face a new requirement to rapidly communicate electronically with healthcare providers whether a patient has insurance coverage, plus what his or her co-payment split will be for a given visit or procedure, and how much that patient will have to pay under his or her deductibles and out-of-pocket limits.
Now the CMS
, an anonymous healthcare provider and a health IT
consultant have teamed up to help narrow the gap between those federal requirements for electronic handling of queries about a patient's health insurance coverage and the rules' implementation in actual practice.
The rules aim to be a boon to both patients and providers, helping them figure out the extent of insurance coverage before care is provided. But despite long-past compliance
deadlines for these rules, not all payers are doing what they're supposed to do, and that's where a consultant and the CMS came into the picture.
Stanley Nachimson, a Baltimore-area adviser specializing in health IT issues, said he was representing a provider client who wants to remain anonymous. The client wasn't receiving all the information from a particular health insurer Nachimson declined to identify that was necessary under the new standards and operating rules.
One set of rules not being met come under a federal mandate to use the ASC X12 Version 5010 standards for electronic claims transmissions. HHS required an upgrade from the older Version 4010 standards under authority granted it in the “administrative simplifications” provisions of the Health Insurance Portability and Accountability Act of 1996. The compliance deadline for the 5010 rule was Jan. 1, 2012, but to accommodate many stragglers the feds twice postponed its enforcement date until July 1, 2012.
Another set of rules not being met are the so-called “operating rules” that flow out of the Patient Protection and Affordable Care Act
. The compliance deadline for claims status and eligibility transactions of these rules was Jan. 1, 2013.
By not complying with the rules, this particular health insurer, which provides health insurance coverage in about half of U.S. states, was causing providers “a significant disadvantage in not knowing the full extent of a patient's insurance coverage,” according to Nachimson.
“Anybody who wants to know the service-by-service coverage of a patient's insurance at the time of service or the days before” could benefit from the electronic transaction capabilities covered by the new rules, Nachimson said. On real-time queries, the response time is supposed to be 20 seconds. On eligibility enquiries submitted in batches, overnight responses are deemed compliant.
Nachimson said the fast turnarounds enable providers to tell patients in advance, “You haven't met your deductible yet this year, or your coverage is 80/20, the bill is $100, you owe us $20. What it used to be under 4010, you only got the answer, yes they're covered, or no, they're not covered. There is a lot benefit in these (new) standards if the plans use them.”
After talking with the health insurer and getting nowhere trying to resolve the problem, Nachimson turned to the CMS, which has enforcement authority for administrative simplification under the Health Insurance Portability and Accountability Act.
“We filed a complaint and sent it in to CMS and said these guys are not compliant and showed them 10 or 12 places where they were not compliant,” he said. The client remained anonymous even in the complaint, out of concern over possible retaliation, said Nachimson, who filed the complaint on his client's behalf. The CMS forwarded the complaint to the insurer. That was around May 1, he said.
“We just got the reply from them and they said, 'OK, we're going to change all of these. The vast majority were done by the beginning of August. A few they need to work a little bit more.”
Nachimson said he and his client are satisfied. “The way this industry moves, three months isn't bad.”
These changes benefit all providers working with this health insurer, not just the one filing the complaint, Nachimson said.
How widespread is non-compliance with these new rules?
“I wouldn't say it's endemic but it's not an uncommon practice for this to happen,” Nachimson said. “I would guess there are plenty of health plans, Medicaid included, that are not yet following the rules.”
“It's a huge win for providers on this,” said Robert Tennant, senior policy adviser for the Medical Group Management Association, particularly considering the growth of high-deductible health plans which expose patients to high cost-sharing. “It's one thing to miss out on a $20 co-pay, it's another thing to miss out on a $1,000 deductible.”
The CMS was unable to provide a person for comment by deadline. Follow Joseph Conn on Twitter: @MHJConn