1	HIPAA Business Impact Presented by: Skip Stein Management Systems Consulting, Inc. http://www.msc-inc.net
2	Healthcare Network
3	HIPAA Defined The Health Insurance Portability and Accountability Act of 1996 (HIPAA), which was the result of efforts by the Clinton Administration and congressional healthcare reform proponents to reform healthcare in a way that would streamline industry inefficiencies, reduce paperwork, make it easier to detect and prosecute fraud and abuse and enable workers of all professions to change jobs, even if they (or family members) had pre-existing medical conditions.
4	Electronic Data Interchange EDI - provides the ability to exchange business documents between trading partners without the laborious, time consuming, and error prone movement and handling of paper.
5	Purpose of Presentation Review the major upcoming health care EDI¹ transactions Suggest ways in which they may impact your client’s business beyond just achieving compliance. Achieving EDI is just the first step. Next Steps 1 EDI means Electronic Data Interchange, exchanging routine business data electronically in a standardized format
6	Major EDI Transactions
7	HIPAA means Standards Standardization saves payers money No need to support multiple platforms to receive/send data Move to a standardized data dictionary Exchange of data with other entities is greatly simplified Still room for contractual differences and competitive advantage
8	Standardization is Good Business Sense Lower maintenance costs Able to focus on developing competitive advantage in core payer products: contracts with providers contracts with employers and other sponsors development of HMO and other types of business combinations
9	Standardizing Data Content
10	Specific Examples of How EDI may Impact Business
11	Automating Enrollment
12	Automating Enrollment What is it’s impact on business? Allows daily updates between partners Keeps data base current Payers: Up-to-date enrollment files Allows for up-to-date eligibility inquiries Employer/Sponsors: Allows pin-point addition/subtraction of employee benefits Reduces fraud
13	Premium Information… how it works……..
14	Premium Information possible impacts…. Contracting between payers and employers/sponsors Tighter controls on enrollment, changes to benefits, and dis-enrollments. Will impact cost of maintaining enrollment Increased accuracy of data
15	Automated Eligibility Impact on Business Eligibility Today Primarily phone inquiries Payers typically limit the number of inquiries per call Providers spend a lot of time on hold, make their (3?) inquiries, then have to call back Very time consuming for Providers Very staff intensive for Payers
16	Automated Eligibility Impact on Business Automated Eligibility Routine inquiries are done by EDI Providers can send in many inquiries Payers can answer these inquiries without human intervention
17	Automated Eligibility Impact on Business Payers can reduce staff on phone banks a significant number of incoming calls concern routine eligibility inquiries Automating eligibility will increase the number of inquiries Goal: payers give enough information for providers to submit a clean claim verify subscriber name, ID, benefit details
18	Automated Eligibility Impact on Business Providers can reduce staff time doing eligibility inquiries probably do more inquiries improve claim submission to correct payer fewer submissions to incorrect payer improve quality of information on claim adjudication and payment can handle more claims as they are cleaner improves cash flow for providers
19	Automated Eligibility Impact on Business Payers benefit reduced customer service staff improved data on submitted claims Providers benefit reduced staff time on phone improved claim submission process
20	Claim / Encounter Submission Payment (Remittance Advice)
21	Claim / Encounter Submission Payment (Remittance Advice) HIPAA brings national standards to data format data content, to a certain extent Still room for contractual differences Still room for differences mandated between states in Medicaid programs
22	Claim / Encounter Submission Providers Electronic submission of claims allows for provider-side data edits to improve data quality prior to claim submission providers can use data from eligibility to improve data quality in claims providers can automate moving data from eligibility inquiries into claim submission reduce staff time on claim preparation and submission
23	Claim / Encounter Submission Payers Current Claim Submission electronic allows payers to move to automated adjudication a great deal of paper paper costs approx. $10+/claim for a payer just to bring it into an internal adjudication system electronic submission is primarily proprietary at this time results in someone having to support many platforms
24	Claim / Encounter Submission Payers Electronic Claim Submission allows payers to automate data management for many more types of data standardization of format/process allows for eliminating maintenance of multiple platforms even if payer doesn’t support the platforms themselves, they pay someone to do this
25	Claim / Encounter Submission Payers Automated adjudication allows for staff to improve productivity up to 6 fold from manual/paper adjudication systems staff can focus on problematic claims rather than processing routine claims allows payer to increase covered lives without increasing adjudication staff adjudication is more standardized when there is less human intervention
26	Healthcare Network & EDI
27	EDI Translation The Rosetta Stone led to the modern understanding of hieroglyphs. EDI leads to the formatting and translation of business documents.
28	EDI Standard
29	EDI Translation ISA00 00 30999003060 30999756858 0106251133U004010000000010T>~GSBE999003060999756858200106251133091X004010X095~ST8341001~BGN0011330920010625113309ET*2~N1P5CHIPSTERSFI236003060~N1INHealthPlanFI299759958~INSY1802128A**FTN~REF0F10000607209~REF1L35S1~REF3H10000607208~REF6M162991010~NM1IL1GeorgeDallasJ*34189783830~N3144222 South Sixth Ave~N4ScrantonGA19904*CY35~DMGD819990324MIC1~LUILEEN~NM1QD1MaletaLisaS*34994648539~PERRPTE5703416671~HD021HLTSubsidizedIND~DTP348D820010701~REF1L35S1~INSY1802128A*FTF~REF0F99000607213~REF1L43N1~REF3H99900607211~REF6M169911012~NM1IL1WymanSylviaM*34995784904~N3PO Box 143~N4West MiddlesexGA16159*CY43~DMGD819980116FIC1~LUILEEN~NM1QD1WymanSamJ*34004681782~PERRPTE5558138028~HD021HLTFreeIND~DTP348D820010701~REF1L43N1~SE351001~GE11~IEA1000000001~
30	EDI Segment Analysis
31	Cost Reduction Potential Full implementation of EDI capabilities provide the basic framework for substantial cost reduction. Leverage existing workforce in more profitable activities. Reduce/Eliminate paperwork, forms, filing and filing cabinets.
