On real-time queries, the response time is supposed to be 20 seconds. On eligibility inquiries 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. There is a lot benefit in these (new) standards if the plans use them.”
By not complying with the rules, this particular insurer, which offers 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,” Nachimson said.
After talking with the plan and getting nowhere, Nachimson contacted the CMS, which has enforcement authority for administrative simplification under HIPAA. “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,” he said. That was around May. 1. The CMS forwarded his complaint to the payer, he said.
The insurer replied Aug. 1. “They said, 'OK, we're going to change all of these,' ” he said. “The vast majority were done by the beginning of August.” These changes benefit all trading partners of the insurer, not just the one filing the complaint, he noted.
“It's a huge win for providers,” said Robert Tennant, senior policy adviser for the MGMA, particularly as patients face higher deductibles, copayments and other cost-sharing under their plan designs. “It's one thing to miss out on a $20 copay, it's another thing to miss out on a $1,000 deductible.”
Nachimson said he and his client are satisfied with the insurer's remedial actions. “The way this industry moves, three months isn't bad.” Nachimson and other experts say many insurers are not complying with the rules. “I wouldn't say it's endemic, but it's not an uncommon practice for this to happen,” he said. “I would guess there are plenty of health plans, Medicaid included, that are not yet following the rules.”
John Kelly, a principal business adviser at Edifecs, Bellevue, Wash., a claims-management services provider to payers and providers, corroborated that. He said there are some plans with “antiquated systems.” When it comes to state Medicaid programs, he said, lots of people say their transactions “are not compliant.”
Kelly said the state Medicaid agencies “will flat out say, yes, we know. We're working on it.” They “feel a little less threatened that they would get penalized” and thus have been “a little bit slower” to seek compliance.
But clearinghouse officials are reluctant to report noncompliant insurers, said Tim McMullen, executive director of the Cooperative Exchange. “We see our role as clearinghouses to mediate as much as possible.”
Secure EDI's Gonzalez said that for insurers, with all the other healthcare reform issues they face, fixing their systems to meet the electronic reporting requirements to providers on patients' insurance coverage “is not in the top 10 things they're worried about.” He attributed insurers' lack of concern and compliance to their perception of a relaxed federal enforcement climate.
The plans won't focus on these rules, he said, “unless there are fines, and they have to be substantial. The first person to get fined $1 million is going to wake everybody else up.”
Follow Joseph Conn on Twitter: @MHJConn