|
In my attempt to review the changes in the next
HIPAA EDI version (ASC X12N 5010) I ran into a major stumbling block. I
couldn’t get the ASC implementation guides without paying $175.00 for
each transaction. Then I realized that I couldn’t even get the
currently mandated 4010A1 guides for free anymore. Most carriers give
out free companion guides for mapping X12N documents with their specific
rules but they are not complete enough to be able to map an entire
document. The carriers generally refer to the Washington Publishing
Company’s website for a “free” copy of the official and complete
ASC X12N Implementation Guide. EDI analysts working for medical, dental,
and durable equipment providers will not find the free documents they
need in order to enable the EDI mandate.
Insurance carriers and medical providers are
required by a federal law known as HIPAA to conduct business using EDI.
The medical section of the Accredited Standards Committee of ANSI (also
known as ASC X12N) is the body responsible for creating the standards
and structures for all the EDI documents used in the medical industry
and mandated by HIPAA. The Washington Publishing Company (WPC) is a
private entity contracted to publish the Implementation Guides. In the
past the Centers for Medicare and Medicaid Services (CMS), the
government entity responsible for administering and enforcing HIPAA
regulations, provided a subsidy to WPC to offset the cost of providing
free implementation guides to the industry. This subsidy is no longer
provided by CMS so therefore WPC now charges for the implementation
guides.
HIPAA mandates that providers be required to
transmit medical claims for payment electronically using
|
ANSI ASC X12N
4010A1 EDI standards to all their carriers, both commercial and
governmental. The carriers are required to send payment advices in the
same manner. There are also transactions specified for claims status
updates, requests for reviews, and coverage verification. Typically, the
carriers will provide a companion guide for all the transactions. This
guide is designed to be used in conjunction with the implementation
guide and defines only the specific needs of that carrier. No other
element is defined in the companion guide which means an EDI mapper must
have a copy of the ANSI ASC X12N implementation guides in order to
complete a compliant map. It is interesting to note that the medical
industry is one of the only industries that require businesses to use
EDI and one of the only industries in which you cannot obtain free
transaction implementation guides.
When asked, WPC would only say that since CMS
stopped subsidizing the publication of the implementation guides they
could no longer provide them for free. They would not comment on whether
or not they are paid any other monies for publishing the implementation
guides nor would they give any other details about their contract to
publish the guides. In fact, I could not speak to anyone other than the
sales staff and when it was revealed that I was researching this issue,
they courteously ended the conversation. As of this writing, CMS has not
responded to my attempts to enquire about the reason they ceased
subsidizing the implementation guides.
Basically it all boils down the cost moves down
to the provider, and in the end, the patient, or consumer. This is
another subtle way in which the cost of doing business increases, which
raises expenses for everyone. |
