Preliminary Discussion Grid for 02-09-09 Uniform Claims Review Process Study
(Preliminary suggested study topics/focus, organized into categories by MDH)
Attendees: Shelagh Kalland (BCBS), Ann Hale (Health Partners/AUC), Janet Silversmith (MMA), Kathryn Kmit (MDHP), Marty
Michael (Health Partners), Liz Quam, Jim Reimann (representing MMGMA), Dave Haugen (MDH), Amy Luitjens (MDH)
Submissions
Discussion
Impact/Practicality, Other
Criteria
1. Continued work of the
AUC/other communitybased organization
• Development of a common
network/portal for
exchange of information
(re: administrative cost
savings, example: UHIN)
• Real time claims
adjudication
• Expand the work of the
AUC on technical issues
• Standard electronic
•
•
Item 1:
-Is Federal HIN money
available for just EHRs?
-MN-HIE currently just
exchanges clinical info,
but is convening a work
group on administrative
strategies
-MN community currently
possesses networks that
work in e-data
transmission, provide
savings
-Community best
formulary exception form
practices are not required,
COB – Hopefully the
but strongly preferred and
implementation of MN
mandate for Claims and COB intended to encourage
on July 15, 2009 will solve a community to participate
majority of the admin issues
-Large organizations
related to this topic, but
using a transmission
discuss potential for future
system that works comes
monitoring
at no charge to users
Additional Service Types
currently
Meeting discussion grid for comments submitted 02-09-09
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Notes/Follow Up
Submissions
added to list of required MN
service types for 270/271 as a
part of 5010 work. This will
continue to help reduce
phone calls related to benefits
Discussion
Impact/Practicality, Other
Criteria
-Value of a UHIN-like
network is really seen to
small and mid-size
provider groups; add’l
value possible for nonmedical providers
Item 2:
-WEDI currently has a
workgroup examining
claims adjud.; 2 pieces are
needed: 1) Provider shift
back office to front, 2)
Acknowledgment
needed—WEDI has not
solved, neither has MN.
WEDI has worked several
years on this already w/o
resolution.
-Pt advocates address pt
liability in advance
-Difficult to reconcile
price vs. codes
-Is it possible to test this?
Response: Highly unlikely
given the complexity of
the issue
Item 3
-COB difficult to resolve
until remit trans. goes live
Meeting discussion grid for comments submitted 02-09-09
Page 2 of 7
Notes/Follow Up
Submissions
Discussion
Impact/Practicality, Other
Criteria
12-15-09
-COB difficult to
automate for secondary
payer
-Significant topic to be
monitored
Item 4
-Service types will be
reviewed as part of 5010
-Work w/providers to ask
what they would like in
order to respond
appropriately
-Need to understand
service types that need to
be more clearly defined
-AUC will continue to
review this process
-Often a limitation of the
vendors in MN, or
provider didn’t implement
module for vendor
-Service types issue will
likely continue to
resurface throughout
implementation
2. Regulation of prompt
payment
Include self funded plans
in prompt payment?
Meeting discussion grid for comments submitted 02-09-09
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Notes/Follow Up
Submissions
•
•
•
•
Develop uniform standard
for retroactive adjustment
Creation of state statute
limiting the amount of
time a payer or provider
has to request a refund or
appeal an overpayment
Include self funded plans
in the state’s prompt
payment law (which
currently only covers fully
insured plans)
Level fines for consistent
underpayment of claims
•
Enrollment Retroactivity
standards
•
Enforce MN Statute
62D.Subd. 19 stating
claims cannot be denied
solely for not obtaining
prior authorization; also
allow for Prior Notification
to be defined as prior
authorization
3. Uniform methodologies
for payment consistency
• Instead of moving to
Discussion
Impact/Practicality, Other
Criteria
-MDH will check with
Commerce
-Role of commerce to
investigate/pursue
Develop uniform standard
for retroactive
adjustment?
-Issue around timing to
complete retroactive
payment
-Establishment of timeline
for adjustment, related to
Enrollment Retroactivity
standards
-Building of common
expectation
Follow up: Enforce MN
Statute 62D.Subd. 19
comment
Item 1:
-AUC developed
guideline exists for
Meeting discussion grid for comments submitted 02-09-09
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Notes/Follow Up
Submissions
•
•
•
Discussion
Impact/Practicality, Other
Criteria
uniform prices, could our
community agree to use
common payment
methodologies? Many
plans/providers use
variation of these
methodologies in their
billing or claims processes
(DRGs, APCs, Others)
Create consistency with
the billing of units (i.e. one
payer wants one line item
with 5 units, another wants
5 line items with one unit)
delineation of units
(adherence may be an
issue, but AUC open to
further fleshing out)
-Bi-lateral standard
created but not necessarily
followed; concern about
how this will affect 07-15
implementation
-Is there a need for add’l
education? AUC has
publicized, but approx.
50% compliance
-Payers and providers
have significant admin.
Having provider utilize the
cost related to lack of
same payment audit tools
compliance with standard
Although bi-lateral
Audit tools:
procedures always surfaces
as a case study of good
-At times, provider may
standard, the actual provider
use audit tool that is not
implementation of the
programmed to work with
standard continues to be
MN standards
problematic. HealthPartners
-Vendors have two tools:
continues to see many
one for providers (to
providers not utilizing the
standard and has had to put in increase revenue) and one
for payers (to decrease
place additional edits,
costs)
programming, and reports to
-Product flexibility may
monitor this. There is
significant concern regarding not be able to work with
Meeting discussion grid for comments submitted 02-09-09
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Notes/Follow Up
Submissions
what will happen with the
provider implementation of
Appendix A in the MN
Uniform Claims Guide and if
providers will follow the
standard.
4. Other Comments
• Now that this industry has
NPI numbers remove the
tax id variable from the
claim form.
• DHS to utilize same
standards as other group
purchasers. Having DHS
required to utilize MN
companion guides for
Eligibility, Claims and
Remits are a step in the right
direction, however there are
still code exceptions, etc.
•
PMAP/MERC data
reporting issues
Discussion
Impact/Practicality, Other
Criteria
MN Guides
Item 1:
-Still required to be
reported (federal standard)
-5010 still maintains this
Item 2:
-837 P and I have slightly
different appendices for
DHS due to State/Federal
MA guidelines
-AUC attempted to
streamline differences,
minimize
-Also a slight difference
in 835 for DLI
Item 3:
-Payments currently being
made based on incorrect
data
-If MN moved to fed
standards, resolution
could be reached on some
of these issues
-Barrier: some state laws
Meeting discussion grid for comments submitted 02-09-09
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Notes/Follow Up
Submissions
Discussion
Impact/Practicality, Other
Criteria
(encounter data reporting,
etc)
-With a standard file
format, data might be
more accurate at DHS, but
might accrue a cost to
DHS when extracting data
5. Coding for new programs
Meeting discussion grid for comments submitted 02-09-09
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Notes/Follow Up