Using HIPAA Transactions for Revenue Cycle Management

HIPAA transactions were developed with the intent to reduce overall administrative costs for the healthcare industry.  This is accomplished in two ways, by developing a standard that can be used to conduct these transactions consistently under all similar conditions and trading partners to create transactions that automate previously manual or semi-manual processes.

This article will discuss how these transactions can be used to support the processing and follow up of claims.

The first step in claims processing is the creation of the claim file itself, the 837i (institutional) and the 837p (professional).  These files must contain all recently produced claims of each type that are destined for a specific entity.  At our company, we use the term receiver to represent the target of these files.  Receiver is distinguished from payer in that a receiver may receive claims for multiple payers in a single file.  For example, a clearinghouse like Emdeon or Availity.  In other cases, the receiver may represent a single payer, or even a sub-classification of a payer, like Medicare Part A and Medicare Part B. Continue reading

The Government Shutdown and Healthcare Claim Processing

CMS has instructed all Medicare Contractors (MACs) to perform all claim processing functions during the government shutdown.  This includes the processing of claim files and the creation of response files (835, 999, 277CA).  Based on our internal operations regarding these processes, we have seen no impact on these activities from any contractor.  Medicare and Medicaid payments should not be delayed.

However, the shutdown will have an impact on other administrative activities that may impact reimbursement in the long run.  All activities related to surveys and certifications have been suspended.  This includes the authorization of new agencies to conduct these transactions or obtain Medicare certification and the termination of certification for organizations under investigation.  Continue reading

My DDE is not working!

As some of you know, CMS is transitioning their DDE connectivity to support a new security standard.  I discussed this topic in a previous article, “Direct Data Entry (DDE) Security Upgrade Requirement” on 9/16.  In this article, I mentioned that this upgrade might cause certain provider systems to fail when they attempt to connect to DDE after the transition.  CMS has two separate systems that provide this service, one is managed by HP (Hewlett-Packard) and one is managed by CDS (Companion Data Services). Continue reading