Industry Groups Urge Changes in Transactions Implementation Process

January 29, 2004 – The Workgroup for Electronic Data Interchange (WEDI), an authorized advisor to the Secretary of the Department of Health and Human Services (HHS), held a special public hearing on January 27 in Tampa, FL, to gather information from the healthcare industry on implementation of the HIPAA Transactions and Code Sets (TCS) standards. Twenty-six healthcare entities presented their perspectives on this matter, including the workability of contingency plans between trading partners. Those testifying represented a cross-section of key stakeholders including payers, providers, clearinghouses, consultants, government, etc. WEDI received input from healthcare industry representatives on the following:

• The readiness of health plans, providers, clearinghouses for HIPAA compliance as well as business associates and vendor partners;
• Information regarding X12N transaction data content concerns;
• Sequencing and strategies for the implementation of future HIPAA regulations; and
• Obstacles and issues the healthcare industry has been dealing with in achieving compliance.

The American Medical Association (AMA) and the American Hospital Association (AHA) both testified that HIPAA TCS standards, such as X12N data content, should be consistent with the goals of administrative simplification. Healthcare providers are "burdened with onerous requirements to collect data" that they do not have access to, and which provides no patient benefit. AHA "urged the Centers for Medicare & Medicaid Services (CMS) to immediately (adopt)...critical changes to the standards that balance the burden of additional data collection with the benefits of requiring the data." Also testifying were the Claredi, a transactions testing and verification firm, Medical Group Management Association (MGMA) and Phoenix Health Systems on behalf of the Healthcare Information and Management Systems Society (HIMSS).

In its statement, AMA said that it "...believe(s) overall industry compliance with the standards, or even testing for all of the transactions, is nowhere near 100 percent." In referring to the weekly graph on CMS' web site of the volume of Medicare electronic claims that it has received in the "HIPAA format," it was noted by the AMA and MGMA that the graph does not indicate whether data content is HIPAA compliant nor does it take into account the readiness level of each sector of the industry.

One of the issues the healthcare industry has been dealing with in achieving compliance is the use of healthcare payer "companion guides" to the HIPAA transaction implementation guides. "One of the goals of administrative simplification was to migrate from the 400 or so different transaction data formats to a single standard format," Claredi testified. "In doing so, the expectation was that a provider capable of sending the standard HIPAA transactions would benefit from transaction acceptability by all payers and clearinghouses, without having to accommodate different requirements from each payer. Through the use of companion guides, most payers have imposed the same sort of private requirements that were in place before HIPAA."

The groups made the following recommendations to smooth the transition to TCS and the remaining HIPAA regulations:

• Enforcement efforts and payer edits for translating the data elements should be lenient, with the objective of smooth claims processing.
  
• Medicare and private health plans should be permitted to continue accepting proprietary claim formats. The current system should be continued until the vast majority of providers can transmit HIPAA compliant transactions. In addition, significant notice should be sent to the industry before Medicare ends this enforcement flexibility.
  
• Adequate communication from payers to providers about what type of data content problems are causing denials or delays in payment.
  
• The AMA believes that the focus should first be on achieving universal use of the standard format and code sets and only after successful transition should the issue of required or situational X12N data elements be addressed.
  
• The standards setting and maintenance organizations must incorporate the concerns of the healthcare provider community into their decision-making process for developing and modifying standards and make the process efficient, proactive, effective, and fair.
  
• The AMA believes that the CPT guidelines and instructions should be specified as a national standard for implementing CPT codes.
  
• Stagger compliance dates and allow sufficient time to ensure successful implementation.
  
• Prior to implementation, completion of an independent and comprehensive analysis of the costs and benefits by provider type, and identify financial resources to assist with the costs.
  
• Expand provider and vendor educational activities.

WEDI will prepare a summary of the testimonies along with specific recommendations that will be submitted to the Department of Health and Human Services for its review and consideration.

Read AHA's testimony.

Read AMA's testimony.

Read Claredi's testimony.

Read MGMA's testimony.

Read Phoenix' and HIMSS' testimony.

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