Beaverlog Tips: Volume 19 - July 12, 2004

The THERAPIST Pro Classroom Instruction

We've had many requests to teach classes on using The THERAPIST. At long last, we have put together a one-day class on The THERAPIST Pro which will be presented on Saturday, August 28, 2004. It will cover features common to The THERAPIST for Windows 1.0, 2.0, and Pro 2.5 as well as some of the newer features added in Pro 2.5. It does not cover The THERAPIST EZ. If there is enough demand we will schedule a class on EZ in the future.

The class will be held in Corvallis, Oregon. Registration is limited to 18 students. The cost of the class is $350 per person. Our web site has additional details, discounted hotel reservation, and travel information.

Electronic Insurance Claims

As far as electronic insurance claims are concerned, HIPPA changed everything, both for good and for ill. Now with two years of experience, it is clear that many of our hopes and fears have come to pass. The new ANSI X12 claim standard (often referred to as the Implementation Guide) is finally a standard with the force of law behind it. It is not a toothless law and it is being enforced. That is good news for you. When the standard says that a patient's insurance ID goes in just this spot, the payers are not allowed to change it. They are not allowed to force your claims to do anything not allowed by the standard. Also, the standard makes every attempt to be unambiguous. It doesn't always succeed but that is the goal.

On several occasions, we at Beaver Creek Software have had to confront payers and clearinghouses (see Beaverlog Tips volume 16). It is usually a painful experience for all involved but we feel it's important to do whatever we can to keep the standard a true standard.

One of our fears was that the complexity and flexibility of the standard would give payers "loopholes" with which to deny claims. That appears to be happening in some cases. Much of the specification (actually, most of it) consists of data elements that are marked as being "Situational." In some cases, that means that the data is present if it is available, such as a patients middle name. In some others, the data is required in certain circumstances. An example of this is the national payer ID. When fully implemented (sometime in 2006), this will become a required entry. Finally, some situational elements are ambiguous in when they might be required. Certain payer, provider, subscriber, and patient ID numbers fall into this category. Also, the standard allows many of these to be in one place or another but doesn't say that it is wrong to put it in both places. It also doesn't say that it is ok to do so. This leaves the payer room to say something to the effect "Our interpretation of the implementation guides is that the ID must be here and must not be there..." Whenever a situation like this comes up, we try to resolve it with those who are in charge of the standard.

Other of our fears, was that the payers would not give providers sufficient information to allow them to find and correct problems. Not only is this happening but it is widespread. The standard payer reply when asked about this is that it is up to the software vendor, in this case Beaver Creek Software. That's equivalent to giving you a traffic ticket but refusing to tell you what law you broke and suggesting that it's up to the automobile manufacturer to fix it. Beaver Creek Software is extremely quick about correcting electronic claim problems when they are found. So far, ninety-nine percent of the problems have been simply putting the proper information in the right place in The THERAPIST.

Fortunately, in The THERAPIST Pro 2.5, we added a tool that will help you find errors in your claim files. Many payers and clearing houses are now returning what is known as a Functional Acknowledgement or 997 file. This is a file, structured similarly to the electronic claim file, that is designed to report errors in the original claim file. The down side is that this is not a simple listing of errors and where they can be found, though it does have that information. This makes it impossible to open the file in NotePad or Microsoft word and figure out where the errors are. In The THERAPIST Pro 2.5, there is now a button on the electronic claim viewer for ANSI X12 claims that lets you analyze your claim from a 997 file on your computer. When the 997 file is read, the errors in the claim file will be shown in red, making it easy to find them.

The 997 Functional Acknowledgement only lets you know when there are problems with the claim file such as missing data. It does not tell you whether the claim will be paid or for how much. That information is in another file, the 835 Claim Payment/Advice file (stay tuned for more on this). This is basically an electronic version of the EOB (Explanation of Benefits) that usually accompanies payer checks. Few payers are currently sending the 835 files but this will change over time. 997 is here now though not yet universally supported.

What About Clearing Houses?

Clearing Houses have special dispensation to use any claim format they want for receiving claims from their customers. This means that you can send claims through a clearing house in a HCFA-1500 print image format, a favorite of many clearing houses. This format is pure text file that, when opened in a word processor, looks like the HCFA-1500 without the lines and boxes. The data is all there and in specific positions but the form itself is not. All versions of The THERAPIST for Windows (1.0, 2.0, Pro, and EZ) support this claim format. It is then the responsibility of the clearing house to convert those claims to the approved ANSI X12 format in order to submit them to payers.

For claims that pass through a clearing house that didn't begin as ANSI X12 claims, a 997 file is useless to providers because it is claim file and format specific. Clearing houses, however, can make use of the information, interpret it, and pass it back to you in a more readable form.