hipaa transactions testing and certification · 2012. 4. 27. · hipaa transaction testing •...
TRANSCRIPT
HIPAA Transactions Testing and Certification
Larry WatkinsExecutive Vice President, Claredi Corporation
Co-chair, WEDI SNIPCo-chair, X12N Health Care Task Group
Member, DSMO Steering Committee
April 29, 2003
Topics
• HIPAA Transaction Addenda Rule• State of the HIPAA transactions• Current testing process• The WEDI SNIP testing model• Certification – What is it?• Measuring progress• Trading partner specific issues• Paradigm change
Transaction Addenda guides• X12N Version 4010A1 Implementation Guides
– Work started October 2000– First drafts completed June 2001– NPRM published May 31, 2002– Small changes in response to NPRM comments
• NDC, Taxonomy, anesthesia, etc.– Published November 7, 2002
• Final Rule published February 20, 2003– Adopts 4010A1 as standard versions for 10/16/03
compliance
Transaction schedule• X12N Implementation Guides for
HIPAA– May 2000
• Current version mandated for 10/16/02• Expected to be obsolete on 10/16/03
– Addenda A1• Published November 2002• Final Rule released in February 2003• Implementation required by 10/16/03• Mandated modification of the May 2000
version
PROVIDERS INSURANCE AND PAYERS SPONSORS
EligibilityVerification
Service Billing/Claim Submission
AccountsReceivable
Enrollment
Claim Acceptance
Accounts Payable
Enrollment
Claim Status Inquiries Adjudication
PretreatmentAuthorization and Referrals
Precertificationand
Adjudication
Enrollment
InvoicePayment Order
Elig. Inquiry
Elig. Response
Health Care Services Delivery
Claim
Patient Info.
Claim Status Inq.Patient Info.
Claim Status Rsp
Claim Payment
EligibilityVerification
Service Billing/Claim Submission
AccountsReceivable
Enrollment
Claim Acceptance
Accounts Payable
Enrollment
Claim Status Inquiries Adjudication
PretreatmentAuthorization and Referrals
Precertificationand
Adjudication
834
820
270
271
278
837I,P,D
835
PROVIDERS INSURANCE AND PAYERS SPONSORS
276
277
EligibilityVerification
Service Billing/Claim Submission
AccountsReceivable
Enrollment
Claim Acceptance
Accounts Payable
Enrollment
Claim Status Inquiries Adjudication
PretreatmentAuthorization and Referrals
Precertificationand
Adjudication
834A1
820A1
270A1
271A1
278A1
837A1
276A1
277A1
835A1
PROVIDERS INSURANCE AND PAYERS SPONSORS
Why Addenda?• The May 2000 versions of the
guides have severe flaws.– Addenda changes only the most critical
errors “required for implementation”– Most significant changes are to the
837’s and the 278• Other errors and omissions will be
corrected in version 4050
Future of transactions
• Version 4050 guides in development– Out for public comment in March
2003– Informational Forums in June
during X12 (Nashville, TN)– Expected approval in June 2003
• Will they be adopted under HIPAA?
New transactions in 4050• Available for voluntary use (not
mandated at this time)– Claim Acknowledgement 277– Coordination of benefits 269– IG Error Reporting 824– Eligibility Roster 271– Claims Attachments 275– Referral Attachments 275– Prescriptions (NCPDP Script)
Implementation Guide Interpretations
• Ambiguous situational language– Companion Documents necessary
• Interpretive issues minimal– Education a more significant factor
• X12N IG Interpretation Work Group– CMS has requested help from X12 on IG
interpretation questions– Single site to post questions– Central place to obtain answers– Expected in place by June 2003
HIPAA Transaction Testing• Finite period of time to HIPAA deadline
– Testing must start by April 16, 2003• Limited resources (internal & external)• Expected testing bubble in late 2003• Testing and production have conflicting
requirements– Testing: detect and reject errors proactively– Production: accept maximum number of
claims. Keep low rejection levels.
Testing Challenge
Payers
HMOs
Gov’t
Physician
Hospital
Pharmacy
Gartner Group: 2.9 million analyst months of end-to-end testing(Assumes 1 analyst hour for each trading partner relationship)
Compliant, or not Compliant?
• What is compliance?• What is a “transaction”?• Contingency Planning
– New Formats– New Business Process
• New data elements• New data requirements (situational)
– Big switch, or progressive steps?• HIPAA compliance or continued business?
