What is your definition of a claim versus an attachment?
The AMA defines a claim is the submission of information by a provider or covered individual to a third- party payer using a standardized format (e.g., HCFA 1500 claim form, Medicare National Standard Format, ANSI ASC X12 N 837) sufficient to establish that covered health care services were provided. The claim includes a request for payment or reimbursement to the provider or covered individual.
An attachment would include information either requested by the payer based on pre-payment or post-payment follow-up or provided by the provider at the time of submission of the claim. Attachments consist of information, presumably not available on the initial claim (or claim format), that provides further supporting details on the claim.
How should we differentiate information that is appropriate for the claim versus information that is appropriate for claims attachments?
The AMA believes the claim should be based on a straightforward minimum/maximum set of well-defined data elements and should be sufficient for payment in the vast majority of submissions. Based on either payer-specific requirements or nationally standardized situational requirements, the claim should also enable provision, at the time of submission, of a limited set of additional data elements that would be included in the standard paper or electronic claim “form”. Consistent with HIPAA requirements and provider/payer needs, the claim should be highly standardized at a national level and should reflect clear mutual expectations between providers and payers as to the information that should be submitted to effect payment for covered services.
Attachment information should include (1) information that tends to be highly situational in nature (e.g., requested only for specific types of services) and (2) cannot be readily accommodated in a standardized paper or electronic claims format. Attachments should accommodate a variety of paper and electronic technologies and should allow for both structured data elements, images, and free form text as appropriate. In addition, providers should have the ability to submit attachments at the time of claim submission and should not have to wait for a payer query or specific attachment requirement (e.g., to explain the unusual circumstances associated with a pattern of treatment).
What types of claims attachments do you currently provide to payers? In what format do you provide such information?
AMA member physicians are currently asked for a variety of supporting information to adjudicate a claim. This can include information that is contained in the patient medical record (e.g., operative notes, test results, etc.). In addition, some payers, especially Medicare and Medicaid, request attachment information using standard forms to reflect patient consent, the medical necessity of ordered durable medical equipment, and the cost and duration of use of drugs and supplies.
The methods by which this information is requested depend on the specific payer, the physician’s relationship with the payer, and their technical capabilities. Submissions can sometimes be made electronically, especially where Medicare has an electronic form in place. All too often however, even where the claim is submitted electronically, the physician must send in the attachment information manually. In some instances, and also contributing to cost and inefficiency, payer requests can be satisfied via the telephone.
Frequently, based on expectations of payer requirements, or specific written requirements, our members submit additional information with each claim of a certain type so as not to delay reimbursement to the patient or payment to the physician. Lack of standardization across or within payers is a real problem, as is the need to go back into the patient’s medical record or administrative file well after the original claim is submitted to gather the additional information and place it in the format required by the payer.
What other types of documentation do you currently provide to payers? In what format do you provide this information?
AMA members also provide additional documentation to payers which can include medical records extracts to substantiate the level of service provided and the provider of the service as well as more administrative information dealing with patient eligibility (e.g., copies of driver’s licenses, social security cards, Medicaid cards, etc. Our members are also asked to verify information of the patient’s relationship with the insured and other information to assist in coordination of benefits. This information is provided in the same means discussed in the previous question.
What purpose(s) do these attachments and other documentation serve?
The AMA believes that, in some instances, these attachment and documentation requirements involve payer’s legitimate needs for sufficient information to assess coverage or medical necessity for specific types of services or to meet specific contractual or regulatory requirements. All too often, unfortunately, our members have concluded that these requests are intended to delay payment of claims or to provide a basis for unwarranted denial. They may also often reflect a desire to pressure physicians into billing at a lower level of service.
How much do these requests differ across payers? Could these requests for claims attachments and additional documentation be classified and standardized across payers?
The AMA has found that requests do vary considerably across payers. This does cause considerable cost and delay for our members. This variation includes when attachments are requested, in what format they should be submitted, and the availability of electronic submission.
The AMA believes that considerable strides can be made in the attachments issue. In order to work, this standardization must apply to all payers and cover both paper and electronic formats. Standardization will be made more difficult in the private sector, where contractual provisions vary across and within specific companies.
In addition, it is essential to standardize when attachments are to be required and not just how they are to be submitted. The AMA is very concerned that lack of standardization in the situations when attachments will be required, coupled with standardized electronic request formats, will lead to an increase on the burden placed on physicians and on the threats to patient confidentiality. We are especially concerned that the payer or governmental response to HIPAA standardization of the claim will be a greatly expanded use of attachment requests to circumvent claims standardization.
What aspects of these processes would be aided by standardization and electronic exchange of information?
The AMA believes that standardization of formats and electronic exchange should reduce the costs of preparing and submitting attachments and enable physicians and the health care system to realize the full benefits of electronic data interchange and administrative simplification. At the same time, as indicated above, accomplishing such partial standardization without standardizing when attachments are required could make matters far worse. Given the current extent of physician use of electronic medical records, the state of standardization of such systems, and the lack of standardized links between clinical and administrative systems, the costs of obtaining attachments information from existing electronic or paper medical records and then placing it into standardized electronic formats could be prohibitive.
