Overview

In this time of increasing financial, operational and regulatory pressures on health plans, payers and providers, executives are discovering that electronic transactions present as many challenges as they do opportunities.

HIPAA legislation mandated the use of standard transactions and code sets between trading partners, in an attempt to ease the burden of telephonic and paper communication between payers, providers, employers and other stakeholders. However, as almost everyone has discovered many backend processes and systems have very specific data content and format requirements, allowable under HIPAA, in order to achieve the highest possible levels of automation.

Contrary to the intent of the law, in many cases, automation rates have gone down, not up-creating unintended costs and negative impacts for payers, providers and consumers. HIPAA transactions are not the only standards that healthcare organizations must support to be effective and efficient. Other standards such as HL7, NCPDP, NSF, UB92 and even proprietary file formats must be supported, given the wide variety of trading partner requirements.

All these requirements have created a number of questions that organization leadership should address to be responsive to their markets. The answers to these questions can determine whether an organization can create and maintain a strategic advantage leveraging electronic trading relationships.

Key Transaction-Related Questions for Healthcare Organizations

• What tools can I use to ensure that the data is compliant — not just with HIPAA, but with my business specific requirements, and those of my trading partners?
• Do I need different software systems for different standards such as HL7, NCPDP, and legacy file formats?
• How will I manage, enforce, or relax edits and errors, based upon the different needs of my trading partners?
• Different types of submitters need to send different types of data in the transactions. How will I manage to ensure that I receive this data when I need it?
• How can I split and route transactions once they hit my firewall — to the right adjudication system, to a carve-out vendor, or even to separate good transactions from bad transactions?
• How will I generate the appropriate acknowledgments and error messages when bad transactions are received?
• How will I keep up with the standards and code sets as they change and evolve, and with new standards as they are implemented?
• How can I serve up this EDI data for new value-added applications in my organization without a huge amount of translator maintenance and cost?