Hubert H. Humphrey Building
Room 705A
200 Independence Avenue, SW
Washington, D.C. 20201
I’d like to open by thanking the committee for this opportunity to share some of our experiences related to HIPAA administrative simplification. As you know from the introductions I come from a clearinghouse background. I have worked in the clearinghouse industry for more than 13 years and have been involved in developing both institutional and professional EDI interfaces.
The electronic HCFA-1500 (NSF) and UB-92 standard formats that are already in use today are both easy to understand and widely implemented. The proposed ruling allowing 24 months to convert the nations health care EDI pipeline from one format to another is an overwhelming task.
The proposed standards are extremely complex and costly to implement. Like other X12 standards, many of the lists of valid values come from sets of codes used by other industries for other purposes. Several X12 data elements have ambiguous and overlapping code values for the same concepts. Use or modification of codes for health care purposes may require the approval of another industry. This has already happened and cannot always be resolved.
A two-year implementation schedule may indeed rush several payers to clearinghouses for isolation from compliance issues. Once reliant upon a clearinghouse for translation, payers in particular may put at risk the vision of HIPAA by leaving legacy systems untouched and too far removed from the data reporting capabilities of the new and evolving standards.
We have been assisting facilities in the completion of HIPAA compliance questionnaires. The questionnaires have been coming from a variety of sources. The questionnaires ask details about formats and EDI standards, which the providers do not understand. The catchall answer is “clearinghouse.” Providers have also requested language in our contracts stating that we will maintain HIPAA compliance. This is difficult to address since there isn’t a consensus on what “compliance” is or will be. The term “compliance” is also confused by its use in the language of both HIPPA and the HCFA Correct Coding Initiative.
The committee has already discussed issues regarding the Local Use Codes. What we have experienced is variances in national code implementation. For example, HCPC codes are updated each year and are valid effective January 1 through December 31. One state Medicaid program we work with implements the same national codes with valid effective dates July 1st through June 30th. Similarly this year, commercial payers implemented HCPC 2000 according to the national standard while HCFA allowed the use of an overlapping 1999 and 2000 code set until April. The reason for the exception is irrelevant, the point is, there have always been and will continue to be exceptions. Be it code sets or optional data segments, the X12 can allow payers to implement various interpretations while still maintaining adherence to the standard.
The flexibility of the X12 is magnificent. The complexities of X12 make it a two-edged sword. Very few payers support the latest version of the 837 claim. The payers that do support the 837 claim have few trading partners submitting data in that format. As long as it isn’t required we, like others, have opted not to use it. Programmers can typically develop a payer interface in the current NSF or UB92 standard in less than 6 hours. The 837 equivalent of these formats has taken roughly four times that effort. The X12 formats are time consuming to read and difficult to modify. It isn’t cost effective to spend time coding an X12 format that is likely to require reprogramming once the final rule is published and payers begin to implement their interpretation of the standard.
Which raises my final point on implementation. The entire process is payer driven. If payers take 20 months to implement channels for receiving HIPAA compliant transactions, then the rest of the industry has only 4 months to comply. We are at the back of the line. Experience shows that payers appear to be in a “wait and see” mode right now. Until the final rule is published and the implementation guidelines released, there is little opportunity for early implementation.
Despite the obstacles I have outlined today, I strongly support the X12 transaction formats as the standard for healthcare EDI. The sharp learning curve will level off and the flexibility of open standards will provide the interoperability pay off in the long run. The one issue, based on experiences so far, is that I believe a 24-month industry wide implementation schedule is unrealistic. Rushing to implement a standard that will itself change to support the exceptions encountered along the way will only risk the legitimate and obtainable goals of HIPAA.
Payers should not be forced to toss out legacy systems, overhaul EDI methodologies or call on a clearinghouse. Ideally, payers would be given 24-months to convert at least 20% of their existing EDI transactions to the X12 formats. Those payers not currently accepting EDI transactions would be required to implement X12 within 24-months. Even the small payers should be able to accomplish this. The payers with existing EDI channels should be allowed to support both standards while phasing out the old. Payers can decide for themselves the most cost effective way to achieve this goal. The industry as a whole should be given an additional 24 months to convert to the X12 formats.
This would provide a more equitable amount of time for implementation among all trading partners, allow for a more stable implementation of the new standard and bring us as close as possible to 100% compliance nationwide in four years.