Distinguished members of the National Committee on Vital and Health Statistics and guests. Thank you for allowing me to share my views from a providers prospective on a very important aspect of the healthcare claims process, claims attachments. My views will be from both the institutional and medical practice prospective.
My name is Paul Cheng, Jr. and I am the Director of Patient Accounts and Managed Care for St. Clare’s Hospital & Health Center (SCH), New York, New York. SCH is a 200 bed HIV designated facility located on the west side of New York City providing a wide range of HIV and Non-HIV medical services both onsite and at several health centers in New York City.
SCH is not a large facility like its neighbors, but SCH does generate a considerable number of billings for both institutional and professional services. Due to nature of services rendered, the attachment requirements or problems are considerable for both institutional and professional claims. The daily requests by payers for additional information before a claim is to be processed for payment are increasing. Progress notes, nursing care notes, physician consultation reports, plan of care notes, therapy notes, etc. are constantly requested. In addition, once the primary payer had paid their portion of the claims, the secondary carrier requests in most instances the same information plus a copy of the explanation of benefits from the primary carrier.
Recently, more and more requests for additional information by independent utilization review agencies representing payers are being made mostly in the form of the complete patient medical record. Should a provider fail to provide such information, payment will be indefinitely delayed.
At the medical practice level, the same phenonomon is occurring, where there is an increasing number of requests being made for the physicians records and the completion of more attachment forms. The physicians are complaining that the completion of additional forms/attachments require them to re-review charts several times and their office records several times which take away from patient care and adds additional costs.
These requests are costly and time consuming for all the providers. In most instances, providers are not able determine why the documents or additional forms completion are required. It has reached the point where a provider will automatically send attachment information if the provider has had experience with the payer who has requested information in the past. Any information over and above what is requested on a claim form is assumed to be an attachment by the provider. At least with Medicare and Medicaid carriers, explanations are given.. Currently, managed care and ERISA type programs have taken the lead in attachment requests and requirements. Many providers feel that these requests are for the sole purpose to delay payment to protect profits especially when non clinical information is requested (i.e.: accident, insurance, family information, demographic information).
In my 25 years of patient accounting, change and standardization in claims processing has been painfully slow. Resistance to change and the cost of change has been enormous and chaotic. Having been involved in both state and national billing committees for many years, I have seen both payers and providers alike argue excessively with each other in the standardization of the claim form. Throw in regulatory agencies, advocate groups and other parties into the mix and you have a real mess. At least with the current UB-92 and HCFA 1500 there is some standardization and simplification. The standardization of the attachment process will require significant amounts of trade-offs, compromise, agreement and trust.
Unlike other states, New York has an electronic claim submission requirement for payers. The National Standards Format (NSF) 2.0 is used for professional claims submissions and the HCFA EMC Version 4.1 is used for institutional claims. Most payers in the state are in compliance with the requirement. In addition, the NYS Insurance Department has minimum data requirements for providers and payers that are appropriate for claims processing. The NYS Universal Data Set Specification Task Force (UDSS) is composed of providers, payers, vendors, governmental agencies and other interested parties which meet to determine the appropriateness of requests for data to be added or removed in the electronic data set. Needless to say, providers and payers alike in NYS are ahead in the EMC world. The key to the success in NYS is the cooperative approach. mutual trust and legislative backing. I would suggest that when attachment standards are adopted, NYS will mandate the same. As a member of the UDSS Task Force, I extend an invitation to you all to attend any future meetings to observe the process.
Once simplification and standardization is achieved in the claims processing and attachment process, I would suggest the following to be included:
The results would be cost savings for providers and payers in programming costs, faster processing of claims, better information for multiple purposes, ease of reporting, etc.. Providers and I suspect payers would welcome the standardization of attachments.
Be aware of one major sector of the industry who will have difficulty, the medical practitioner providers do not have the same experience nor have they made the advances in EMC as institutional providers. This sector will need additional time to reach the same level playing field as the rest of us.
My thanks to the committee for allowing me to testify in this important matter. If I may be of future assistance feel free to contact me.
What is your definition of a claim versus a claim attachment?
Form or electronic format to request payment for services rendered.
Claim attachment is information requested over and above what is required on the claim or electronic claim format.
