Health plans and providers breathed easier last week after the federal government announced it would look for good-faith efforts toward conversion to electronic insurance-claim standards instead of hard-and-fast compliance with the complicated computer formats by a mid-October deadline.
But some provider groups still worried that the government's stance would not eliminate the prospect of disrupted reimbursement as hundreds of insurers struggle to synchronize with thousands of provider customers during the transition.
The Centers for Medicare and Medicaid Services, which has enforcement authority over the transaction standards, said it could not legally grant the healthcare industry extra time to finish preparatory work and conduct tests to ensure successful exchanges of information between payers and providers.
But the CMS will act only on complaints about noncompliance after the Oct. 16 deadline, allowing insurers and healthcare organizations to work out their own contingency plans, said Leslie Norwalk, CMS acting deputy administrator. That could include continuing to exchange claims and adjudication information in the current nonstandard formats while working on glitch-free transmissions beyond the compliance date established by the Health Insurance Portability and Accountability Act of 1996, she said.
The government guidance eases the concerns of health plans that they could be held liable for accepting compliant claims that are less than perfect from provider customers even though a regulatory provision requires payers to accept claims only in the required formats, said Karen Ignagni, president of the American Association of Health Plans. Those concerns threatened to touch off an avalanche of paper-based claims, which are not subject to the electronic requirements (July 21, p. 17).
"It's prudent and reasonable," Ignagni said about the CMS position of considering good-faith efforts when fielding complaints. "It continues the progress toward the electronic transition, and that's good."
The guidance doesn't explicitly permit submission of nonstandard claims. Healthcare organizations will have to cite increasingly compelling reasons for failing to comply as time goes on, Norwalk said. The CMS will be less likely to take good-faith arguments into consideration in response to complaints well beyond the deadline, she said.
What's more, health plans aren't required to offer their customers an option to accept nonstandard claims, said William Jessee, president and chief executive officer of the Medical Group Management Association. "We remain concerned that physician practices may experience delayed payment of claims since the compliance flexibility offered by the government remains voluntary for health plans," he said.
The American Hospital Association unsuccessfully proposed that the government mandate a period of interim payments from insurers based on claims history, which would be triggered if errors in the swap of claims information caused a significant disruption of cash flow to providers.
Still, the AHA was pleased by the light enforcement outlined by the CMS, said Lawrence Hughes, AHA regulatory counsel and director of member relations. "We wish, however, that they would have gone further and provided a guarantee in terms of payment of claims," he said.