Mr. Chairman, members of the National Committee on Vital and Health Statistics (NCVHS) and staff, ladies and gentlemen. Good morning!
My name is Dan Rode. I am speaking to you today on behalf of the Healthcare Financial Management Association (HFMA), where I am the Technical Director in the HFMA Knowledge Network™. We thank you for your invitation to testify this morning on the issue of attachments as they relate to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Given that my colleagues on this panel basically represent the healthcare vendor community, I believe it is important to point out that HFMA is a 51-year old professional association made up of more than 35,000 individuals. HFMA members work across the nation in various financial, information, and administrative settings including clinics, hospitals, integrated delivery systems, physician offices, home health agencies, and skilled and long-term care facilities. In addition, many members work in the payer arena, in managed care organizations, and third party administrative organizations, as well as in consulting firms, academic settings, and vendor firms.
HFMA members have been involved in the quest for a uniform claims process for almost 30 years. During this time we have participated in the formation of the National Uniform Billing Committee (NUBC) and the American National Standards Institute’s Accredited Standards Committee X12N and its healthcare task force. HFMA also participated in a national task force to standardize claims audits with a panel of payers and providers early in the 1990s. Claims audits are often requested by third-party payers to determine the veracity of the provider’s claim.
My written testimony includes answers to the specific questions that were issued with your invitation. Given the depth of your questions, I will try to summarize, here, our overall response to this issue of “attachments.”
The request for additional information or attachments has plagued the healthcare claims process for many years. Some providers will argue that the additional information sought by the payer is not needed and is just a stall tactic used by payers to delay the payment of a claim. Some payers will argue that they need the additional information to process the claim accurately and ensure that the claim is “clean.” They will tell you the uniform claim, whether it is a UB-92 or a HCFA 1500, just does not do the job. There is more than a hint of truth in both statements.
The uniform bill has failed to do the job for a number of reasons. The most significant reason is that it can not meet the demand for additional information. While the NUBC and, I suspect, the National Uniform Claims Committee (NUCC) have attempted to meet the constant requests for additional information with more fields and codes, this task has not kept up with the demand for even more information, much of it extraordinary and forcing the provider to send its response via paper, therefore defeating the potential for a fully electronic billing process.
Very early in the use of the UB-82, many hospitals found themselves required to submit an itemized bill or invoice along with the UB-82 in order to be paid. Traditionally, even while providers have tried to stay within the scope of the uniform bill or claim, the demand for “attachments” is generally accompanied with the threat of delayed payment or no payment at all. The provider’s need for cash flow and capital therefore resulted in additional information being returned to the payer and it is not unusual to find providers sending more than enough information just to ensure that their claim is paid promptly. This paper work then clogs up the system.
As I have already noted, some of this request for additional information was due to the lack of data on the uniform claim or bill. Both uniform claims are based on paper formats that limit information to the fields that can fit on a 8 ½ by 11- inch paper. Electronic flat files can handle additional items in a specific field, but no additional fields or code types can be added. Payers who want additional information have provided their own proprietary form, requested notes or data from the medical record, asked for the record in part or in its entirety, or simply asked the provider to submit specific information in an unspecified format. I must also note that while some of this information is new, many payers require data already on the claims from or previously requested of the provider.
Payers, such as Medicare, Medicaid, some Blue Cross and/or Blue Shield plans, and other similar large plans have developed “preprinted” forms and specify what additional data are necessary before billing. Others do not request the additional data until after the initial claim is filed. While some of the “up-front” data may not be all that difficult to obtain, a paper claim must still be filed. This slows down the process and increases operating costs for both provider and payer. In addition, the processing of attachments, whether sent with the initial claim or as the result of post-billing requests for further information, add to the providers costs due to the delayed payment.
Based on our history with this issue and our concern for administrative simplification and uniformity throughout the healthcare industry, HFMA has recommended that:
I will elaborate.