Fundamentally, the AMA believes that the HIPAA mandate for claims standardization, as well as emerging electronic claims formats that are less constrained than the paper form, provides a conceptual, regulatory, and technical framework to reduce or eliminate much attachment use.
For example, the AMA supports the position and efforts of the National Uniform Claim Committee and the National Uniform Billing Committee to use the claim format to eliminate the need for specific types of attachments through efficient use of specific data elements and associated code sets (e.g., a code attesting that a signed consent or medical necessity form is on file in the physicians’ office). With this vision, there would be substantial cost savings for providers and payers and a realization of the true potential for administrative simplification.
What is the relationship between claims attachments and the medical record?
The AMA has determined that although quite often attachment information is drawn from the medical record, we believe that attachments and their standardization should be viewed primarily as part of the administrative and claims-related process.
Do you ever submit the entire medical record to payers in support of the claim? Under what circumstances is the entire medical record submitted?
AMA members have indicated that physician practices do often submit the entire or large portions of a medical record to support a claim. We understand that hospitals do so as well. The decision on what to submit will depend on the extent of the payer’s request, the physician’s expectation of the documentation that will be needed, and, the extent to which the information in the record is in the format requested by the payer. In the latter instance, or when a request is overly broad or vague, it is often the case that the entire or large portions of the record will be submitted.
Do you have any suggestions that would assist us in the task of standardizing the requests for additional information from payers?
The AMA suggests that, first, the instances in which attachments can be required by payers must be standardized, with the goal to reduce the need for and use of attachments. Second, standardized mechanisms to submit attachments should allow for use of both free form text and standardized messages and codes for results, etc. The standards should accommodate the range of current administrative and clinical information systems in physicians’ offices.
Would the automation of health care claim attachment information and standardization of the payer’s requests for information reduce operating costs for your facility?
The AMA believes that with the caveats that have been raised in prior questions, there is substantial opportunity for cost savings if the attachments are standardized along the lines that we suggest and if this standardization is not tied to particular technologies or levels of practice automation. We cannot stress too highly, however, the potential for systems upgrade and training costs, coupled with increased practice costs if payers generate an increased number of automated attachment requests that require non-automated or semi-automated responses.
A recent study commissioned by the AMA determined that, in general, the use of electronic medical records systems in the health care arena is relative to the size of the practice. The larger the practice, the more likely the use of an electronic medical records system. However, it was found that with the ambulatory practice, less than 5% of outpatient records were computerized as of 1997. Group practices of 20 or more had 20% of their patients records automated and 25% of the hospital had their records automated.
In this same study, it was determined that the electronic medical records systems ranged significantly in cost from $4,400 to $775,000 depending on the size of the installation. In addition to these purchase expenditures, the physician should also expect an initial increase in administrative costs as well as a decrease in productivity for several weeks while physicians and staff adjust to the newly installed systems. These are very important factors that need to be taken into consideration.
Can you clearly differentiate “clinical information,” “claims information,” and “attachment information?”
The AMA has determined that claims information contains some clinical information (e.g., CPT and ICD codes). Clearly, however, the range of clinical information that could be contained in an attachment is much broader, including patient health histories, examination findings, provider notes regarding diagnoses, treatment plans and services rendered, laboratory data, consultation reports and a record of therapeutic agents administered, provided or prescribed.
Administrative records contain patient identification data, clinical data used for billing purposes (e.g., CPT and ICD codes), and demographic and financial data. Claims can also contain additional clinical data (e.g., birth weight, date of last visit for this condition, and test results).
A claim is derived from the patient administrative record and clinical record associated with services rendered.
Attachment information could include additional clinical or administrative data. The main distinction seems to be the extent to which the information can be included in a standardized claims format, even if some data elements on the claim are situational.
Are there health care claim attachments that do not contain “clinical” information?
The AMA, as previously indicated, believes that attachments can also include patient or insured administrative information.
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 the responsibility for approving the content of claims attachments? Can you suggest which organization(s) should have this responsibility?
Yes. The AMA believes that there should be an organization, other than those responsible for the messaging transactions, to be responsible for approving the content of claims attachments transactions. This organization should also be responsible for the content and for transactions applicable to the attachment and be representative of all parties affected by health care electronic data interchange (e.g., providers, payers, standards development organizations, regulatory agencies). Based on their structure and current and anticipated responsibilities, the NUCC and the NUBC are appropriate to assume this task.
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 NUCC has an official operating protocol that addresses modifications to claims data content. This protocol provides full due process, open meetings, and the ability of non-members to generate agenda items. It is being revised to broaden the parties represented on the NUCC and to address the need for additional appeals processes. Fundamentally, data content should be maintained through committees, like the NUCC and the NUBC, that focus on formal representation of key parties to the transactions for which they are responsible, using a consensus approach to decision-making. Data content maintenance is a quasi-policy activity that should be conducted through the kind of public/private partnership that these two committees exemplify and not viewed as a primarily technical communications standard.
What impact will the incorporation of HL7 messaging in the standardization of attachments have?
In the AMA commissioned study referenced previously, it was found that 46% of health care software systems support HL7. However, the AMA believes that the use of HL7 by physician systems is not sufficient at this time to base an attachments approach on this messaging standard.