Medicare Compliance & Reimbursement

Three months before the Health Insurance Portability and Accountability Act's transactions and code sets rule goes into effect, health plans and providers are disagreeing about which side is going to cause the most problems.

A July 1 letter from a coalition of provider groups - which includes the American Hospital Association and the American Medical Association -called on the Department of Health and Human Services to do something to avert a "train wreck" on Oct. 16, when the rule goes into effect. It is unclear whether HHS will indeed act, which could mean that provider groups won't be up to speed come October. And that would be bad news for health plans.

Many provider groups have been contracting with clearinghouses, and some clearinghouses have not been testing as thoroughly as they should, says attorney Michael Roach of Michael C. Roach and Associates in Chicago. Some clearinghouses aren't even planning to start testing until September, which would not give them much time to rectify any problems they might find.

As a result, some clearinghouses could send claims data that either don't satisfy the transactions standards or that can't be read by the health plan, Roach says.

This poses a number of questions. For example, say a clearinghouse or provider submits an electronic claim that is riddled with syntax problems, making it impossible for the health plan's computer to access it. "Does the clean-claim time clock start to tick on that day, or does it start to tick on the day that the plan can actually read it?" Roach asks. Plans and providers obviously would answer that question quite differently. But how will insurance commissioners answer it? Even their answers could differ from state to state.

Also, a large provider group or hospital that has trouble submitting HIPAA-compliant electronic claims might just decide to revert to paper while it tries to fix its mistakes, and that could "bury the plan in paper," Roach warns. The plan would have to wade through a sudden onslaught of paper claims, and meanwhile "the clean-claims clock is ticking."

Roach warns that some hospitals "are stockpiling paper forms" for just such a scenario. If they have trouble complying electronically, they will be quite willing to hit the plans with paper.

But not everyone is predicting a train wreck. "There will be some delays in payment," says attorney Alan Goldberg, of Goulston & Storrs in Washington. "But you know what? There are delays now, too."

Goldberg doesn't think health plans should fear that providers are procrastinating and deliberately setting the stage for an October of botched claims. "Trains don't wreck very often anymore," he says, "and to the extent they do, it's not because of electronics, it's because someone fell asleep at the wheel or there was a cow on the tracks."

Provider groups have accountants and lawyers and billing departments, people who are working hard to ensure the deadline goes by without a hitch, Goldberg points out. The bottom line for providers: They want to get paid, so they'll do what they have to do to get in compliance.

Regardless, plans and providers should take the October deadline "very seriously," Roach says. Though it doesn't pose the same risks that some experts thought the Y2K crisis would pose, Roach recommends that plans approach this dilemma with the same foresight and planning with which they prepared for Y2K.