HFMA has consistently suggested that “attachment” information, if justified, should be included in the basic electronic claim. In the ASC X12 environment this information could actually be either added to the potential data in the claim (X12-837) or electronically stapled in the form of a transaction, like the X12-275 (health care data), the X12-278 (healthcare services review information), or the X12-148 (first report of injury). Note, in many cases the ASC X12N has already added data elements commonly requested that could not be handled by the UB-92 or 1500.
HFMA has also called for the creation of a maximum data set. This means that there would be a set of data elements, determined nationally, that for some period of time would represent the full amount of data a provider (potentially broken down into groups) would need to accumulate in order to fulfill the administrative transactions required under HIPAA. While a provider and a payer could agree to transfer less than the maximum data set, no payer could require more data than the maximum in order to be paid. Payers seeking to expand the data in this maximum data set could petition the Secretary’s designated group on a periodic basis and make a case for expanding the data set.
The data discussed here could either be added to the claims transaction (837) or be placed in an existing or new transaction that would be electronically stapled to the claim. The X12N would be the group that could determine which way was most economical and effective with in the ASC X12 framework. The Secretary, working with an industry panel would then specify the data definitions, clinical content, and appropriate process for sending and receiving the added data. The Secretary would also determine, when and why such additional data should be sent or requested.
Unfortunately, clinical data such as emergency room or operating room notes, etc., that are often asked for have no current standard format. As the electronic medical record is developed, there is reason to believe that some of these clinical reports could be included in the “attachment” category. Development of the uniform electronic medical record will take time. The NCVHS is well aware of its progress and could perhaps take on the role of developing standardized clinical reports. On an interim basis, the NCVHS or a similar group, under the Secretary, must determine when it would be appropriate for a provider to respond to requests for paper records. For the provider who can scan or digitize data, the X12-275 offers a means of sending data. But, the data are not uniform and can be misconstrued by the reader.
The X12 837 claim is based on the existing UB-92 and HCFA 1500. These forms, in both their paper and electronic versions, are the purview of the NUBC and NUCC respectively. To fill the limited space available on these paper-based forms, the NUBC and NUCC have developed a series of codes which they oversee and coordinate. The Blue Cross and Blue Shield Association also oversees code sets for the X12-835 (healthcare payment and remittance).
HFMA believes that it is now time for an industry panel or committee, responsible to the Secretary under HIPAA, to take over these processes and codes as they will relate to the X12-837 claim and the other HIPAA-covered transactions. This is not because the NUBC and the NUCC have not served a valuable purpose. Rather it is because times have changed and the healthcare industry cannot continue to segregate the institution and provider processes and data. The integration of providers in various service delivery mechanisms as well as the integration of providers and payers have created a new era that must see the end of this artificial division. There must be uniformity across provider and payer groups as well as transactions and it is best served and coordinated by a single group. To continue the NUBC and NUCC past the HIPAA implementation creates unnecessary redundancy, cost, and confusion. While a new panel is needed, it ought to include those currently represented on the NUBC and NUCC as well as other professional, trade, and information systems vendor groups. Whether this can occur under the auspices of the NCVHS is open to question given your other goals and responsibilities; nonetheless it must occur under HIPAA and therefore under the direction of the Secretary. This same group that could also coordinate and work with the attachment issues outside of the electronic medical record.
Your questions also raise our concern regarding state and local healthcare (clinical, financial, and socioeconomic) data-reporting agencies. We do not question the role of these groups or their need (or the general public’s need) for data. We do question whether this should be considered as part of the claims process. The advent of a maximum data set in an electronic processing environment, as we have recommended, means that most providers will be able to more easily respond to these data group requirements outside of the claims process.
As we have already seen in a number of locations, even using a claims transaction format, such as the UB-92, data groups are capable of obtaining necessary information. The State of New York has in past times piggy-backed onto the claims process with a central claims clearing house. But at what cost to the claims process?
