I am Elise Lauer, and I am employed by Northwestern Memorial Hospital (NMH) in Chicago, as the Director of Patient Accounting. I have been employed by NMH since 1975 and have served in various roles; however, the last sixteen years specifically in Patient Accounting.
NMH is a 750 bed acute care, academic teaching facility serving approximately 270,000 patients in the last year(1) and having processed over 525,000 related claims. I am responsible for all billing and collection processes, including government (Medicare, Medicaid) programs, commercial and managed care payers, corporate, research, and self-pay.
I am currently the Chairman of the Committee on Patient Financial Services for the Metropolitan Chicago Healthcare Council. This committee’s membership includes representation from approximately 60 Illinois hospitals. This group meets regularly to raise, discuss, and resolve reimbursement issues impacting our institutions. Payers also participate on a regular basis to inform hospitals of upcoming changes and assist/participate in problem resolution. I have served on this committee since 1993 and have been chairman since July, 1997.
Because NMH was one of the first institutions in Illinois who successfully implemented and fully integrated the Medicare electronic remittance process into our day-to-day operations (by developing a number of automated functions and audit tools, as described in Attachment B), I was also asked to serve as co-chairman of the EDI Task Force, a subcommittee of the same group, along with the EDI Manager of the Health Care Services Corporation, who is currently fiscal intermediary for the Medicare program in our area. This group was instrumental in the successful implementation of the original Medicare EFT/ERA and continues to review and address issues relating to subsequent version implementations. I have served in this capacity since its inception in the mid ‘90s
NMH has filed claims electronically for commercial, Medicare and Medicaid claims for several years and is able and willing to submit electronic claims to any payer who is able to accept them. Although approximately 85% of our claims are initially transmitted electronically (Attachment A), the increasing demand for additional documentation continues to draw upon our resources, increase cost, and delay reimbursement.
It appears many of claims attachments described (including those provided in my responses to the provider questions), can be categorized into three groups.
The first represents requests for information that is already provided on the claim form; however, because a plan and/or payer is unable to interpret the data due to older technology/systems which do not support current formats or, the payer’s inability keep current with the coding schemes. In both cases, the information is re-requested in a format suitable to the requestor’s operation.
The second group represents information that payer’s are unable to successfully obtain directly from their employers, subscribers, healthcare professionals, or other plans/payers. In these cases, hospitals’ reimbursement is delayed and the hospital is charged with the tasks of gathering, formatting, and submitting required information that, in some cases may be unrelated to the services provided, in order to obtain reimbursement, (i.e., COB forms, authorization documentation, medical records in order to investigate and/or identify pre-existing conditions, EOBs, etc.)
These situations are the result of an industry unable, and sometimes unwilling, to effectively communicate with its members. As you may recall in the early ‘90s, significant and unsuccessfull efforts were exhausted attempting to develop local area CHINs to assist in resolving the problems associated with the overwhelming demand for access to information.
The third group represents information either supplied earlier by the provider, or actually resident in the payer’s systems; however, due to manual processing backlogs, inadequate storage and retrieval systems, or just a genuine inability to link information, payers will request we provide information again with the claim, (i.e., Medicaid split billing and spend down documentation, UR/case management documentation, etc.)
Another cause for increased manual processing is the new wave of complex reimbursement arrangements, and a genuine lack of products to support these arrangements. In order to maintain patient populations, providers are faced with increasing resources to accommodate the manual processes associated with administering these contracts. As is the case with many of our specialty contracts, it appears the insurance industry is slowly transferring the costs associated with reporting and claims administration to the healthcare provider; a savings to the carriers, but not a savings to the industry as whole.
Overall, I welcome the legislation. It has the potential to provide definition and standardization and improve the mechanical functions associated with data collection, storage, transmission, and processing. However, commercial payers have been slow to adopt standardization practices and to making their businesses electronically accessible. In my opinion, the penalties described in the HIPAA legislation for non-compliance could in fact actually be the more cost effective approach to responding to this legislation, rather than developing or accessing the technologies necessary to support it. This is one case where I hope to be proven wrong.
With regards to the claims attachment, I would recommend developing mechanisms that would effectively evaluate the information being requested as a claim attachment, ensuring that to the extent possible, these data requirements are incorporated into the claims themselves.
