security Rule: Administrative, Physical, and Technical Safeguards  Administrative safeguards  information access controls  internal audits  risk analysis and management  termination procedures  Technical safeguards  access controls  audit controls  automatic log-offs  use of passwords

Slide 28 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. The Security Rule (cont.)  Physical safeguards  media and equipment controls  physical access controls  secure workstation

Slide 29 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Computer Security Prevention Measures  Use software that stores files in coded form  Never leave disks or tapes unguarded  Use a privacy filter on the computer monitor  Log off computer before leaving work station  Double-check credentials of all consultants  Read equipment manuals, especially “Security Controls” information, and follow all directions  Store confidential data on diskettes or “zip” disks, not the hard drive  Store all diskettes in a locked, secure location  Use firewall and antivirus software  Develop passwords for all computer users  Use only account numbers in

Slide 30 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Records Management  Data storage: back up data frequently  Electronic power protection: surge suppressors or uninterruptible power supply (UPS)

Slide 31 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Selection of an Office Computer System  Cost of basic equipment—purchase or lease?  Accessories  Space requirements  Electrical/transmission lines  Separate fax and modem lines?  Costs of electricity  Telephone lines  Maintenance  Software