Jim Whicker, director of electronic data interchange for 24-hospital Intermountain Health Care in Salt Lake City, wonders if providers across the nation understand the scope of new transactions processing mandates in the recently enacted health reform law.

The law requires adoption of "operating rules," between 2013 and 2016, to make electronic claims and related transactions more uniform. It also requires creation of two new HIPAA transactions--electronic funds transfer and claims attachments--and the long-delayed unique payer identifier.

Much of the compliance work will fall on transactions processing and revenue cycle management software vendors, but providers will have their own work to do. Whicker worries that providers don't understand the law's provisions. "I get the feeling a lot of people think it will take care of itself and we'll implement whatever 'they' come up with."

But these operating rules need input from the people doing the actual billing, collections and other revenue cycle work in provider organizations. Whicker remembers when the Utah Health Information Network developed similar uniform transactions for the state. "We thought we did a good job, but people who do eligibility verifications noted our transaction didn't cover preexisting conditions," he says. "Once that was identified, UHIN made adjustments to that requirement to meet the need."

So at minimum, providers need enough awareness of the coming operating rules to make sure their needs are met, he advises. They also need to make sure their EDI and software vendors are aware of and preparing for the changes coming to claims, eligibility, claim status, referral, preauthorization, payment and remittance transactions, among others.

"You need to talk to your vendors and ask what they know about the rules, and what they will build into their tools to ensure we can take advantage of them," Whicker says. "So, providers need to know enough to know that their vendors are on track."

The mandate to adopt operating rules comes as the industry is preparing to adopt a new version of the existing HIPAA transactions, called 5010, and effective in January 2012. That means vendors and providers will start modifying the 5010 transactions, shortly after implementing them. Delaying the 5010 deadline isn't a good option, Whicker notes, because the transactions support the upcoming ICD-10 diagnosis and procedure code sets, effective October 2013.

Further, vendors say it would be preferable to have ongoing updates to HIPAA transactions then having a Big Bang change, such as the conversion from the existing HIPAA 4010 transactions to 5010, he adds. "Let's get 5010 out there, then tweak. "There's enough good stuff in 5010 that we should move forward."

The HIPAA 5010 transaction sets start the work that operating rules will accelerate to enable insurers to provide more information, such as a patient's benefit levels and deductibles, back to providers when they check eligibility. With operating rules added, providers and patients should know at the time of service what the patient's payment responsibility is, and much of the billing, payment and posting process should be automated.

But taking advantage of better transactions means being able to capture--and use--every data element a payer can send, Whicker says. And that means workflow changes will help determine the benefits that a provider organization receives. "What do you do with all that data once it's in house? How much benefit do you want to derive from the transactions?"

To get full benefits, providers must be proactive and make sure the operating rules have what they need, contends Whicker, who is past chair of the Workgroup for Electronic Data Interchange, a Reston, Va.-based industry advocacy organization. "We need to make sure from the provider perspective that we have a voice out there. The goal is to improve efficiencies and there's a lot in these rules to do that."

--Joseph Goedert


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