Many times the time line for obtaining such information is different than that of claims processing so that the data groups can take advantage of post billing, payment, and medical record development. We do not object to filing existing transaction sets for this additional data purposes. We hope that such data collection can be electronic and take advantage of the ASC X12 expertise, but such data collection should not be part of the claims process itself. It should be a separate process and perhaps a separate transaction.
As state and local groups collect the necessary data that is the reason for their existence, please do not let their needs result in delays and confusion in the claims billing and adjudication process! Do not let our claims forms and attachments be enlarged and convoluted to carry this additional data. This is against the simplification goals of HIPAA. We are sure that as the administrative simplification transactions and process proceed under the HIPAA mandate, and as the national uniform electronic medical or health record progresses, the needs of the state and local data groups will be met.
I am sorry that I was unable to be present for all of the testimony that has been given here the last two days or submitted to the NCVHS in writing. I would be happy to answer any questions related to my testimony or raised by others’ testimony. HFMA also stands ready to answer or assist in answering any future questions this attachment issue or other administrative simplification issues might raise.
Listed below are specific answers to the questions sent to those invited here today. We stand ready to entertain any questions you might have on these or other issues, today, or in the future.
Our thanks again for this opportunity to testify.
Gen 1. What is your definition of a claim versus a claim attachment?
Claim: Currently, we would define a claim as the UB-92, HCFA 1500 (1500) (paper or electronic versions), or ASC X12 837, used as a standard data set, for payment of healthcare services by a third party payer. However, there are also a number of claim forms and formats that cover the exchange of data for payment under managed care up to and including the standard claims just mentioned; there are still a few payers that will accept either an invoice (itemized bill) or “superbill” for payment. (Note: there are also dental claims that most of our members do not use but would fit the same definition.)
Claim attachment: There are a number of uses for the term claim attachment. Some use the term to describe specific forms that must be submitted with the claim. These would include proprietary forms used by Medicare and others for therapies, home health services, etc. Both payers and providers are aware of the up-front requirement for these additional sets of data.
The “first report of injury” is typically used by worker’s compensation programs as an attachment for any claim representing a work related injury. The X12-148 is an electronic transaction set for this form and could therefore be electronically stapled to a X12-837.
Many third party payers or third party administrators (TPAs) also use the term claim attachment to mean just about any “additional” data they wish attached to the initial claim or sent in response to an inquiry for additional data. Instructions or requests for this addition information come to the provider in a number of different ways and throughout the claims cycle.
Unfortunately, it is difficult to staple a paper attachment to an electronic document; therefore, either the entire transaction has to be done on paper or the paper attachment has to catch up to the claim before it can be adjudicated. This is not efficient or effective. It also means that providers who would like to utilize the services of a clearing house or value added network may instead have to maintain a paper system, just to meet the needs of third parties that want attachments. We see this as a barrier to smaller third parties being able to experience the positive aspects of administrative simplification.
Gen. 2. How should we differentiate information that is appropriate for the claim versus information that is appropriate for claims attachments?
One goal of the HIPAA legislation is administrative simplification. If there is significant and appropriate need for information that has not been accommodated by the UB-92 or 1500, then it would be prudent to add a data element(s) or segment (s) to the claim (X12-837).
The UB-92 and the 1500 are still basically paper documents. Any additional data, therefore, have to be “attached” or placed in the claim’s comments section. With an ASC X12 transaction, additional data that are standardized can be included in or “electronically stapled” to the 837, whichever is more efficient. There are ASC X12 transactions such as the X12-271(benefit information), X12-275 (patient information), and X12-278 (Health Care Services Review Information) that can be used if trading partners agree on standards.
All payers and providers need to agree on standard attachments or additions to the claim to complete the claims/adjudication process. The NCVHS or another industry group sponsored by the Secretary could serve this purpose. An example of a “standard process” would be to “electronically staple” an X12-148 (first report of injury) to an X12-837 for all industrial accidents. Fortunately, the “first report of injury” is a commonly used form. Most attachments are not as common.