I thank the NCVHS for the opportunity to participate in this process.
1.What is your definition of a claim versus a claim attachment?
Let’s look at the definition of the terms.
Claim (noun)
The UB92 format has been determined as the claim submission method for hospitals to use to obtain payment for services provided to patients who are identified as beneficiaries of the policies issued by these payers.
These formats were developed to be the sole mechanism to bill and/or make claims to insurance companies for payment of covered healthcare services, based upon the provisions of the plans, provided to their beneficiaries.
Attachment (noun)
The definition of the term implies a physical attachment; however, our experience is that more often this term relates to additional documentation requests to providers by payers well after or as a result the claim submission.
The following examples represent documents that are required at the time of billing and often prevent electronic submission of claims. These samples include (but are not limited to):
1. How should we differentiate information that is appropriate for the claim versus information that is appropriate for claims attachments?
Information appropriate for a claim should provide the necessary information to process the claim. For example:
who (patient, provider, payer),
what (services, procedures, diagnosis),
where (location),
when (dates of service), and
how (inpatient vs. outpatient, skilled nursing vs. hospice vs. acute care setting, etc.)
And the UB92 does provide this information.
If in fact claims are complete and accurate, there should not be a need for attachments. In my opinion, whatever information is required in order to process the claim should be incorporated into the claim form itself.
Currently, the NUBC is the vehicle to change required UB92 data elements (add, delete or alter or expand). However, because of a lack of federal legislation, payers have not been compelled to accept and/or adopt the formatting of this information.
16. What types of claims attachments do you currently provide to payers? In what format do you provide such information?
As stated previously, the following examples represent documents that are required at the time of billing and often prevent electronic submission of claims. These samples include (but are not limited to):
a)Referral/Authorization forms
b)State mandated forms (IDPA2432 Split Billing Document)
c)Electronic Remittance Advices (ERA documentation) and
Explanation of Benefits forms (EOBs)
They are all paper documents in a variety of formats, defined and/or supplied by the payer.
17. What other types of documentation do you currently provide to payers? In what format do you provide this information?
See 18 below.
18. What purose(s) do these attachments and other documentation serve?
a) Non-Clinical Information
i)Itemized bills are requested for a number of reasons:
ii) Reimbursement calculation worksheets (Managed Care Payers)
As managed care products and contracts have become more complex, and because contract periods continue to be shortened, calculation worksheets have been developed to support our claims. Specifically to reflect the current contracted rates and method of calculation.
iii) Proof of program certification (by Medicare or State)
iv) Hysterectomy and sterilization consent forms (Medicaid)
Some consent forms require signature at least 30 days before the procedure, the state requires this document, (reflecting the appropriate lead-time) be attached to the claim at the time of initial submission.
v)Hospice Election forms (Medicare, Medicaid)
Because beneficiaries are allowed to move between programs easily, often times the documentation is not submitted timely by the beneficiary or the systems are not updated timely. As a result, copies of the actual program election forms are requested before claim payment is made.
vi) Copies of Insurance Cards
In an attempt to continue to control costs, employers more frequently change plans/products for their employees. These typically manual enrollment processes (for both employers and payers) are frequently backlogged and payers often do not have the beneficiaries identified in their systems, at all or incorrectly. As a result, payers request copies of the insurance card to identify the policy, employer, and even the product so that the claim can be processed.
vii) Coordination of Benefits (COB) or MSP (Medicare Secondary Payer) forms
· COB: The perception is that either payers are unable to obtain regular updates from their subscribers or are unable to assign this responsibility contractually to the employer. As a result, providers’ reimbursement is delayed until we either successfully convince the patient to contact the carrier or actually obtain information about any other policy/payer for which the patient may be identified as a beneficiary, thereby reducing the originally billed carrier’s responsibility for payment of benefits.
· MSP: Incorrect billing by one provider showing Medicare as the secondary payer automatically updates the common working file to now show this information as accurate. No supporting information (i.e., MSP) is required or validation performed prior to updating Medicare’s records to place Medicare in the secondary payer position.
