Hello, my name is George Arges and I am the chairman of the National Uniform Billing Committee (NUBC). On behalf of the NUBC, I would like to thank the NCVHS for the opportunity to speak today on the important subject of attachments. My brief statement is intended to provide a framework for a process that can begin tackling the problem of attachments. Let me preface my remarks with an acknowledgment of support from all of the members of the NUBC that have and continue to act with passion and responsibility to achieve the vision of uniform claims standards. Their actions help to bring about administrative simplification. (Any critisim directed toward providers, payers, or other third-parties are not intended to apply to these members.)
Today the growing number of requests for attachments is unpredictable, unstructured, and unrelenting. The result is a claim processing system that is burdensome, costly, and inefficient with respect to processing claims and improving our knowledge of health status. Generally, the most frequent reasons for requesting attachments stem from two distinct needs. One need is for additional information to control the reimbursement being made, while the other need is to request attachments to arrive at an understanding of a specific aspect of the delivery system.
Recently, we heard the President of the United States in his State of the Union speech talk of strengthening the special relationship that exists between patients and their physicians. Clearly this special relationship has eroded, with more decision-making going to third-parties who request additional information that goes well beyond processing a claim or simply managing the care of the patient. In many of these cases the request for an attachment occurs because these third- parties seek to first manage their financial risk rather than manage the patient’s care - basically a reimbursement issue.
Health care providers often receive requests for additional information when third-party reviewers bring into question the medical necessity for some services delivered or even the medical necessity for the entire episode of care. In these situations providers receive requests for additional information about the clinical decisions made on behalf of the patient. These requests for additional information are often unstructured or insufficiently defined as a standard document. This becomes problematic for providers’ information systems designed around specific routines. The lack of specific definitions, structure, and methods for handling and reporting the additional data results in a process that cannot capture the data at the most efficient time and place - namely when the care is being ordered and rendered.
As many of you know, providers create a medical/patient record to track the significant events or services during the patient’s stay at their health care facility. The creation of a medical record involves many specific information gathering routines, yet the process that yields the creation of a medical/patient record is itself unique - if you have seen one process for developing a patient record then you have seen only one process. Since the delivery of health care services is done on a credit basis, many providers find themselves forced to gather more information and jump through many administrative hoops to receive payment. Their reimbursement for services rendered becomes a hostage of third-party payers until the additional data demands are satisfied.
There is no question that a high degree of accountability is needed to safeguard the financing of the health care system. We believe that the UB-92 data set provides the structure and level of accountable detail needed, and, can serve to further improve claims processing efficiency. There are already many claim details included on the UB-92 data set. Much of the detail is codified and intended to provide specific information as abstracted from the medical record. The purpose for the codes is to allow for further development of the claim and to allow any necessary edit logic to be programmed into automated claim processing systems. Unfortunately many people that request attachments do not know how to derive the information from the UB-92, or do not keep current with the data set’s codes. Consequently, the primary purpose for the creation - namely to reduce the need for an attachment- is lost as a result of their inaction.
As I mentioned earlier there are also other reasons for requesting additional information besides reimbursement. The other reasons are the needs of public health or health care researchers to examine with more specificity certain types of services delivered with each episode of care. These requests are in essence used as a means to gauge the pulse of health care delivery within and across communities. For instance the need to track pacemakers is one example; the need to report sexually transmitted diseases is another example. These requests, however, are more defined and structured. Therefore it is easier for providers to establish routines and methods for gathering and supplying this information. Providers know when they need to collect this information and the frequency of when to report this information. However, there still needs to be controls at the national level for these requests particularly when providers must deal with bordering states.
The NUBC realizes that there are specific circimstances for providing additional data or information. The process for evaluating the merits of the request should be coordinated through a national oversight body like the NUBC that has already established a method to evaluate the best course for gathering and reporting this information. The process should set clear policies and procedures for when and how to report additional claim attachment information. This could be through the establishment of a code to the UB-92 data set or perhaps establishing a separate electronic record or document designed around specific events or circumstances.
Committees like the NUBC have a proven management process that balances the viewpoints of providers and third-party payers alike. In addition, we have recently extended an invitation to include the National Center for Health Statistics (NCHS) as a member. This was done in light of the growing use of the UB-92 as an instrument used by public health and health services researchers and to gain their perspectives for the management of the claims transaction.
At the November NUBC meeting, we heard from HCFA representatives who were coordinating a “proof of concept model” for dealing with attachments using one of the ASC X12 transactions. While the design of the X12 transaction is promising as a transport mechanism for carrying attachment information, it can become meaningless and expensive if we neglect the policy and related management process which evaluates and establishes the business needs for the attachment information in the first place.
