Gaffey + Associates | GEMS News | Issue 1

HIPAA Status The Status of HIPAA Transactions
An Aerial View for GEMS Clients

OK, so the HIPAA transaction deadline is October 16th, 2003 — Does that mean the race for healthcare trading partners to send and receive standard, HIPAA compliant transactions is about over?

Not Quite…
Gaffey + Associates works toward one goal: To increase and maintain your cash flow. We have had our fair share of success in sending and receiving HIPAA compliant transactions. However, we still face many more challenges as we continue testing and pushing forward the use of HIPAA compliant transactions to our trading partners.

As a premier EDI billing vendor, and your business associate, we hope to present an aerial view of today’s HIPAA landscape; and share with you the efforts we’re making, the challenges we’re facing, and recommend some approaches you may consider as we collectively move toward HIPAA compliance.

The UB92 you see is now... an 837 Version 4010A1!

More than any other HIPAA transaction topic, Gaffey + Associates and other HIPAA experts advise, answer and ask questions about data. The healthcare industry is a “UB92-centric” world. Trading partners’ mainframes, software applications, coders, doctors, and claims processors all think in terms of UB92 data.

Currently, through Gaffey + Associates’ GEMS billing software (GEMS), all of our clients submit claims to Medicare in the HIPAA 837 Version 4010A1 transaction format (837-4010A1). Was achieving this huge task easy? No. It took many dedicated hours of testing, retesting, corrections, analysis, exemplary communications, study and hard work.

Through constant and consistent monitoring of our clients’ submissions, the process is still being modified. Gaffey + Associates and its clients work closely, reviewing confirmation reports and scrutinizing data. The results of our monitoring are recorded and adopted, to help simplify the transition to HIPAA compliant formats required by all other payers.

When we began to prepare and plan for HIPAA two years ago, Gaffey + Associates recognized several “moving targets” preventing us from taking steady aim. It was already clear that providers and payers alike would be challenged with providing and processing new data: there were a lot of vague, undefined nuances in building the new transaction format from payer-related requirements and an incomplete implementation guide.

Furthermore, changes in implementation guides, delays in testing data with payers, and upgrades to health information systems interfered with the compliance process.

We’ve responded by combing through companion guides, providing UB92/837 gap analyses, and developing tables and software logic; all in the name of submitting 837-4010A1 claims for adjudication and payment, while patiently waiting for the UB92-centric data world to conform to a HIPAA data world. This strategy is in place right now.

By eventually discarding the UB92 print image, GEMS will now upload and use the full 837-4010A1 data set from most health information systems.

As we verify 837 data streams through our edits, we will turn-off certain data tables and certain software logic currently needed to create “standard” 837-4010A1 claims for your payers.
The next big step is to test data in parallel from health information systems, through GEMS, and to each payer.
These tests will be conducted even while we continue to transition and transmit claims in an 837-4010A1 format with each payer.

Contingency Plans

As we near the October 16th, 2003 deadline, notice the emerging headlines, filled with contingency plan announcements and strategies. National statistics are proving that most payers and providers are simply not ready to conduct ‘perfect’ HIPAA compliant transactions.

While a lot of progress has been made, all required 837 data is not available yet for various (and valid) reasons:

Several issues, obstacles, training, and data gathering surveys still need to be assessed by many providers and payers.
Payers are deciding to ‘loosen’ their edits, and continue to accept legacy claims formats (e.g. NSF formats) to follow CMS’s lead in contingency plan guidelines.
The Blue Cross Blue Shield Association announced:
It will continue to accept existing claim formats, in addition to HIPAA compliant transactions, under its contingency plan. During this time, the Plans will continue to transition their providers to HIPAA compliant transactions. Each Blue Cross and Blue Shield company will make a determination on how long to continue its contingency plan based on the unique business environment of its service area*.

All of us should comprehend that, although contingency plans are temporary, they are realistic, sound approaches to achieving compliance with HIPAA.

In the meantime, GEMS allows you to submit both the 837-4010A1 format and legacy formats to all payers. From our clients’ successful submissions to Medicare, Gaffey + Associates leverages the experience in moving to take our providers’ HIPAA compliant claims LIVE with payers like WebMD, Horizon Blue Cross, Empire Blue Cross, Independence Blue Cross, Blue Cross Blue Shield of Massachusetts, New York Medicaid, Champus, and New Jersey Medicaid.

Focusing on the increase and maintenance of our clients’ cash flow, we recommend using GEMS to continue sending legacy format claims to payers that accept legacy format claims. Many of our clients have used the newly added “837 Downloader” in GEMS to test 837-4010A1 claims with Claredi, Gaffey + Associates, and several payers.

Furthermore, “good faith efforts” toward compliance can now be claimed by all our clients submitting 837-4010A1 claims to Medicare. This compliance effort clearly demonstrates diligence and reasonable progress toward taking a course of action that moves your facility toward compliance. For more guidance on compliance, please reference the Department of Health and Human Services.

Where Do We Go from Here?

All of our clients have developed, or are developing, a HIPAA contingency plan.

We encourage the adoption of legacy claims formats, a useful capability of our software, as one contingency alternative. If this option is considered, make sure it’s disclosed in your organizational minutes.

Our company hopes we’ve helped paint an aerial view of today’s HIPAA landscape. If the view still conjures up questions and concerns, let us know! We are in this together. The Gaffey + Associates HIPAA Compliance staff is happy to help address issues regarding testing, going LIVE, and payer contingency plans. Send your questions, concerns, or share comments by e-mailing us at hipaa@gemsedi.com.

* 9/23/03 - Blue Cross Blue Shield Association Official Press Release

Issue 2 | October 5th, 2003

The Status of HIPAA Transactions
An Ariel View for GEMS Clients

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With HIPAA taking effect this month, we felt it was important to dedicate this issue of GEMSNews to an overhead view of the challenges each of us are facing as we comply with HIPAA requirements, and to suggest a few sound strategies for moving forward effectively.

We already see most payers, providers and vendors working hard to address the challenge of protecting patients' confidential health information. But we also see significant opportunities for business offices to leverage their investments in meeting HIPAA compliance in order to gain new business advantages. One such opportunity is the use of standard transactions and code sets to dramatically reduce the time required to process claims payment and, in turn, to increase cash flow.

With the deadline for HIPAA compliance upon us, it's easy to see the obstacles. Our goal is to help our clients turn those obstacles into opportunities to improve their business. We hope to see you at this month's HFMA meeting in Atlantic City. Thanks for reading this issue of GEMS News.