– WEDI White Paper being drafted
Testing today• Find trading partner that agrees to test
with you– Typically one that will eventually benefit
from your transactions.– They must be ready. Or “readier” than
you are.• Send or get test files• Get test report from/to trading partner• Correct errors found with trading
partner• Repeat the cycle until no more errors
Graphical view• EDI Submitter contract• Telecom / connectivity• X12 syntax• HIPAA syntax• Situational requirements• Code sets• Balancing• Line of business testing• Trading partner specifics
1-2 days
3-4 days
2-3 weeks
3-4 weeks
Testing with multiple Trading Partners
TP Specific
TP Specific
Common in HIPAA(2-3 weeks each)
Today’s Testing• Creates a bottleneck
– Cannot start until both trading partners are ready
• If trading partner does not care about certain data elements– No errors reported this time
• If trading partner requires some data elements– Not an error for anybody else
• Is the error in the sender or the receiver of the transaction?– Cannot tell for sure.– Different interpretations.
• Unfair cost for the “readier” partner.– They end up debugging their trading partners.
Result from Today’s Testing
• Repeat the testing for each trading partner
• Common HIPAA requirements tested again from scratch each time
• Never sure of whether the testing is:– Complete, correct, repeatable
• Very time consuming, expensive, wasteful process
• Certifiable “capabilities”– Type of claim
» Specialty, POS, other– Medicare payer
» Primary, MSP, COB– Additional claim “features”
» Claim level, service level, identifiers, COB, etc.• Overwhelming number of possible permutations!• Is it useful to certify “capabilities” and “features”
by themselves instead of all the permutations?– Is it feasible to do otherwise?
Testing Complexities
Breaking the cycle• First phase: Testing
– Start testing as early as possible. HIPAA IG’s.– Confidential Testing against a neutral third
party test tool, not with my trading partners.– You know where you are. Interpret the results.
• Second phase: Certification– Now I am really ready. Third party verification.– I want the world to know.– I want to start engaging trading partners.
• Third Phase: Business to Business– Repeat for each “companion document” / TP
Certification is:
• Third party verification of the capability to send or receive HIPAA transactions, for specific business purposes, in compliance with the HIPAA Implementation Guides
• Testing• A guarantee that all transactions will be forever
perfect• The assurance that there are no errors in the
transactions
Certification is not:
Valuable Transaction Certification
It’s about production!
• Testing solution must consider all aspects of transaction success
TransactionError Free
Errors
Compliant
Non-Compliant
Relevant
IrrelevantRational
Irrational
Don’t stop here!
Testing in Complex Environment
• Is testing of vendor, billing service, or clearinghouse enough?– Specific business process differences
• Examples: Referring Dr., Secondary payer, Patient relationship to Subscriber
– Entire process must be tested:Data collection
Data formatting Reformatting (if applicable)
Trading partner acceptance
Medicare
MCOs
Commercial
HMOs
BCBS Plans
Medicaid
Beneficiary
Physicians
Labs
Hospitals
Surgicenters
Billing Agents
IDS/LDS
ClearinghousesPPMS Vendors
HIS VendorsVANS
Private NetworksLDS/IDS Initiatives
Telecom Companies
The EnvironmentThe Environment
Clearinghouse
Clearinghouse
VAN VAN
Payer
Payer
Provider
Provider
BillingService
P
P
P
P
P
Simplified Connectivity Model
ConnectivityConnectivity
BeneficiaryBeneficiary ProviderProvider PPMS/HISSystem
PPMS/HISSystem
BillingAgent
BillingAgent
MSOMSO
VANVAN
NationalClearing-
house
NationalClearing-
house
Proprietary/Private
Network
Proprietary/Private
Network
Private
MCO
HMO
PAYORS Blue
Medicare
MedicaidProprietary/Private
Clearinghouse
Proprietary/Private
Clearinghouse
InformationFlow
InformationInformationFlowFlow
Today’s ComplexEDI EnvironmentToday’s ComplexToday’s ComplexEDI EnvironmentEDI Environment
Elements of ProcessData CollectionData FormattingData Re-formattingData Reception
Elements of ProcessData CollectionData FormattingData Re-formattingData Reception
CollectionCollection FormattingFormatting Re-formattingRe-formatting ReceptionReception
• Certify your HIPAA compliance– Indicates capabilities related to requirement to
comply with the HIPAA law– Utilizes “learning curve” time effectively
• Certify the transaction capabilities you can demonstrate– Ensure compliance of complete information
flow – Collection through Reception– Reduce interpretation battles– Reduce amount of trading partner testing
required
Valuable Transaction Certification
Progress not perfection
• Certification of the capability– Certif. for some transactions, not others– Certif. for some Bill Types, not others
• Not all claims will be compliant– Gap filling issues– Implementation guide errors– Legacy data, data errors
• Perfection may be impossible
How are you doing?• EDI implementation of the claim
takes about 6 months– Compare with 2-3 weeks for NSF or
UB92• Waiting for your trading partners?
– Are they waiting for you?• What is the plan to start testing?
– ASCA deadline April 15, 2003• Avoid last minute rush!
One locust is called a grasshopper.
A Plague.A Plague.
Put a few thousand in one place and we call it…
TEST NOW!TEST NOW!