Capitalizing on HIPAA

The HIPAA transaction sets promise to be a boon for revenue-cycle leaders. Although health plans have exhibited varying

To accomplish these goals, you should evaluate each transaction set to understand how business flow will change, staff skills will be enhanced, and the new dialogue will develop with health plans.

Eligibility The 270/271 transaction set (270/provider asking, 271/payer responding) will help providers dramatically increase clean claim submissions. Payers cite ineligibility and a lack of match between name and number as the primary reasons they deny claims. By making the eligibility request a part of the daily batch routine or real-time processes for all payers (except for worker's compensation and liability payers, which are not considered "health plans"), you will be able to resolve eligibility issues before submitting claims. Consider hiring an eligibility specialist to focus on implementing an action matrix for all standard 271 payer responses.

Referral and authorization Under the traditional manual process, revenue-cycle and utilization management staff spend considerable time pursuing authorizations and managed care referrals. The 278/referral transaction set standardizes this function, enabling you to supply required data automatically to health plans. Some manual follow-up may still be necessary, but it will be considerably reduced under the new automated processes.

Claim submission. The 837P (old 1500 forms) and 8371 (old UB-92) transaction sets are intended to standardize the claim submission process for all payers (again, except for those not considered "health plans"). A compliant claim may pass the "format" test, but payers have more flexibility in determining the "content" required to adjudicate a claim. Work closely with your payers to determine situational requirements and, to the extent possible, help improve their internal processing.

Claim stafus. The electronic transaction for verifying the claim status (276/provider asking, 277/payer responding) has been standardized to allow providers to more easily check claim status throughout the payment pending cycle. As a result, you can become aware of pending issues earlier in the process and alert the payer, thereby ensuring that the issues are resolved rapidly.

Electronic remittance. All payers are required to submit an 835/electronic remittance with a single, standard set of payment and adjustment codes. However, because many payer-specific codes are not included in the 835 transaction format, a crosswalk needs to be developed between existing remittance codes and the new, standardized format.

To effectively realize the benefits of the HIPAA transaction sets, you should set priorities for rolling out the transaction sets. Make sure your implementation plan is on target, and that all goals and objectives are clearly defined and outlined to identify all potential "wins." Once all payers have fully developed and implemented all of the transaction sets, you can start developing standard denial management processes, allowing the focus of denial management resources to shift from "clean up" to "prevention."