I am Jerry Henry, Chairman of the Kentucky State Uniform Billing Committee. I have served on this committee since its inception in 1982 and have been chairman since 1984. I am employed by Baptist Healthcare System based in Louisville, Kentucky. Our system includes five hospitals located in Louisville, Lexington, Paducah, Corbin, and Lagrange. These facilities range from 130 beds to more than 400 beds with a total of more than 1500 beds for the system. Two of our facilities have Medicare designated separate psychiatric and rehabilitation units. All five facilities have Skilled Nursing Facility units. Three of our facilities routinely treat patients living in Indiana, Tennessee, Illinois, and Missouri as well as Kentucky.
I am directly involved with our Business Offices in computer support functions for both paper and electronic billing for all five facilities. Our system was the pioneer in Kentucky in developing electronic claims with Blue Cross of Kentucky in the 1970's. We have been filing Commercial Electronic Claims through NEIC since 1980. Today we file electronic claims to any payer who is able to accept them. Our volume of electronic claims would be significantly increased today if we could eliminate paper attachments.
Kentucky passed Uniform Health Insurance Claim Forms legislation in 1982. At that time the Kentucky Hospital Association asked the Insurance Commissioner to delay implementation of the legislation until the UB-82 claim form could be started. The commissioner agreed and issued an order to that effect on July 1, 1982. On July 8, 1993, the commissioner issued a new order that dealt with the implementation of the UB-92 claim form. The state manual details the attachments that are still necessary. Providers are asked to notify the Kentucky Hospital Association if a commercial payer attempts to require additional attachments or certifications.
Kentucky is a No-fault Auto Insurance state. The rules used by Medicare in the Medicare Secondary Payer arena have been adopted by every payer in the state. Every payer requires a copy of the Auto Insurance EOB or denial before processing the claim.
Our Kentucky rules work well except when dealing with self-insured plans (or others hiding behind ERISA). There are also problems with out-of-state payers who are not licensed in Kentucky. While we have a uniform claim form, we do not have uniform billing.
Federal plans such as Black Lung, Champus, CHAMPVA, and Federal Worker's Compensation are among the worst offenders in requiring attachments or requiring hospital providers to file HCFA 1500 forms rather than accepting UB-92 claims forms. These plans also require a variety of attachments. Likewise these payers have been slow to accept electronic billing.
State Medicaid agencies cite federal law as requiring Sterilization Consent Forms, Hysterectomy Consent Forms, and copies of EOB's for any prior payments on a Medicaid claim. Kentucky Medicaid requires a copy of the spend down letter (which they issued) be attached to any spend down claim. Their system should be revised to hold this information rather than require an attachment.
Many payers apparently require attachments to cover the deficiencies in their internal systems. For example Anthem (formerly Blue Cross of Kentucky) converts both paper and electronic UB- 92 formats back to UB-82 for processing. There are many elements unique to the UB-92 that may not convert. This may also explain why some commercial payers require their own form attached to the claim.
Federal legislation is needed to control attachments and the effect of attachments on payments. We have accomplished nothing if we forbid attachments and payers hold claims waiting for the patient or subscriber to complete and return their referral form. We know of some payers today who are guilty of this.
EOB's should not be required when payers begin forwarding adjudication information to subsequent payers. The rules need to state clearly that subsequent payers must accept the electronic format and not require separate claims submission with copies of EOB's attached.
An excellent candidate for electronic attachment is the ER report that New York state has added within their system.
The penalties in the HIPAA legislation need to be revised. The current monetary penalty will not encourage payers to revise and update their systems. Creating standard electronic attachments will have little effect unless payers accept them.
Attached to my statement are specific answers to your Questions for Presenters.
Thank you for the opportunity to share this information.
1. What is your definition of a claim versus a claim attachment?
A claim is the information required by the payer to adjudicate a claim and is generally in the UB92 paper or electronic format or a HCFA1500 paper or NSF electronic format. By contrast a claim attachment is physical form or copy which a payer requires as a condition of adjudicating a claim.
2. How should we differentiate information that is appropriate for the claim versus information that is appropriate for claims attachments?
Data which is required consistently for all payers and claims should be contained within claim information. Data which is required on an exception basis should be considered as claim attachments. Attachments should be kept to a minimum.
16. What types of claims attachments do you currently provide to payers? In what format do you provide such information?
The State Uniform Billing Manual specifies required attachments for Medicaid only. These are Sterilization Consent Form, Hysterectomy Consent Form, Medicare EOB when Medicaid is secondary to Medicare, a copy of the Medicaid identification card when verification of coverage is needed, and a copy of the Medicaid Spend Down Letter with a summary bill (for spend down accounts only) . In the past state Medicaid personnel have cited federal law as requiring these attachments. The issue is that the forms must be signed before the procedure is done.
Realistically many other attachments are required. The most common requirements are from Self-insured plans hiding behind ERISA and Federal Programs which appear not to be able to agree on common rules.