It should be noted that an often requested item is the itemized statement, itemized bill, or invoice. (There are a number of different names.) In this case, the X12-837 was designed to permit the sending of such detailed information. Until the industry is up and using ASC X12 standards, however, the invoice is generally sent on paper.
Extraordinary information creates a number of problems. Presently, it usually means that a paper document carrying the requested information must be created. This might also mean that the claim itself must be converted to paper. This situation generally slows down claims processing and there are some who believe that such extraordinary requests are done for just this purpose (to slow down the payment for claims). Extraordinary information not only means additional process costs for providers and payers, but also loss of capital caused by the delay in processing and payment. This adds to the cost of health care.
It is my recommendation that the NCVHS consider eliminating the concept of extraordinary requests. This means that the NCVHS and/or some designated body should consider initially and on a periodic basis the need for additional data that should potentially be included in the claim or electronically attached to the claim using another X12 standard, whichever is more effective. Since much of the attachment data are clinical, the NCVHS might serve very well to develop the appropriate uniform data and data sets necessary to complete this task.
In promoting administrative simplification, HFMA and others have called for a “maximum data set.” This data set would be comprised of all the data needed to complete the HIPAA transactions. Essentially a provider or payer that maintained this data set could rely on the fact that they had all the data needed for claims processing. Payers would not be permitted to request additional data for payment purposes. If the case arose that additional data were needed to adjudicate claims, it would have to be added to the maximum data set by the designated group on a periodic basis. Some allowance would obviously have to be made for situations in which medical record information is needed for adjudication and legal purposes. But, even here criteria could be established to determine if the information request was appropriate, making such requests the exception, not the rule. Even here it is possible that the X12-275 could be use to send digitized data for certain specified reasons.
In talking with HFMA members who are both payers and providers, it also becomes apparent that some of the current “attachment data” are requested out of habit, rather than for any real need. Perhaps the data were needed at a time when a procedure was experimental or a population was new. Now the data are no longer needed but since “we’ve always collected it,” it is still collected. It is important that the claim and any standardized attachments be examined on a regular basis to determine that collection of the data is still necessary. A standard use requirement should also be flexible enough to allow a particular provider and payer to agree to send less than the maximum data, when they may see good reason to send everything. These two trading partners must remember, however, that secondary and tertiary payers may have reasons to see such data even if the two primary parties do not have such a need.
Most of the attachment information often requested (see questions 3 and 16) is currently not standardized, but has some use in the claims adjudication process. A good example would be an emergency room or operating room report. Presently, the X12-275 transaction would serve as a good vehicle to allow the provider to “staple” the report to the claim. It would be beneficial if the NCVHS, or a similar group under the Secretary, could determine which reports (actually which data) are necessary claims processing and when. Appropriate data definitions and data sets could then be established. Since some of the data is already redundant with the claim, this should not be too difficult. In the mean time, the X12-275 offers a method to keep the transaction electronic, but not standardized with regard to content and design.
Pyr. 3./Pro. 16. 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?
Respn. We expect that with the exception of Medicare you will find as many variations in response to this question as there are payers. Without standardization the transmission of such data is generally on paper and consists of itemized bills (invoices), parts of the medical record, and occasionally a proprietary form.
As part of a project for the Provider Electronic Billing Technical Advisory Group, we found the following routinely requested. Our designation (C = clinical, A = administrative, A/C = both) is a bit arbitrary, but shows fairly commons request that could serve a number of purposes. [Note: For some of these requests, programs such as Medicare, Medicaid, and Blue Cross or Blue Shield have specific forms on a local or national basis. These forms can therefore be anticipated in the data process.]
