Madame Chairman, Members of the Subcommittee: Thank you for the opportunity to offer a statement about this important concern.
My name is Pete Anderson. I am an Information Systems Director at United HealthCare Corporation. United HealthCare provides a full spectrum of resources and services to help people achieve improved health and well-being through all stages of life. The company is comprised of six business units: Health Plans, Insurance Services, Strategic Business Services, Retiree and Senior Services, Specialized Care Services, and Knowledge and Information Services. Over 75,000 employers offer our products to millions of Americans.
I am responsible for Electronic Data Interchange (EDI) in our Government Operations. I have 30 years of technical and management experience in information systems, including 17 years with the electronic exchange of Medicare claim data. I am the United HealthCare representative to Accredited Standards Committee X12 (ASC X12) and I worked closely with the Health Care Financing Administration (HCFA) to develop the implementation guides for the Part B Medicare electronic claim and remittance transactions.
On behalf of the management of United HealthCare, I'm happy to be a part of this session and to assist in any way that I can.
I'd now like to respond to the questions posed by the Subcommittee.
1.What is your definition of a claim versus a claim attachment?
A claim is a request for payment of services provided. This is usually a HCFA-1500, UB-92, or the electronic equivalent.
A claim attachment is extra documentation that supports or supplements the request for payment. A provider might submit an attachment to substantiate higher reimbursement or we might request an attachment to make a determination regarding coverage or medical necessity.
Supporting information can also be requested after a claim has been received by a payer. For purposes of defining electronic claim attachments, we prefer to include these items as well, even though they are not "attached" to, nor do they accompany, the submitted claim.
2.How should we differentiate information that is appropriate for the claim versus information that is appropriate for claims attachments?
The claim should provide demographic information for the provider and member, policy information, dates of service, charges, diagnosis and procedures. In most cases, this is all that is necessary to process the claim to payment.
When required, claim attachments should support the medical necessity and reasons for procedures rendered, past and future frequencies and duration of treatment, and outcomes of treatment. Claim attachment information should be specific to the type of attachment and include more detail on the type of services provided.
We believe a key objective of any approach to differentiation should be to simplify the implementation of both standards for as many submitters as possible.
3.What types of claims attachments do you currently request from providers? In what format do you make such requests? In what format do you receive this information?
We request the following types of claims attachments:
We request these items using form letters, telephone calls, and explanations of benefits.
We receive this information on paper.
13. What other types of documentation do you currently request from providers? In what format do you make such requests? In what format do you receive this information?
We request the following other types of documentation:
We request these items using form letters, telephone calls, and explanations of benefits.
We receive this information on paper.
20. What purpose(s) do these attachments and other documentation serve?
These attachments and documentation provide the claims processor or medical reviewer with information to determine coverage, medical necessity, and which payer is primary. This is needed to determine the benefit due. Some information is also used to check for fraud and abuse.
21. What aspects of these processes would be aided by standardization and electronic exchange of information?
With standardization, providers could expect to be asked the same questions in the same way by all payers. Providers would submit the same information in response to the standard requests. This would make the process more consistent for both providers and payers.
Both the payer request for additional information and the provider response can be handled electronically. Electronic request and return of additional information would speed up the payment process, and generate savings for postage and paper handling. If the additional information were available in the provider’s system, clerical retrieval could also be eliminated.
In 1996 and 1997, United HealthCare participated in a proof of concept with HCFA. We converted several of our computer-generated form letters into electronic requests for additional information. From this pilot, we learned it is feasible to ask for such supplemental information electronically. In fact, the participating providers suggested the next logical step was for them to return the requested information electronically.
22. What aspects of these processes are not conducive to standardization?
While the process will benefit from standardization, there are some aspects, which may gain less immediate benefit.
Some attachments, such as treatment plans and operative notes, are non-codified text. While these may be electronically delivered to the appropriate reviewer more rapidly, they will still require human interpretation.
Also, some attachments prove that services were actually rendered or that they were ordered by a physician. For example, physician certification is required for many therapy services. Since this certification is indicated by a physician’s signature, an electronic attachment may be considered insufficient.
23. What is the relationship between claims attachments and the medical record?
Claim attachments are not typically part of the medical record, but are an extract or summary of specific information contained in the record. Unlike medical record entries, claim attachments can be typed by any individual with access to the data entry system.
24. Do you ever request the entire medical record from providers in support of the claim? Under what circumstances is the entire medical record required?
We request the entire medical record in only a few circumstances.
29. Currently, the NUCC and the NUBC have the responsibility for approving the content of information contained in the standard health care claim. Do you think such an organization should also have responsibility for approving the content of claims attachments? Can you suggest which organization(s) should have this responsibility?
We believe that the National Uniform Billing Committee (NUBC) and the National Uniform Claim Committee (NUCC) should have responsibility for approving the content of claims attachments.
For attachments dealing with basic non-skilled services, this would be sufficient. For other attachments, additional collaboration would be appropriate.
Attachments for complex skilled services should be reviewed before they are released to the NUCC or NUBC for approval. For example, attachments for respiratory therapy might be reviewed by the Health Care Financing Administration (HCFA) in collaboration with a national association of Respiratory Therapists, Pulmonary Physician Specialists, and health plans.
Attachments covering services considered prone to fraud should be reviewed by fraud agencies, such as the FBI and health plan fraud units, before they are released to the NUCC or NUBC for approval.
30. If there was a governing body over data content of the standard attachment data, there would have to be a protocol in place to add, delete, modify, etc. existing data content of the attachment. What are your suggestions/concerns regarding this process?
31. We believe that multiple attachment types should be developed, rather than one or two all-inclusive formats. This will reduce the impact on existing implementations when formats must be modified in the future. It will also reduce the amount of data transmitted for each claim and limit it to that which is essential.
32. The ASC X12 patient information transaction set, the “275”, is a standard transaction that can be used to return claim attachment data. Work is progressing on the implementation guide describing how this “envelope” will carry a variety of claim attachments within it. This architecture will accommodate new attachments as they are identified in the future. We believe this concept of a standard envelope to carry attachments is appropriate.
33. We believe that the standard claims attachment contents for this envelope should be constructed from existing standards, such as Health Level 7 (HL7), whenever possible. This incremental approach will take advantage of work already done to define supplemental claim information.
34. Since there are many types of attachments, the standard should be explicit and unambiguous about the format to be used for each type. An implementation guide or other specification covering the various attachments must be available to providers and health plans. As new standard attachments are developed, they’ll need to be added to the specification.
United HealthCare endorses the Subcommittee’s charter and invites further discussion in any area of concern. Thank you again for this opportunity.
Peter L. Anderson
Information Systems Director
United
HealthCare Corporation
CT29-05AA
PO Box 150450
Hartford, CT
06115-0450
www.unitedhealthcare.com
(860) 702-6670
(860)
702-6635 (fax)
panders@uhc.com