However, correct claims submitted to Medicare showing Medicare as the primary payer, (after the incorrect update identified in the previous paragraph occurs), are automatically challenged by the fiscal intermediary. The original claim is “suspended” and a request is generated for the MSP questionnaire to support Medicare as the primary payer.
Because this is a manual process, processing of the correction by the fiscal intermediary can take as long as 6 months. And once corrected, if another claim is submitted incorrectly showing Medicare in the secondary position again, before our claim is processed, the common working file is again automatically updated to reflect the wrong information and the process to correct the file starts over.
viii) Medical Necessity Letter
These are typically letters requested by payers (from physicians) to support private room accommodations during the hospital stay. Often times, the diagnosis and treatment levels coded on the UB92 reflect the need for these accommodations.
For example, a post transplant patient is admitted for complications; many if not all of these patients are on immunosuppressant drugs and because of their conditions require private rooms.
ix) HCFA L-365 (Medicare Liability)
Required by Medicare for claims typically reflecting trauma related services, (requests accident related information, the patient’s intent to file a claim against another’s liability carrier, or intent to file suit).
x)Claim Alterations
· Request to change bill type on claim
On occasion, payers have requested providers resubmit claims reflecting another bill type because the provisions of the policy only pay for these services in a certain setting, (i.e., will only pay for service if rendered in outpatient setting). Be advised we deny these requests and insist the claim be processed as originally submitted.
· Request to combine claim (mother/baby)
This example is typical of managed care payers who process claims and determine benefits payments based on combined mother/baby claims, (i.e., per diems, case rates, etc.). However, even though they expect the claims to be submitted combined, they often request another claim separated for individual subscriber records purposes.
· Resubmission of claims in an alternative format (hospital services on a HCFA1500)
More recently, payers have demanded certain services be billed on the HCFA1500 format, even though UB92 guidelines indicate they should be billed on the UB92, (i.e., 510 clinic visits).
In this particular example, the payer indicated their system was unable to link UB92 billed services with those services billed on a HCFA1500, and as a result, they made a policy decision not to accept any claims for 510 clinic visits on a UB92 form.
xi) Proof of compliance with contract requirements
Some payers require ongoing case management/utilization review; however, this too is typically a manual process. At the time of claim submission, the payer’s records are not current and as a result they request we send copies of our documentation, including with whom we spoke, date/time, and outcome/decision. The documents are typically faxed to the designated payer department.
b) Clinical Information
i)Entire Medical Record for the Specified Stay
· Payers have set dollar thresholds for medical record requests, typically claims totaling $10,000 or more automatically generate a request.
These requests are based solely on total dollar value of the claim, not as a result of claim review, errors or omissions, or, that the claim was not procedure or diagnosis coded correctly to support the type and quantity of services provided.
Once these requests are received, we attempt to locate, copy, and send within 10 days of receipt; however, payers delay reimbursement on average between 14 – 90 days for “medical review”.
· Investigation of Pre-Existing Conditions
· Audits
Payers will request full medical records (and the itemized bill) and have auditors ensure that every item charged is documented in the medical record.
· To identify services related to a non-covered procedure, within a covered stay. An example would be a maternity patient who wants a sterilization procedure performed after the delivery (as an elective procedure). The plan covers maternity, but will not cover sterilization unless it poses a health risk to the patient. The plan will request records to identify the OR time, supplies, drugs, additional recovery, etc. associated with the sterilization and carve that component out as non-covered.
ii) All Records related to a specific patient (even those unrelated to the claim)
This pertains specific to individual policies, not group. These policies contain long “contestability” clauses. The contract provides the payer with a set amount of time (i.e., two years) to contest the validity of the information provided at the time of application. Many health insurance applications request from 2 – 10 years of medical history (on the application).
The first provider who submits a claim against this type of policy (no matter how large or small), receives a request for all hospital records related to the patient for the period originally referenced on the application (2-10 years); including the names of every physician, their addresses and telephone numbers, who serviced the patient during that period. The payer then contacts those physicians for all of their records for the same period.
The goal is to find information in the records which support the patients omission and/or deliberate withholding of requested information in the application process, which would then allow the payer to “rescind” the policy (returning all premiums) without paying any benefits.
iii) Partial Medical Records
· Therapy, Progress, or Nurses Notes
· History and Physical
· Admission/Discharge Abstracts
· Operative Reports
· Emergency Room Reports
Typically requested by payers to determine if use of the “emergency room” was appropriate (gatekeeper plans).