How should we differentiate information that is appropriate for the claim versus information that is appropriate for claims attachment?
From a provider perspective, it is difficult to differentiate, The NYS Insurance Department has defined the provider’s obligation for claims made to include:
Admitting and discharge diagnosis, operative procedure, itemized bill
What types of claims attachments do you currently provide to payers? In what format do you provide such information?
Medical charts or part of, plans of care, misc. questionnaires.
Attachments are provided in paper form with the exception of Medicare requests and most Medicaid requests.
What aspects of these processes would be aided by standardization and electronic exchange of information?
The entire attachment process would be aided by standardization with the effects of cost reduction and increased cash flow.
What other types of documentation do you currently provide to payers? In what format do you provide this information?
Progress notes, nursing notes, plan of care notes, consultations, etc. Non clinical information are, accident information, other insurance information, family information and demographic information.
What purpose(s) do these attachments and other documentation serve?
In most instances, providers are unaware of the purpose of the requested. information.
How much do these requests differ across payers? Could these requests for claims attachments and additional documentation be classified and standardized across payers?
The requests are similar, most require the same information in the form of the complete patient medical chart.
Claims attachments and additional documentation can be easily classified and standardized for all payers.
What is the relationship between claims attachments and the medical record?
In most instances, the medical record information is gleamed for the attachment.
Do you submit the entire medical record to payers in support of the claim? Under what circumstances is the entire medical record submitted?
Many payers are requiring the copy of the medical chart before payment. But if a payer has requested a chart in the past, all future claims will be sent with a copy of the chart.
Would standardization and simplification of the questions asked by the payer make the claim adjudication process easier?
Standardization and simplification would make claims processing easier. Problems would arise when payers arbitrarily add additional questions in the claims process without approval from a governing body.
Do you have any suggestions that would assist us in the task of standardizing the requests for additional information from payers?
Formulation of a single maximum universal provider data set(s) for claims and attachments.
Providers population of all locators.
Payers gleam only that information they require for claims adjudication.
Payers then forward the complete data set with their additional processed data to the secondary carrier.
Appointment of a single body composed of a cross section of the industry (i.e.: payers, providers, regulatory agencies).
Legislation be introduced and passed requiring all payers and providers to adopt the standards. There must be no exceptions or failure is inevitable
Would the automation of health care claim attachment information and standardization of the payer’s requests for information reduce operating costs for your facility?
Operating costs would be reduced in one time programming, labor for copying, costs for supplies, etc. Standardization of maximum provider data elements and format and codes and payer requests for information will reduce costs for both payers and institutional providers alike. Medical practice providers will experience difficulty.
Can you clearly differentiate “clinical information,” “claims information,” and “attachment information”?
Clinical, claims and attachment are too interwoven for a provider. It is easier for the provider to just send a complete copy of the medical chart to speed payment.
Are there health care claim attachments that do not contain “clinical” information?
Yes, accident information, other insurance information, demographic and family information.
Currently, the NUCC and 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?
The appointment of a single body composed of a cross section of the industry (i.e.: payers, providers, regulatory agencies, etc.). Actual providers, institutional and medical professional must be a part of this team, or there will be a feeling of mistrust.
If there was a governing body over data content of the stand 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?
Change is difficult in the current environment. The provider community as a whole will change when necessary, but in the past, the changes have occurred to frequently and to make matters worse, many changes are retroactive. In addition, many changes effect procedures and reimbursement. With the current paranoia because of fraud and abuse initiatives, the process of standardization and simplification must be approached with due care.
What impact will the incorporation of HL7 messaging in the standardization of attachments have?
Institutional providers will be better prepared than the medical provider community. The EMC environment of the medical community is still in its infancy stage. Solo practitioners and small group practices are not as sophisticated and advanced in the EMC arena as institutional providers.
Does your automated information management system have the capability to create a standard electronic health care attachment?
Our current hospital system has the ability to create electronic attachments for both institutional and medical attachments.
(For hospitals) Would a standard claims attachment for State-mandated health care data reporting ease the reporting requirements for your facility?
In NYS, standardization works. For several years, the NYS Universal Data Set for providers is an example of the ease of provider reporting.