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January 23, 2006
Mark B. McClellan, M.D., Ph.D.
Administrator
Centers for Medicare and Medicaid Services
Attn: CMS-0050-P
P.O. Box 8014
Baltimore, Maryland 21244-8014
RE: CMS-0050-P HIPAA Administrative Simplification: Standards for Electronic
Health Care Claims Attachments; Proposed Rule (70 Federal Register 55990)
September 23, 2005.
Dear Dr. McClellan,
On behalf of our 200 member hospitals and health care systems, the Illinois
Hospital Association (IHA) appreciates the opportunity to comment on the
proposed rules for standards on electronic health care claims attachments as
mandated by the Health Insurance Portability and Accountability Act (HIPAA).
While we support several of the recommendations of the proposed rules, we
also are once again concerned that there is a lack of business rules governing
the HIPAA rules. That is, the usage of an attachment should be a rare occurrence
and not routine. If it is a routine practice and will be required on all claims
of a particular condition, then the reporting requirements should fall under the
actual HIPAA claim, the 837, than under an attachment.
Current Limitations of Health Plans Effecting Provider ROI
IHA members continue to be concerned about the overall lack of usage of the
features of the 837 claim and find that many health plans can readily have their
issues resolved if they would only read in and process the data currently
required to be reported to them. For example, while providers are required to
submit up to and including 25 diagnostic and 25 procedure codes, most health
plans only process 9 diagnostic codes and 6 procedure codes thereby reducing the
understanding of the complexity of the patient’s condition and often times
reducing payments to providers. One of the largest health plans that requires
all 25 codes to be reported but only processes the first 9 diagnostic codes and
first 6 procedure codes is Medicare.
Business Rules Required
We remain extremely concerned that the amount of resources required to
implement the attachments is significant and that providers remain concerned
about receiving a return on investment for both the 837 and the attachments.
While HIPAA has not in the past addressed business rules or processes, the fact
that attachments are subject to be required when a health plan decides they need
them, could serve to delay payments and not allow a hospital to operate
efficiently. There needs to be business rules and guidance around the usage of
attachments and under what circumstances they will be required. Providers are
extremely concerned that there are large amounts of dollars involved in building
the systems and programs for the attachments and there appears to be no return
on investment.
Formal Process Needed for Coordination with 837 and Future Modifications
Additionally, there is no formal process for coordination of attachments
with the 837 and therefore there are redundancy of information requirements and
inefficient solutions being proposed. IHA strongly recommends that the process
using the Data Standards Maintenance Organizations (DSMOs) established under
federal rule, be utilized for this purpose. The DSMOs have a well established
process for under-taking and reviewing requests and for coordinating activities
to allow for the most efficient approach to be utilized by a requestor.
Effective Date (page 55994)
Given the amount of programming involved and the need for testing and
training, a minimum of a three year time frame is needed from the time the final
rules are issued.
Tied to the date issue, is the concern over reference to a Version 4050 which
at the point of implementation will be Version 5010. IHA strongly
recommends that the versions be in sync with practice at time of implementation.
Electronic Claim Attachment Types (Pages 55996 – 55997)
It is unclear why emergency services are being requested to have emergency
room notes reported. According to hospitals, this is a very rare occurrence as
the ‘patient’s reason for visit’ was added to the 837/UB format in 1999 and it
is a rare occurrence for health plans now to need emergency notes.
Rather than focus on the rare occurrences which have no return on investment,
it would be best to focus on the attachments that have delayed payments and are
increasingly being required by health plans. These occurrences include:
Secondary Payer Questionnaire, Sterilization Consent Forms, Medicaid Spend Down
Forms, and DME – Medical Necessity.
Thank you for the opportunity to comment on the proposed rule for electronic
claims attachments. If you have questions or require further explanation of our
membership issues, please contact me by telephone at 630-276-5590 or by e-mail
at pmerryweather@ihastaff.org.
Sincerely,
Patricia Merryweather
Senior Vice President
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