Uniform Claims Review Process Study
February 9, 2009 Meeting
Flip Chart Notes
Suggested Possible Areas for Study Focus and Notes/Comments
(Headings below refer to suggestions noted in
“Preliminary Discussion Grid for 02-09-09 Uniform Claims Review Process Study”)
•
Portal/ “UHIN” Concept
o Sections of the community concerned with connectivity
o Larger organizations already are “hooked up” and replication would be
costly
o Common network portal would likely not be ready by 07-15-09
o Value to smaller providers
o Standards are in place
ƒ Streamline to access?
•
Real time claims adjudication
o WEDI work group currently examining, not resolved at national level
o 2 pieces needed for consideration
ƒ Providers shift back office to front
ƒ Acknowledgments/handshakes needed
o No national standard exists
o Patient advocates address patient liability in advance
o Issue of “price”
ƒ Price “per se”
ƒ Codes to be submitted
•
COB
o When providers receive primary payer data, it is difficult to automate for
the secondary payer
o Will have to monitor with December implementation
•
Service types as part of 5010 update
o Work with providers needed to ask specifically for the service interested
in, check vendor limitations
o MN BCBS: Difficult responding to 17 service areas (slows system), went
back to 11
o Ask “what are hot services of interest?”
•
Include self-funded plans in prompt payment
o Check with MN Dept of Commerce
o Role of Commerce to investigate, pursue?
Suggestions for ranking
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•
Develop uniform standard for retroactive claims adjustment
o Issue: payer going to provider 3-5 years after the fact
ƒ Need firm timeline
ƒ No common filing timeline
ƒ Plays into enrollment activity
•
Enforcement of MS62D.12 Subd. 19
o Submitted as a prior authorization issue
•
Uniform payment methodologies
o For second part of study charge (related to potential impacts of “uniform
pricing”)
•
Create consistency of billing of units
o Bi-lateral standard created, but not followed
o Significant costs when standard not followed
•
Audit tools similar
o Tool should take into account standard approach
o Competing interests, revenue maximization makes difficult
o Product flexibility to meet MN Guide Requirements?
•
NPI, tax ID
o Tax ID still required as part of federal standard
•
DHS same coding as rest of community
o 837 P&I have separate appendices for DHS due to DHS requirements
•
PMAP/MERC reporting
o DHS FFS review does not recognize certain services—yields different
info for MERC calculation
o Use of standard transactions would allow better way to transmit payerpayer data
•
Coding for new programs
o Example: baskets of care, unique services/programs that are ahead of
coding standards
Suggestions for ranking
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