A -- Admissions Report
C -- Ancillary Test Results
A/C -- Conditions of Admission
C -- Consultations
A -- Detailed Statement of Charges/Itemized Statement/Invoice
A/C -- Discharge Summary
C -- Dictated Emergency Room report
C -- Doctors First Report
C -- EEG Report
C -- EKG Report
A/C -- Emergency Room Face Sheet
C -- Extended Services Report--psychology services
A/C -- First Report of Injury
C -- History and Physical
A -- Insurance ID Card -- Copy
A -- Invoices: pacemakers, implants, etc.
C -- Laboratory Results
C -- Medical Record (complete admission or encounter)
A -- Medicare Secondary Payer Questionnaire
C -- Medication Administration Records
C -- MRI Report
C -- Mammogram Report
C -- Nurse’s Notes
C -- Nutritional Services Orders
C -- Occupational Therapy Notes/Treatment Plans
C -- Occupational Therapy Reports
A -- Other Payer EOB
C -- Open Biopsy Reports
C -- Operative Report
C -- Pacemaker--notes for the medical record
A/C -- Partial Hospitalization Reports
C -- Peripheral Vascular Studies Reports
C -- Perinatal Summary
C -- Physical Therapy Notes/Treatment Plans
C -- Physical Therapy Reports
C -- Physician Orders (specific date or entire encounter)
A -- Prior rejection notice -- primary third party
C -- Progress Notes
A -- Proof of Benefits (Medicaid)
A/C -- Referral Information
C -- Respiratory Therapy Notes/Treatment Plans
C -- Respiratory Therapy Reports
A/C -- Second Surgeon Authorization/Certification
C -- Skilled Nursing Report
C -- Speech Therapy Reports
C -- Speech Therapy Notes/Treatment Plans
A -- Sterilization Consent
A -- Transitional Care Unit Admission Records
C -- Ultrasound Report
C -- Wound Care Report
C -- X-ray Results
Pyr 4./Pro. 17. 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?
This answer is similar to that of question 3 (documentation requests will vary). While one payer might request an attachment, another might request additional information (post submission). Obviously where a payer and provider work closely together and share a number of transactions, many of these requests become the norm. Pretty soon the provider generates the extra information even if it is not needed just to keep the payment cycle short. Generally, any information sought beyond that provided with the claim relates to some or all of the medical record(s).
Pyr 5./Pro. 18. What purpose(s) do these attachments and other documentation serve?
Some of this information is needed for adjudication and is requested as an attachment because it cannot be accommodated on the current (non-ASC X12) claims format. Some of this data are also available to the payer through other sources (or pre-service data exchange) and the attachment is redundant. Certainly this will be more the case once a full implementation of the administrative simplification transactions occurs and the requests for attachments could diminish.
It would seem apparent that if there is certain clinical, financial, or sociological data needed to generally (some type of 80/20 approach) adjudicate a particular type of claim, then these data should become part of the claim form itself, identified to be used (responded to) in certain specified cases. This doesn’t mean that there couldn’t be some payer-specific data, such as the Medicare 1485/SR form used in home health. But it does mean that (in this example) Medicare would seek inclusion in the transaction and approval from the oversight group.
There will always be some need for additional information in some adjudications. But, this need should be limited, both to preserve privacy as well as to decrease the cost of claims administration. As the medical record becomes standardized, the transmission of such data electronically will lend itself to specific data sets within the claim or as a standard attachment. Overall this means that there should be a maximum data set any particular provider should need to collect to meet third party adjudication needs and not find that there is a constant demand to produce extraordinary data. Meanwhile, there is an ASC X12 transaction (the X12-275) that would allow an entity to transmit data in its existing form electronically. Many institutions, short of scanning these data, do not have it available electronically.
Over the period of the last seven or eight years we have also seen an increase in requests for more data as part of fraud prevention. Fraud is a serious problem, but the Secretary, the NCVHS, and the industry must balance the need for more data against the cost of maintaining and transferring such data. Administrative simplification and uniformity, along with a full understanding of what data need to be collected by the provider, will serve to eliminate much of the error currently associated with claims processing. If this is the case then we should see less need to transfer all of these data as part of the claims process. Whoever oversees this function must keep this in mind or the industry will stagger over the vast amounts of data that in reality serve limited purposes for claims adjudication.