Sometimes to gain access to information that would otherwise not be available, (i.e., injuries sustained while performing a crime, in police custody, MVA/DUI, workers compensation, self-inflicted, etc.).
· Test Results, (i.e., x-rays, labs, etc.)
· Pharmacy Profiles
19. How much do these requests differ across payers? Could these requests for claim attachments and additional documentation be classified and standardized across payers?
The formats for providing the information vary; however, the information can be classified and standardized across payers. I would strongly encourage an evaluation mechanism be put in place to analyze the data being requested to determine whether it is already provided in an existing format, or, whether it could be incorporated in the claim’s data elements.
20. What aspects of these processes would be aided by standardization and electronic exchange of information?
Referral/authorizations
Emergency Room Reports
MSP Questionnaire
HCFA L-365 Liability Form
Reduced manual efforts and costs associated with manual data storage, retrieval, reproduction, and submission in hard copy format, (which are currently duplicated on the receiving end).
21. What is the relationship between claims attachments and the medical record?
See response to question 22.
22. Do you ever submit the entire medical record to payers in support of the claim? Under what circumstances is the entire medical record submitted?
a)Entire Medical Record for the Specified Stay
i)Payers have set dollar thresholds for medical record requests, typically claims totaling $10,000 or more automatically generate a request.
The majority of these requests are based solely on total dollar value of the claim, not as a result of claim review, errors or omissions, or, that the claim was not procedure or diagnosis coded correctly to support the type and quantity of services provided.
Once these requests are received, we attempt to locate, copy, and send within 10 days of receipt; however, payers delay reimbursement on average between 14 – 90 days for “medical review”.
ii) Investigation of Pre-Existing Conditions
iii) Audits
Payers will request full medical records (and the itemized bill) and have auditors ensure that every item charged is documented in the medical record.
iv) To identify services related to a non-covered procedure, within a covered stay. An example would be a maternity patient who wants a sterilization procedure performed after the delivery (as an elective procedure). The plan covers maternity, but will not cover sterilization unless it poses a health risk to the patient. The plan will request records to identify the OR time, supplies, drugs, additional recovery, etc. associated with the sterilization and carve that component out as non-covered.
b)All Records related to a specific patient (even those unrelated to the claim)
This pertains specifically to individual policies, not group. These policies contain long “contestability” clauses. The contract provides the payer with a set amount of time (i.e., two years) to contest the validity of the information provided at the time of application. Many health insurance applications request from 2 – 10 years of medical history (on the application).
The first provider who submits a claim against this type of policy (no matter how large or small), receives a request for all hospital records related to the patient for the period originally referenced on the application (2-10 years); including the names of every physician, their addresses and telephone numbers, who serviced the patient during that period. The payer then contacts those physicians for all of their records for the same period.
The goal is to find information in the records which support the patients omission and/or deliberate withholding of requested information in the application process, which would then allow the payer to “rescind” the policy (returning all premiums) without paying any benefits.
Often times, the patient is continuing to receive services as the payer/plan continues to verify eligibility, perform case management and authorize services or days for periods of confinement. It is not until the claim is submitted (and services provided) that this process begins and the provider made aware that reimbursement may be in jeopardy. In one particular case, the time between claim submission and the actual request for this data barred our organization from pursuing other reimbursement alternatives, (Medicaid eligibility).
c)Partial Medical Records
Overall, these are typically requested to clarify one aspect of the care given, or, to provide the information in an uncoded format.
i)Therapy, Progress, or Nurses Notes
ii) History and Physical
iii) Admission/Discharge Abstracts
iv) Operative Reports
v)Emergency Room Reports
Typically requested by payers to determine if use of the “emergency room” was appropriate (gatekeeper plans).
Sometimes to gain access to information that would otherwise not be available, (i.e., injuries sustained while performing a crime, in police custody, MVA/DUI, workers compensation, self-inflicted, etc.).
vi) Test Results, (i.e., x-rays, labs, etc.)
vii) Pharmacy Profiles
23. Would the standardization and simplification of the questions asked by payers make the claim adjudication process easier?
