HIPAA Transactions

1
HIPAA Transactions Code Sets Have the
Standards Been Successful?
2
Study Background

• Transition from paper-based administrative/financi
  al transactions to electronic transactions
• To maximize efficiency, standardization was
  needed
• Standardized electronic format
• Standardized data elements for various
  transactions
• The HIPAA Transactions Code Sets Rule - 2000
• Identified 8 specific transactions (e.g. claim,
  eligibility inquiry)
• Specified specific electronic format and data
  standards for each

3
Study Background

• Anticipated Benefits of the TCS Rule standards
• Reduction in transaction processing delays
• Savings due to increased use of electronic claims
  submissions
• Savings due to increased electronic non-claims
  transactions, such as eligibility verifications
  and coordination of benefits
• Easier integration of data across entities

4
Study Background

• Anticipated Benefits of the TCS Rule standards
• Reduction in exposure to health care fraud due to
  security controls for electronic health care
  transactions
• Reduction in administrative burden and increased
  job satisfaction
• Promotion of the accuracy, reliability and
  usefulness of information shared
• Enhanced sharing of data within and across
  entities

5
Study Objectives

• Conduct a national study using the survey
  instrument developed in the HIPAA TCS Have the
  Standards Been Successful? pilot project.
• Document specific aspects of the current status
  of the effectiveness of standardization under the
  HIPAA TCS rule in hospital settings.

6
Need for Study

• Industry emphasis on standardization
• Electronic Data Interchange
• Health Information Exchange
• E-prescribing
• Need to measure success of standardization
• Identify measures of success
• Consider measures in other efforts to standardize

7
Methods

• Survey instrument developed in pilot study
• Likert Scale
• Health Care Financial Managers Association
• Director/Manager/Supervisor in Finance, Patient
  Financial Services/Billing, Reimbursement-Commerci
  al (Managed Care), and Reimbursement (General)
  or
• Analyst/Accountant/Consultant in Finance, Patient
  Financial Services/Billing, Reimbursement-Commerci
  al (Managed Care), and Reimbursement (General)

8
Methods

• 3,500 HFMA population (excluding 800 surveyed for
  pilot instrument, and undeliverables)
• Paper mailings
• 1 million dollar bill incentive

9
Methods

• Limitations
• Representative population
• Getting survey to the right desk
• Low response rate
• 6
• Pilot instrument was 20
• Focus on claims transaction and response
• Data collected in 2007

10
Results

• Subsequent analysis yielded two constructs

Cost Process
Data Quality
11
Validity Reliability

• Construct Validity
• Confirmatory factor analysis model assuming
  normal distribution theory (after appropriately
  dropping items) Fit indexes RMSEA and CFI
• Convergent Validity
• Manifest variables significantly correlated with
  the corresponding construct
• Internal Reliability
• Cronbachs alpha
• Discriminant Validity
• Constructs have correlations that are high but
  not too high to say that they are redundant
• Criterion-related Validity
• was not established no external measure
  collected

12
Cost Process
The rejection rate of our claims has decreased
since implementation of the standard 837 claim
format.
13
Cost Process
The length of time necessary for full
adjudication of claims has decreased since
implementation of the 837 format
14
Cost Process
It takes us less time to investigate and correct
rejected claims under the 837 standard than it
did prior to implementation of the 837 standard.
15
Cost Process
The 837 claim standard fulfilled an unmet need at
our facility.
16
Cost Process

• Overall, the transaction standards have reduced
  the amount of paperwork necessary for claims
  adjudication.

17
Cost Process
Too much time will be necessary to provide our
staff with ongoing training about TCS standards.
18
Data Quality
We also use the data sets collected for
submitting 837 claims for non-reimbursement
purposes.
19
Data Quality
Unnecessary data for adjudicating claims are
submitted under the 837 standard.
20
Data Quality
The elimination of payer/provider non-standard
code sets (local codes) has been beneficial for
our hospital.
21
Data Quality
Our health plans have rejected an 837 standard
transaction because it contained information the
health plan did not require.
22
Data Quality
Most of the time, we can identify the specific
reason for a rejected from the 835 response alone.
23
Data Quality
Our system must accommodate differing
requirements contained in multiple companion
guides.
24
Discussion

• Cost and Process Responses Summary
• Rejection rate not decreased (57.5A)
• Time for adjudication not decreased (53A)
• Time for investigation of rejected claims not
  decreased (65A)
• Unmet need filled (55D)
• Training time not excessive (51A)

25
Discussion

• Data Quality - Summary
• Data useable for non-reimbursement purposes
  (33D/46A)
• Unnecessary data for adjudicating claims required
  (23D/41A) 24 not sure
• Elimination of non-standard codes beneficial
  (26D/43A)
• Rejection of claims because of unnecessary data
  (46D/28A)
• Can identify specific reason for rejected claim
  from response alone (49D/40A)
• Must accommodate differing requirements in
  multiple companion guides (75A)

26
Discussion

• Cost/Process
• Efficiency, in terms of time necessary for
  resolution of claims does not appear to have
  increased
• Data Quality
• Uncertainty as to usefulness of TCS claims
  transaction data

27
Conclusions

• This general topic of research is still
  relevant/needed
• Good 20 item instrument
• Needs to be re-administered
• Improve response rate
• Account for passage of time

28
Contacts

• Julie Roth, MHSA, JD, RHIA
• jroth_at_lathropgage.com
• Norbert Belz, MHSA, RHIA
• nbelz_at_kumc.edu