Pyr.6./Pro. 20. What aspects of these processes would be aided by standardization and electronic exchange of information?
As previously noted, any of the data that can be proved necessary to the claims adjudication process and can be standardized should be considered for inclusion in the claim itself or another electronic transaction that can be stapled to the claim. Providers and payers, acting as trading partners, should not be permitted to send such data except when necessary. Payers should not be permitted to request additional data except where permitted. The NCVHS or a similar industry group under the auspices of the Secretary or the NCVHS should develop uniform clinical and/or administrative data sets when proven necessary.
Pyr 7. What aspects of these processes are not conducive to standardization?
It is conceivable that all of the adjudication processes could become standardized. As with standardizing the medical record, however, it might take significant time to determine just how and when this can be accomplished. Data beyond that “normally” requested with the claim, are often used to provide plan purchasers (sponsors) with information that has been promised in the marketing effort of the plan. If data needed by sponsors, plan coverage purchasers, and government entities can be agreed upon as necessary, then they should be included in a data set and data standard, along with when and under what circumstances they are necessary. Unfortunately, this is a long way off and in the meantime the Secretary will have to reach some intermediate conclusions with the help of the industry.
We all have to accept the fact that there will not be a perfect data set. But if we can revisit the data set over time, we ought to be able to standardize during the interim and reach a consensus.
Pyr. 8./Pro. 21. What is the relationship between claims attachments and the medical record?
Much of the claim attachment information and the claims data itself come from data that currently or ultimately are stored in what we call the medical record. The medical record itself is considered the primary backup to the itemized statement, et.al. At times some data may come from other sources including the payer and possibly the patient, employer, sponsor, or gatekeeper.
Pyr 9./Pro. 22. Do you ever request the entire medical record from providers in support of the claim? Under what circumstances is the entire medical record required/submitted.?
While it is rare for the complete record to be demanded except in matters were legal action is occurring to determine the payer or liability in some locations, others inform us that one or more payers routinely request the complete medical records. Some providers have taken to sending the entire record when the payer consistently asks for multiple attachments and “additional information.” This is not a response that should become the norm. It has significant cost and privacy implications and should be considered by the NCVHS and the Secretary in developing criteria for when a full record should be considered necessary.
Pay. 10./Pro. 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?
Since the early days of working on what has become the HIPAA legislation, HFMA has called for a single industry committee/commission to oversee the standard use of electronic claims transmission, and the data contained therein that was not already under the auspices of other organizations such as the Health Care Financing Administration (ICD-9-cm), the World Health Organization (ICD), the American Medical Association (CPT-4), or the ASC X12 (transaction codes and sets) . Uniformity is key to the success of this effort. HFMA has called for uniform data definitions and data sets that can be used throughout the healthcare transactions, while still recognizing different provider types. While we originally recommended a new industry-based group, HIPAA designated you, the National Committee on Vital and Health Statistics to serve in this capacity.
The NUBC and NUCC have served a vital capacity for many years. However, theirs has been a single focus on the institution- or physician-based claim. In the name of uniformity, the focus must be directed at and common to all the HIPAA transactions. The code sets overseen by the NUBC and the NUCC must be incorporated and unified into a HIPAA group. The associations and perhaps even the individuals that make up the NUBC and the NUCC along with some others (e.g., information service or communications vendors) need to be involved in whatever body that takes over this function. If the NCVHS’s member resources and agenda is too full to handle such a task, or if the NCVHS can not be expanded to represent the full industry, then we suggest a subgroup under the NCVHS be established to fulfill the functions of determining standard data definitions, data sets, code sets, etc., not currently designated to the groups noted above (HCFA, WHO, AMA, and ASC X12). Code sets coordinated by other groups (such as payment codes housed by the Blue Cross and Blue Shield Association for ASC X12N use) should also be handed over to this new group. The only why to achieve industry use of the codes and consistency is to have input from the industry into one such body.
