Commentary: Your Plate Just Spilled Over

If you think the perfect storm was having to comply with electronic health records meaningful use criteria, HIPAA 5010 transactions, ICD-10 and the Red Flags rule at the same time, you are not alone.

In public comments to federal officials about the proposed meaningful use criteria, one message came through loud and clear: "We already have a lot of regulatory deadlines on our plate and the meaningful use criteria are too much, too soon."

Well, your plate just got fuller. Assuming the Senate holds its end of the bargain, President Obama within days will sign health reform legislation into law. And that law will have a lot of new electronic data interchange/transactions processing mandates imposed on the health care industry with the first deadlines only three years away (see story).

On the surface, the EDI mandates are good for the industry, and especially good for providers who should see improvements in their revenue cycle management processes. Providers will have a much better idea at the point of service of how much insurance will pay and how much the patient will owe. Providers, ideally, will experience fewer denied or pended claims because they thoughtlessly forgot how each of the dozens or hundreds of payers they deal with like their transactions to be sent to them.

The EDI mandates in the reform bill are designed to, finally, make the HIPAA transaction standards far more standardized. They also will add new transactions, such as electronic funds transfer and claims attachments, as well as a unique health plan identifier. The mandates require consensus-based "operating rules" be adopted for each HIPAA transaction to make the movement of electronic claims and related transactions as easy as ATM transactions. Payer advocacy organization CAQH has championed these operating rules and has prodded industry stakeholders to negotiate and develop them to make transactions more uniform.

In theory, that means you'll fill out and send your claims, eligibility and claims status inquiries, authorizations and other transactions to Aetna the same way you send them to Cigna, UnitedHealthcare, the Blues and everyone else. And the payers will send their responses back in a uniform manner. And who owes what and when it will be paid will be far more clearer than today. And you'll save money by having fewer employees spend large parts of their day on the phone, on hold, waiting to talk to insurers. And more claims will get adjudicated on the first pass through payer systems, improving your cash flow. And auto-posting of payments to patient accounts will be a breeze.

But many providers may view the deadlines for all this nifty administrative simplification stuff to be as unrealistic as they viewed the meaningful use deadlines.
The reform bill calls for a unique health plan identifier by October 2012; and operating rules in place for eligibility and claim status transactions by January 2013; EFT and payment/remittance advice transactions by January 2014; and claims/encounters, enrollment/disenrollment, premium payment, referral certification/authorization and attachments transactions by January 2016.

That means that by the time HIPAA 5010 transactions go into effect in January 2012, work will be well underway to significantly change those transactions--and add new transactions--within just a few years.

And that also means all this transactions/operating rules developing, building, testing and implementation will come during the same time providers are handling ICD-10, Red Flag, and meaningful use requirements.

If that doesn't seem realistic, then the transactions timetables must be extended and that means getting amendments approved to a health care reform bill that just passed after decades of trying. That won't be easy. Still, maybe the 5010 transactions shouldn't go into effect in January 2012 as scheduled. But that argument can't be made to policymakers until it is clear how a delay in 5010 would affect ICD-10's deadline of October 2013--and the degree to which a 5010 delay would impact the industry migration to ICD-10.

Regardless, it won't take long for the ink to dry once President Obama signs the reform legislation, and that's when a new round of questions will arise.

--Joseph Goedert