Many hospitals routinely attach a copy of the ER report to a commercial claim to speed up processing of the claim. The issue is whether the visit to the ER meets the insurer's criteria for a medical emergency.
Certain Workers' Compensation insurers require a copy of the medical record. Black Lung requires a copy of medical records. If a Black Lung claim must be refiled then a new copy of medical records must accompany it.
Black Lung also requires a detail bill with the claim.
17. What other types of documentation do you currently provide to payers? In what format do you provide this information?
Requests for Medical Records are generally sent directly to the Medical Records department. Most insurers requesting the information require a photo copy of all information in the medical record.
Humana, an HMO, requires that the "Notification of the PCP" be clearly documented and on the report. The reports must be faxed daily to Humana's UR department to be on file before the claim arrives.
Many HMO/PPO's have their own referral forms and patients often present them. If received, they are often attached to the claim in the hope that it will speed claim processing. These forms vary in content and are usually unique to the payer.
18. What purpose(s) do these attachments and other documentation serve?
Insurers claim a need for medical review, verification of number of visits authorized, medical necessity and/or accident information. At times it appears that the request is being used only to delay payment of the claim.
19. How much do these requests differ across payers? Could these requests for claims attachments and additional documentation be classified and standardized across payers?
Many insurers require a form completed by the patient or subscriber. Information concerning the subscriber should already be in the insurer's data base. Other elements such as accident information are already contained within the claim. It appears that the payers want the patient's signature attesting to the validity of the information.
20. What aspects of these process would be aided by standardization and electronic exchange of information?
Referral forms should be reduced in content or eliminated wherever possible. In the past payers have delayed paying the claim until the patient or subscriber has completed and mailed the claim to the payer.
21. What is the relationship between claims attachments and the medical record?
Clinical type documents are part of the medical record. These include the Sterilization Consent Form, Hysterectomy Consent Form, and ER reports.
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?
The Federal Black Lung program requires medical records be attached to the claim. This program does not accept electronic claims at this time.
Other requests vary by payer. Some payers automatically request medical records if the claim exceeds a preset dollar figure. Other payers are suspected of using these requests as a tactic to slow the payment process.
23. Would standardization and simplification of the questions asked by the payer make the claim adjudication process easier?
Yes, without a doubt. Some payers ask questions of the patient or subscriber for which the answers should already be in their data base.
24. Do you have any suggestions that would assist us in the task of standardizing the requests for additional information from payers?
Standard rules need to be created and federal law changed to make all payers follow those rules. Payers should be forced to modify their internal systems rather than forcing every provider to provide information which payers should already have. This is especially true of the self-insured plans and managed care plans.
25. Would the automation of health care claim attachment information and standardization of the payers' requests for information reduce operating costs for your facility?
Automation and standardization would allow providers and third party vendors to develop data elements within their internal systems. This is not feasible at the current time due to the wide variety of requests.
26. Can you clearly differentiate "clinical information", "claims information", and "attachment information"?
As a rule clinical information relates to the patient's care and is generally a part of the medical record. Claims information may include patient and subscriber demographic information, charge information, assignments, and conditions of admissions, etc. Attachments are generally external forms which the payer requires.
27. Are there health care claim attachments that do not contain "clinical" information?
Copy of the EOB(s) from any previous payer(s) is required for almost every claim after the primary payer has paid. In Kentucky the exception to this is for Medicaid and Blue Cross of Kentucky where Medicare is primary and crosses the claims over to either Kentucky Medicaid or Blue Cross of Kentucky. This requirement should cease altogether when payers forward claims to the next payer.
Copy of any denial from the primary payer for the secondary payer.
Kentucky Medicaid requires documentation of original claim filed if a claim is being refiled more than one year after the date of service. A copy of the Medicaid EOB must accompany the claim.
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?
The NUBC appears to control the format and content more consistently than the NUCC. The HCFA 1500 is a poorly designed form. We sometimes fill it out in a clockwise sequence and other time in a counter-clockwise sequence. One payer may want the information blocks in a reverse sequence from other payers. There needs to be clearly designed rules for which form is be used when. Hospital providers should not have to complete HCFA 1500's for non-professional charges.
It is reasonable that the same organizations should control the content of claims attachments. Requests for new data elements must be investigated for placement either in the claim or an attachment.
29. If there were 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 content of the attachment. What are your suggestions/concerns regarding this process?
The current process being used by the National Uniform Billing Committee works well when it is used. The absence of federal legislation is used by many payers to bypass the deliberations made by this committee.
30. What impact with the incorporation of HL7 messaging in the standardization of attachments have?
Should have none but a wider acceptability among payers is needed.
31. Does your automated information management system have the capability to create a standard electronic health care attachment?
Yes, any automated system can be enhanced to create standard electronic health care attachments.
32. (for hospitals) Would a standard claims attachment for State-mandated health care data reporting ease the reporting requirement for your facility?
Kentucky uses the electronic UB-92 flat file for submission of health care data to the state. At the current time only one additional field, newborn birth weight, is required. It is submitted via record type "22", Unassigned State Form.