Pyr. 11./Pro. 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?
Assuming that the Secretary accepts the ASC X12 transactions, then it would remain with the ASC X12 to determine the technical aspects and standards for accommodating “attachments” within other transactions (X12-837, X12-278, etc.) or to establish a new transaction set(s). It would be the function of the NCVHS or a similar group (see above) to serve as the industry committee that would establish the actual use of these transactions and the healthcare data that would be contained within.
It will be arduous to determine what will constitute the maximum standard set(s) of data for use by providers and payers under administrative simplification, especially since we do not want these transactions to require any additional data outside of that agreed upon. This same group would also assign codes where appropriate, much as the NUBC and NUCC have in the past.
SDO. 12. Do you currently require providers to submit information that is not part of the standard claim?
Many data organizations do require additional information, but not as part of the claims process. They may, however, use a claims format or form to make it easier for the provider. The collection of this type of data for this purpose should not be merged into the claims process. A good claims process will attempt to bill the services rendered as soon as possible; therefore, while the data is accurate for billing, it may not be considered accurate for other data purposes that require review before transmission.
SDO. 13. How do you intend to continue to collect information from providers that is not part of the X12N health care claim?
If state or data organizations cannot use existing ASC X12N data sets for the collection of data, we would urge them to approach the ASC X12N for the expansion of an existing data set and/or transaction or the creation of a new transaction or data set. At the same time, the National Association of Health Data Organizations ought to coordinate its efforts with the NCVHS and any other HIPAA groups to ensure that affected providers and payers collect and distribute consistent data to meet the needs of their locality.
SDO. 14. Will states come together (e.g., under the aegis of the National Association of Health Data Organizations) to design a claims attachment that would serve their information needs in a standard way?
Data collection for these purposes should not occur as part of the claims process and therefore should not be a claims attachment. (Please see our other comments.) Data gathering of this type should be handled as a separate process and transaction, even if it uses the same standard transaction sets.
Pro. 19. 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 have differed by payer, region, and service type. Some of the data are consistent, some are not. It would seem that if the need for data is to complete the adjudication process, then a mechanism to expand the uniform data set(s) would be appropriate. If there is a uniform need for certain medical reports, such as the emergency room/department report, the NCVHS might also want to consider taking on developing uniformity in these aspects of the medical records. Again, a 90/10 or 80/20 approach might serve to begin the process and standardize the most common reports and attachments.
The eventual standardization of health data in the form of the medical record will greatly enhance this process. However, this will take several more years, far too much time to delay the implementation of a uniform claims process.
Pro. 23. Would standardization and simplification of the questions asked by the payer make the claim adjudication process easier?
Definitely! As noted before, it would allow for determination of a maximum data set to be used and accepted. Using a 80/20 or 90/10 approach, most of the needs of payers should be met and providers could submit the necessary data with the original claim, therefore generating the savings previously discussed.
Pro. 24. Do you have any suggestions that would assist us in the task of standardizing the request for information?
A formal query of representatives of the payer/health plan segments of the industry could be made to determine the data currently collected outside of the current claims formats (UB-92 and the 1500). It could also be determined when and under what circumstances additional information is needed. Once the data and/or sets of data are determined, the ASC X12N could then determine whether the additional data should be placed in the claims form (X12-837) or another transaction. The NCVHS or a similar group (as discussed above) could propose to the Secretary the data, data sets, code sets, etc., necessary. Providers and payers could petition for additions, changes, and deletions on an annual basis. This would be somewhat similar to the process used by the NUBC and NUCC, but centralized and involving all payers and providers.
Pro. 25. Would the automation of health care claim attachment information and standardization of the payer’s requests for information reduce operating costs for your facility?
