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BY SHERI PORTER
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Not worried about the Oct. 16 deadline for making all your electronic health claim transactions compliant with the Health Insurance Portability and Accountability Act? You should be.
This fall, when the HIPAA transactions and code sets standards go into effect, Medicare and other health plans will deny non-HIPAA-compliant claims. According to David C. Kibbe, M.D., AAFP's director of health information technology, it's entirely possible that millions of claims could be rejected, resulting in severe cash flow problems for physician practices all over the country.
To avoid financial disaster, physicians must talk to their practice management system or billing system vendors to determine their practices' readiness to send HIPAA-compliant claims to payers. Without end-to-end testing now, from your practice to each payer's computer system, there's no way to know what glitches in the system might kick claims out come October.
It's not just FPs tangled up in this red tape -- physicians in every specialty will be affected by this impending crisis.
Rick Ruther-ford, director of practice management at the American Urological Association, said he recently spoke with a member of a four-physician urology group in Florida.
The practice partners did exactly as they were advised -- they began testing live claims in April after their system vendor informed them that their system was ready to submit claims in the new HIPAA format.
The first batch of test claims included 390 Medicare claims. Within 10 days, Medicare rejected all 390 of those claims. Within a few weeks, more than 1,000 claims had been denied by Medicare and Blue Shield of Florida, causing a severe cash flow problem within the practice.
Clearly, the system vendor was not ready for HIPAA, reported the urologist.
Steve Fisher, manager of practice management affairs for the American Association of Orthopaedic Surgeons/American Academy of Orthopaedic Surgeons, has talked to enough physicians in his organization to know that trouble is brewing.
"The practices think that the software vendors are doing what they're supposed to be doing -- physicians are making that assumption," said Fisher. In fact, he has learned through conversations with physicians that many of them don't even know what additional data elements they're supposed to be collecting -- elements that under the law have to be provided as of Oct. 16 in order for a claim to be processed.
"If physicians don't know what the data elements are, I think it's highly unlikely that they're going to collect them," said Fisher. "What's going to happen is that people are going to be merrily submitting claims on Oct. 17, and the claims are going to go nowhere. People are not going to get paid.
"It's sort of like everybody is ignoring the fact that a meteor is streaking towards the earth. Physicians are saying, 'Well, it'll probably miss me, or maybe it'll just end up in Antarctica.'"
Kepa Zubeldia, M.D., is in the transactions testing and certification business. He is the chief executive officer of Claredi, a company that provides software that can identify errors in a batch of claims -- errors that, come October, may cause those claims to be rejected.
Zubeldia estimates there are half a million medical practices in the country. His company, the largest provider of independent testing, currently has about 1,000 customers. If advance testing is the only way to ensure HIPAA readiness, "then these numbers show that the readiness level is very low," said Zubeldia.
"It's extremely important that physicians not rely on hollow statements from their vendors and clearinghouses saying that they're going to be compliant and not to worry. Physicians need to get proof for their own offices as to the readiness of their own transactions," he said.
To reach writer Sheri Porter, e-mail sporter@aafp.org.
FP Report is published by the
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Copyright © 2003 by
American Academy of Family Physicians.