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For the past few years, claims payors such as insurance carriers, claims administrators and third-party administrators, and health care providers such as doctors and physicians groups, have been working to make their systems HIPAA compliant.

They?ve spent hours and thousands of dollars working to standardize electronic billing procedures, claim types and submission formats so that an insurance carrier can make sure it?s reimbursing a doctor for the services he or she provided to a patient. They are doing this while meeting the strict privacy requirements of HIPAA, which forbids the disclosure of information in the name of protecting the privacy of patients. The way in which claims attachments--additional medical data required to process a claim--are handled, however, has been causing big headaches for health care carriers and providers.

But there are certain claims, in particular those coming from hospital emergency room services, rehabilitation services, ambulance companies, specialized labs, and even some pharmacies, where additional supporting information is required before a claim can be paid.

For those types of ?problem? claims, there is no standard format that meets HIPAA requirements for electronically sending or accepting claim attachments.

?Claims attachments require intelligence in the flow of data,? says John Sarich, insurance industry marketing manger at Filenet, a Costa Mesa, Calif., company that specializes in managing content in large companies. ?For example, if a payor (an insurance company) gets a bill for a broken arm, the system should know that the payor will likely get a bill from a radiologist, an emergency room, and an ambulance service.?

Yet, many systems are still not capable, based on the diagnosis and treatment codes, of telling users to expect bills from other specialists. They are, quite literally, dumb to the flow of data.

?SMART FILES? TO THE RESCUE

?Payors need to create a ?smart file?--what we call active content--that would give the documents certain built-in attributes that would identify what else is coming, based on diagnosis and treatment codes,? says Sarich.

The bad news, he says, is that these gaps lead to ?an incredible amount of duplication and overpayment.?

Some companies in the health care industry, of course, continue to evolve technologically. They have access to the best software available, and so do their clients. For this group, delivering attachments that comply with HIPAA is not a problem.

But many other companies in the health care industry, even those that routinely use the best X-ray machines or CAT scans to diagnose patients, lag in terms of sending documents that will assure prompt reimbursement from a claims administrator.

The irony isn?t lost on consultants like Dawn Burriss, vice president, constituent connectivity, at the TriZetto Group, a Newport Beach, Calif., technology consultant to health plans and carriers. She runs into these discrepancies every day.

?Attachments reside in so many different formats--electronic images, proprietary data, paper, fax--and every provider has a different system for submitting attachments, which makes the process very difficult,? says Burriss. ?While larger health plans can typically scan and image these attachments, carriers usually receive this information via paper, then need to match the attachment to the original claim,? she says.

It?s as if health plans, speaking only English, were trying to communicate with carriers who only spoke French.

?Every provider we deal with requires a different type of submission for claim attachments, not all of which are electronic,? says Kim LaFontana, vice president, collector services, at Athenahealth Inc., a Waltham, Mass.-based practice management and billing service for doctors.

The Attachment Special Interest Group at Health Level Seven, an Ann Arbor, Mich.-based organization that advocates for standards, and the American National Standards Institute, say they are working to create a standard for attachments to support electronic claim submissions.

The goal of setting standards to govern electronic attachments is to make submitting health care claims more efficient by providing a formal structure for electronic data to payors.

By so doing, payors should, in theory, reduce administrative costs and cut turnaround times on claims, according to the ASIG.

Unfortunately, many doctors and medical practices do not yet have the technology to send claim attachments electonically. And until those standards are adopted by the entire industry, payors and providers are looking to various software programs, and the Internet, for answers.

A WEB OF ANSWERS

Athenahealth?s LaFontana, says the company has an application in its software to anticipate, based on CPT codes, when a claim will require an attachment. The system will automatically ?hold? the claim until the attachment arrives.

If a provider can?t send the additional information electronically, the data on the paper documents is scanned into Athenahealth?s system and automatically attached to the claim. It then becomes a permanent part of the claim record.

But that too, is not without its challenges.

A major challenge for payors, says Ken Hannigan, director of systems development at MedRisk, a provider of specialty managed care services based in King of Prussia, Pa., is keeping the claim and the attachment ?married? electronically.

?There are multiple mechanisms available to capture attachment data, which has to be put into a common format acceptable for payors? systems so the health care provider gets paid,? he says. ?Providers can export attachment data from their systems or send the supporting documents via mail or fax to our system. We then use a content management process to electronically marry the documents so the claim and the attachments can be processed as a whole.?

The ultimate goal is to improve the efficiency and reduce the cost of processing a claim.

At the TriZetto Group, health plan data is captured via Electronic Data Interchange or a Web browser as part of the company?s HealthWeb eBusiness product.

In addition, its Direct Link program provides simplified connectivity between providers and health plans, allowing them to exchange any type of file, regardless of format, using HIPAA privacy and security standards.

?We provide a low-tech, interim step to allow providers to exchange data with health plans using a Web-based connectivity tool,? says Burriss. ?This direct-connect technology, combined with the Web application, allows us to marry claim data to the attachment, and move this data securely between payors and providers.?

MINDY TORAN, a former Risk & Insurance® staff editor, is a freelance writer and frequent contributor.

April 1, 2005

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