Any appropriate standardization should reduce operating costs, and if such data are truly being requested for adjudication, it should also reduce processing costs for payers and the outstanding receivables cost for providers. The danger comes in adopting a process that can be continually expanded to request more and more data as part of the claims process. This is why the Secretary must ensure some limited means of expanding such data requests as part of the administrative transactions. There are many in the provider and patient communities who fear that as data are standardized and digitized it will be demanded in its entirety by payers. This is a fear that the Secretary and the NCVHS must keep in mind as decisions are made.
Pro. 26. Can you clearly differentiate “clinical information” and “attachment information?”
As shown above, not really. Providers can differentiate between the data, but the questions being asked in many of the requested “attachments ” are for data that include or are mostly “clinical information. For this reason the need to determine on a periodic basis what really makes sense for the administrative transaction data set is absolutely necessary.
Pro. 27. Are there health care claim attachments that do not contain “clinical” information?
Yes, there are a few that contain only financial or socioeconomic data, but for the most part just about all attachments and claims contain some “clinical” information.
Pro 30. What impact will the incorporation of HL7 messaging in the standardization of attachments have?
None, if you do not have HL-7 in your information system software base. If you do have the HL-7 messaging, it will be easier to send your attachments. [Note, the majority of providers do not use the HL-7 messaging available to them at this time and there is significant misuse of HL-7 standards as well.]
Pro. 31. Does your automated information management system have the capability to create a standard electronic healthcare attachment?
For the most part, no. Some systems are able to create certain of the Medicare attachments (e.g., in home health), but until there is uniformity most providers cannot do so electronically and thus must submit paper data. A few providers can use report writers or can scan paper data into an electronic format, but this is far from universal.
Pro. 32. (Hospitals) Would a standard claims attachment for state-mandated healthcare data reporting ease the reporting requirements for your facility?
This would depend on where the hospital is located. Many locations capture data by having hospitals submit a report in UB-92 format (but in most cases separate from the claims transaction). It is not that difficult to do. It will greatly depend on what data are needed and when it is needed. As we move into the concept of data transmission, rather than forms transmission, and as we move into the standardization of clinical data, it may be wise to keep such data reporting separate from the claims process. This would keep claims processing simple and data reporting more accurate. (Claims are many times billed well before the final sign-off of the medical record).
Ven. 33. What positive/negative impacts on existing systems would the inclusion of X12 and HL-7 Messaging in one standard have?
We have not heard of any issues or problems here with the exception of some concerns on the HL-7 implementation guide documentation and multiple versions of HL-7. Most providers, however, are not using either X12 or HL-7. They are waiting for national standards, so that vendors are forced to introduce such products. Vendors, too, are awaiting the standard use of X12 and HL-7 standards.
Ven. 34. How common are systems that integrate information across departments so that electronic requests for clinical information can be fulfilled electronically, regardless of the data source?
Currently, this would be a big problem. Most hospitals, physician groups, integrated delivery systems, and health plans do not have such a integrated system. Groups like the Health Information and Management Systems Society, the American Health Information Management Association, HFMA, the Medical Group Management Association, the American Hospital Association, and the American Medical Association could help the NCVHS to determine the extent of such integration but this will take time and some money. Integration will take place when there is an economic reason to do so and affordable proven technology is available.
Ven. 35. What problems do you foresee in implementation of standards for health care claims attachments?
Obviously, a process has to be put in place to incorporate the commonly collected data and reports into either the claim or the attachments. This means the formation of a group and a determination of where to begin. Some of the standard HCFA attachments could initially be handled, but from there it might be most appropriate to survey for common practices. The group overseeing this effort will also have to ascertain whether or not the requested information is necessary, when there are very few asking for it.
HIPAA suggests that “attachments” follow the implementation of the other HIPAA transactions. We suggest that, when possible “attachment” data be integrated into claims and other transactions.
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