ISMIE Mutual Insurance Company

Mutual Interests

HIPAA Transactions - Get Ready for October 16

For many, summer vacation is already a memory. It's time to point toward autumn and a reminder that health care practices are required to comply with HIPAA electronic transaction standards by October 16, 2003. Included in the mandate are electronic transactions (sent directly or through an outside vendor) to:

Submit claims.
Receive claim payment and remittance information.
Query insurance companies about the status of a claim.
Receive information about the status of a claim.
Query insurance companies about the eligibility of a patient to be covered for services.
Receive information about patient eligibility.
Send referral authorizations.
Receive referral authorizations.

Vendor relationships

Most practices that electronically send or receive information use a practice management system, billing software system or an outside billing service. Practices depend on these products and vendors to make sure electronic information is sent to health plans in the correct format, and that electronic information from the health plans is read and used appropriately.

Ask your software vendors and billing services if they have developed or are developing software updates that will allow you to use the standard HIPAA transactions. If your vendors do not plan to make their products or services "HIPAA compliant," there is no time to waste. You will need to find new vendors who are capable of meeting your needs by the crucial deadline.

Of note...

HIPAA does not require the submission of electronic claims to any health plan, with the exception of Medicare. Medicare requires all practices with more than 10 full-time equivalent workforce members (including the physicians) to submit electronically.
HIPAA electronic transactions are complex and may vary by health plan. Many health plans, including Medicare and the Illinois Department of Public Aid, are developing customized "companion guides."

(At press time, most of these guides have not been issued due to late government issuance of the final transactions rule.)

On the other hand, if your software vendors and billing services assure you that they will meet HIPAA's standard transactions requirements on time, explain to them that you require these assurances in writing.

Your vendors should certify that they have tested their procedures to meet HIPAA requirements. Let your vendors know that you'll need the software in time to do a few test runs to make sure it works.

Contingency plans

With the October 16 deadline quickly approaching, it is important to develop contingency plans. Keep in mind that it may take a few weeks to determine if your electronic claims are being accepted. If you cannot submit claims and get paid in a timely
fashion, you may experience difficulties paying your bills and meeting your payroll. Accordingly, make sure that your practice has a sufficient line of credit. It's a good idea to prepare to go to a paper process if that becomes necessary to get paid.

More help available

ISMIE Mutual and ISMS have prepared comprehensive documents and publications to help you prepare for all aspects of HIPAA. Detailed information regarding transactions and contingencies may be found in the sixth of the HIPAA brochure series. Watch your mail for a copy of the new brochure or download it today at www.ismie.com.