To transition from paper to electronic health care transactions and eliminate the numerous phone calls, faxes and e-mails that plague the current system, patients, physicians and other health care providers need to receive all the information necessary to determine patient and payer contractual responsibilities and to automatically reconcile and post claims payments. The current cost for just physicians and other health care providers is 10 to 14% of their revenue. The lack of a clear identification of both 1) the patient specific benefit plan/product type and 2) each of the entities involved in the processing and payment of a claim prevents easy determination of the information necessary to navigate the typical health plan: covered versus non-covered benefits, benefit management requirements (prior authorization and carved out benefit managers), in- versus out-of network services, and which fee schedule will apply to the services which are ultimately provided.
To automate the health care system, patients, physicians and other healthcare providers as well as patients need timely electronic access to all of the following:
The identity of the patients insurance benefit plan/product type in force for the specific patient.
The identity of the entity that will initially receive each health care transaction.
The identity of the entity responsible for administering each health care transaction.
The identity of the entity that will fund the claim payment (not payment of the premium).
The identity of the entity that contracts directly with the health care provider if any, and for each of these contracts:
the identification of the contracted fee schedule that applies to each specific claim.
Although this information is necessary for patients and their healthcare providers to automate the administrative functions associated with the provision of medical care and getting paid, these pieces of information are often not included in the X12 271 or 835 electronic standard transactions today.
The solution to this problem will depend on how the Secretary chooses to enumerate health plans through the Health Plan ID. However the Secretary chooses to enumerate health plans through the Health Plan ID, this DSMO change request is being submitted to ensure that the impacted HIPAA transaction implementation guides allow for the reporting of the patient-specific benefit package/product type and identify each entity that has undertaken a health plan role for the specific transaction.
To the extent that the Secretary adopts a Health Plan identification scheme that covers the patient-specific benefit package/product type and each of these entities. the challenge will be the development of implementation guidelines or operating rules as appropriate to ensure that these HPIDs are included in the appropriate fields in the Transactions. To the extent the Secretary adopts a less robust identification scheme, this task will be further complicated by the need to adopt another identification system to cover the relevant health plan products or entities that are not covered by the HPID.