Yes, however the penalties for non-compliance are probably far less than the cost of adopting the standardization requirements. Unfortunately, it appears it might be more cost effective for some companies not to comply.
24. Do you have any suggestions that would assist us in the task of standardizing the requests for additional information from payers?
I would strongly encourage developing a mechanism to analyze the data being requested to determine whether it is already provided in an existing format, or, whether it could be incorporated in the claim’s data elements.
25. Would the automation of health care claim attachment information and standardization of the payers’ requests for information reduce operating costs for your facility?
Unknown at this point, as the attachment has yet to be defined in terms of data content and frequency of use, compared to the costs of development, integration, and maintenance of automated systems.
26. Can you clearly differentiate “clinical information”, “claims information”, and “attachment information”?
At this point, no. Attachment and clinical information tend to cross over one another. Claims information from the hospital’s perspective is already very clearly defined (UB92).
27. Are there health care claim attachments that do not contain “clinical” information?
Yes. MSP questionnaire, HCFA L-365, Medicaid (IDPA2432) split billing document, referral/authorization form, benefits explanation forms.
28. 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?
From a hospital’s perspective, the NUBC seems to be the most appropriate organization; however, if the claims attachments are to include more in depth clinical information, an additional review and input process from possibly a medical records organization or HIMSS might be appropriate. I realize these are not perceived as standards setting organizations; however, they might raise valid issues for consideration in this process.
29. 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?
The current process used by the NUBC works well; however, the lack of federal legislation has allowed many payers to adopt only those components they find valuable and develop their own requirements for the remainder.
30. What impact will the incorporation of HL7 messaging in the standardization of attachments have?
None. HL7 compliance is becoming a standard in many organizations.
31. Does your automated information management system have the capability to create a standard electronic health care attachment?
No, but most major application vendors are developing X12 transaction capabilities currently to meet existing demands. In addition, most major applications vendors support federal requirements, so as these are developed, they will bring this functionality to their products. I would encourage communication with the major applications vendors and to the extent possible, work with them to identify their issues and potential barriers to delivering these product capabilities.
32. (for hospitals) Would a standard claims attachment for State-mandated health care data reporting ease the reporting requirements for your facility?
Illinois already has standards which primarily utilize UB92 data elements and formats. They are attached.
Medicare 33.3% Y Y
Medicaid 11.0% Y(4) Y
Managed Care 30.2% N(5) Y
Blue Cross 11.2% Y Y
Charge Based 14.3% Y(6) Y(7)
· Direct cash posting from the electronic remittance advise (ERA) to our patient accounting system and the individual account level,
· Direct adjustment posting for the contractual adjustments,
· Programs to process the resulting payer-to-payer transactions to automate secondary billing of deductible and co-insurance amounts, without manual intervention,
· Tools to aid in monitoring and auditing of accurate reimbursement,
· Programs to “up load” corrected information from the ERA fiscal to our patient accounting systems, (correct HICN numbers, subscriber data, etc.)
· The electronic remittance advise, a required attachment for secondary claims, showing Medicare’s payment, deductible, co-insurance, and non-covered amounts,
· An on-line function to reconcile the electronic funds transfer to our bank deposit and to the fiscal intermediary’s ERA.
(1) FY97 Admission/Registration statistics (i.e., Med/Surg, Psychiatric, Skilled Nursing, Hospice and Newborn)
(2)The American Heritage® Dictionary of the English Language, Third Edition copyright © 1992 by Houghton Mifflin Company. Electronic version licensed from INSO Corporation. All rights reserved.
(3)"The American Heritage® Concise Dictionary," Microsoft® Encarta® 97 Encyclopedia. The American Heritage® Concise Dictionary, Third Edition Copyright © 1994 by Houghton Mifflin Company. Electronic version licensed from and portions copyright © 1994 by INSO Corporation. All rights reserved.
(4) The majority of our Medicaid claims are submitted electronically; however, certain populations do require paper attachments, and as a result submitted manually.
(5) Only 4 payers have indicated an ability to accept electronic claims, and only on certain types of services. Overall volume is minimal.
(6) NEIC Payers only (approximately 35%).
(7) NEIC Payers only (approximately 35%).