At that meeting, the NUBC questioned the creation of some claim attachments being presented. From our perspective, the request for attachment information should only be supplied in extraordinary circumstances - they should be the exception and not the rule. We would urge the NCVHS to consider whether the attachment data needed is a result of a deficiency in the information contained on the claim, or whether it is a result of the inability of users to accept and use the information contained in the claim data set to its fullest potential.
As I mentioned in one of the earlier NCVHS hearings, if we are going to achieve administrative simplification then each transaction identified in HIPAA should fulfill its intended purpose. Attachment information should not be routinely prepared for each claim. If specific information is needed, then those organizations requesting the data should go before the NUBC to make their case. Otherwise, we will never have a standard for a claim transaction.
Finally, I would urge the NCVHS to establish a management oversight process to examine, evaluate, and handle any attachment requests to the claim. The NUBC stands ready to serve in this capacity. Our protocol is structured to be sensitive to the needs of the provider, payer and public health research community. NUBC meetings have and will continue to be open to the public, so that the review and deliberation process for any request(s) for additional data receives a fair hearing.
As chair, I am required to include on the NUBC agenda those requests that come to my office. All I ask is that the request be properly filled-out in terms of purpose, what it hopes to accomplish, and if known the UB-92 data set element that would be affected. The committee will then review the request at the next meeting. At the meeting we discuss and deliberate on how best to handle that particular information. It should be noted, that there are also many important steps that take place between the time the request comes into our office and before the meeting takes place. Once the request is properly documented, it is added to the NUBC’s meeting agenda and the material is sent to each state uniform billing committee. This action is undertaken so that each of the major advocacy organizations, and HCFA’s Medicare and Medicaid programs, has an opportunity to formulate an opinion. This process allows us to gain perspectives from various constituencies on whether they support the request. Finally, these viewpoints help the NUBC members to formulate an opinion.
If a data request is rejected by the committee, the committee will explain its rationale and will usually make recommendations on alternative actions that should be followed. Our operational protocol does not limit or prevent the resubmission of a request. We do ask, however, that resubmissions be accompanied with a rationale which explains why the NUBC should reconsider the request, and to include any new information that would help to alter the committee’s thinking regarding the collecting and reporting of this information, or, if there are any special circumstances that pertain to the request (for example - legal requirements, federal law, state law, etc.).
With regard to the questions, since there wasn’t a category of questions geared to committees like the NUBC, we did not attempt to answer them. The first two questions, however, are probably the most important to answer. Coming to terms with the definitions of a claim and a claim attachment is extremely important. The Webster’s dictionary refers to attachment “as the physical connection by which one thing is attached to another; or, the process of physically attaching”. Is this the same view that Congress had in mind in the HIPAA legislation? If so what is it that we are attaching to the claim?
One of our payer representative gave an apt definition of a claim - “it is a formally defined series of structured data elements used to request payment for the rendering of health care services to the patient.” It should be noted that the key term here is: “formally defined and structured data elements”. For my purposes this defines the claim as a document. And, a document according to Webster’s dictionary is “official paper; proof or evidence relied on as the basis, proof, or support of something; something that serves as evidence or proof” .
If the claim is construed as a document that serves as the basis for seeking payment, or for describing the services, rendered to the patient during an encounter, can the same be said of the term “claim attachment”? Does claim attachment then mean the process of adding another document to the claim? What document is it that is being added? Some have described the use of the X12 N attachment transaction not as a document per se, but rather the process of adding other data to the claim. If we assume that it is a process of adding more data to the claim, then the administrative simplification benefits outlined in HIPAA would be lost. I do not believe this is what Congress had in mind when it identified attachments as part of the administrative simplification provisions in HIPAA.
Each of the transactions outlined in HIPAA are distinct and specifically referenced. Even the sections that deal with compliance to the administrative simplification provisions treats them as separate and distinct transactions. The law made no reference of attaching additional data to each transaction in order to embellish and make suitable that transaction for processing purposes. Instead the attachment section of the law specifies the creation of attachments at a latter date when the business case warrants the use of the attachment transaction for inclusion of separate documents. What then are these documents? And, what purpose do they serve?
Identifying these documents can be a daunting task, however, the process has already begun.
Already there is a large inventory of some of these documents, however, many are unique to a particular health plan or program. If these documents are to be part of the claim then committees like the NUBC, NUCC, ADA or NCPDP, which are responsible for managing the data content of the claim, as it pertains to their sector of health care delivery, should review them and evaluate how one needs to handle these documents as national standards. That means removing any variations that may exist for each health plan. Finally, I would urge that a bold plan be put in place, so these committees can work outside the traditional lines and be creative in their approach for handling these attachments and achieving the goals of administrative simplification.
Thank you for the opportunity to comment.