32	Benefits Improved accuracy. Reduced data entry time & staffing. Reduced operational costs (office supplies, postal costs & telephone charges). More efficient information delivery. Improved relations with other organizations. Create ‘Partnership’ relationships.
33	Technology
34	EDI Translator An EDI Translator is a software tool that provides the ability to translate application data to/from standard formatted EDI transactions. Translation codification is based on standards developed by Industry committee groups under the auspices of the American National Standards Institute (ANSI).
35	Translator Components Most EDI Translator tools are comprised of these sub-components: Core EDI Standards translation engine. Data Mapping Utility – map EDI data to application data base or files. Mailbox (inbound/outbound) repositories for Trading Partner Transactions. Communications Gateway Proprietary Language/Scripting Dialogues
36	Enterprise Accessible Single Translator can serve multiple departmental entities. Single Workstation or Server-based implementation options. Common Standards Repository. Shared Resource Pool.
37	Component View
38	EDI Integration Synchronous Interaction Asynchronous Interaction Routing & Distribution Rules-based Transformation Application Integration Rapid Implementation Security, Audit Trails and Tracking
39	Translator/Translation Translator Functions Software Tool EDI Segment Processing according to ANSI Standards Component Data Organization, Routing and Transport Translation Functions Application Data Base Integration Business Rules and Application Data Flow Security, Privacy, Audit & Control Localized/Integrated Data Management
40	EDI Resources Complete business process support. Pre-existing transaction sets defined for virtually any business process including HIPAA. Open standards make communications between different systems and technologies possible. Tested and Proven methodology. With lower entry costs, available to even the smallest business enterprise today.
41	HIPAA X12N Transactions HIPAA 270 - Eligibility, Coverage or Benefit Inquiry HIPAA 271 - Eligibility, Coverage or Benefit Information HIPAA 276 - Health Care Claim Status Request HIPAA 277 - Health Care Claim Status Notification HIPAA 278 - Health Care Services Review HIPAA 820 - Payment Order/Remittance Advice HIPAA 834 - Benefit Enrollment & Maintenance HIPAA 835 - Health Care Claim Payment/Advice HIPAA 837p - Health Care Claim: Professional HIPAA 837i - Health Care Claim: Institutional HIPAA 837d - Health Care Claim: Dental
42	EDI HIPAA-Repository Translated EDI data stored in localized common data base tables. Governed by Business Rules Common Language (SQL/C#/Java/XML/even COBOL) program access. Expandable to future use. Auditable, Controllable & Secure
43	Repository Features Store EDI Data Elements required by Trading Partner or HIPAA exchange without defined storage in applications systems structure. Gain control of inbound data in open and accessible format. Provide staging area for outbound EDI data.
44	EDI Translation Process
45	Benefits Reduced dependency on an outside vendor. Broadened use of existing open data structures and coding standards. Limit use of specialized expertise in proprietary/closed language and scripting. Faster time to deployment of the EDI translation process. Simplification of the overall translation process. Open systems accessibility to the gateway enabling easier application integration in the future.
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47	HIPAA is the LAW This is not a voluntary process. HIPAA is a Federal Mandate. Overrides local government and private industry medical claims processes. On December 27, 2001, President Bush signed HR 3323, which enables entities covered by HIPAA to delay compliance with the Transactions and Code Sets Rule by up to one full year until October 16, 2003.
48	Where Do We Go Next? Determine What Clients and potential Clients are doing/have done with regards to HIPAA Compliance. Offer assistance with a readiness ‘checklist’.
49	HIPAA Readiness Checklist Learn About HIPAA Prepare a HIPAA Plan Increase HIPAA Awareness
50	Checklist for HIPAA Electronic Data Interchange (EDI) Prepare to Standardize Claims Transactions Prepare to Standardize Code Sets Prepare to Standardize Healthcare Identifiers.
51	HIPAA Privacy Checklist Appoint a HIPAA privacy officer. Develop HIPAA Policies & Procedures. Develop appropriate administrative, technical and physical safeguards. Train workforce. Develop and disseminate privacy notice. Limit disclosures
52	Compliance Deadlines April 14, 2003 Privacy - all covered entities except small health plans. April 16, 2003 Electronic Health Care Transactions and Code Sets. October 16, 2003 Electronic Health Care Transactions and Code Sets. April 14, 2004 Privacy - small health plans. July 30, 2004 Employer Identifier Standard
53	HIPAA – Pervasive Impact Not just EDI and Transaction Sets. Huge potential Data Base Impact. Policy & Procedures. Security (data, network, access). Conversion & Migration. New Development and Integration. EDI infiltration into other business areas.
54	Thank You!~ I hope this has been helpful. All content has been included in the CD we have made available. Management Systems Consulting, Inc. Orlando, Florida 407-856-1691