Payer – Provider Interoperability Issues Created by the HIPAA Administrative Simplification Provisions MEDINF 405-DL Dave Robbins

Provider-Payer Administrative Provision Transactions Payment and Remittance Claims and Encounters Claim Status and Inquiry Code Sets HCPCS CPT-4 ICD-9 Identifiers Providers Employers Patients

Goals Not Reached Redundancy Limited evidence of ROI Limited Efficiency Compliance Costs

Problem 1: Lack of Business Rules Standards Defined Without Business Rules Payers Published Standalone Companion Guides with Unique Interpretations Little or No Net Reduction in Complexity

Problem 2: Complex Systems Environment Mergers and Acquisitions Legacy Systems Commingled With Modern Systems Peripheral Systems

Problem 3: Missing Pieces Provider Identifier 12 Years for Implementation Employer Identifier Patient Identifier Failed

Possible Solutions Regional Cooperatives NEHEN Health Plan Cooperatives Availity United Health

Conclusion Preferred Solution: Federally Responsibility Medicare Claims Management Policy HIPAA Transaction Clarification Solve Unique Patient Identifier Problem