Rather than update their software, many practice-management vendors have said they will sunset their packages and provide no further upgrades. "There is a prevailing wisdom that the amount of paper will move sharply upward," says John Dyer, marketing segment manager for health care at IBM, who expects small providers to outsource claims processing to clearinghouses, such as WebMD.
Perhaps the biggest challenge is standardizing the EDI transaction formats that insurers and medical providers use to exchange information about claims. The current systems are designed to send and receive small blasts of information, such as an inquiry into whether a patient is eligible for a certain procedure or a check on the status of a claim. Even though there are standards that define the format of those blasts--for instance, UB92 for Universal Billing--insurance companies such as Aetna, BlueCross and Cigna represent those transactions differently in their own systems.
Under HIPAA, hospital claims can also include up to 999 items called service lines, which are the specific supplies and medical services that make up a single claim for payment. This means accommodating more information packed into fewer transactions. Rather than perform Y2K-like remediation on mainframe applications written in COBOL and assembler--which can't handle files with so many service lines--many payers and providers are placing XML gateways in front of their back ends to turn proprietary formats into standard ones.
Children's Hospital built such a gateway to aggregate the blasts, package them into HIPAA-compliant transactions and route them to the appropriate payers. In reverse, the gateway continuously watches for returning transactions and converts HIPAA-compliant formats back into Children's native formats.
The gateway was implemented in accordance with standards developed by the New England Health Care EDI Network (NEHEN), a group comprised of hospital and insurance company CIOs and CTOs formed in 1998 to address HIPAA, which was passed two years earlier. The goal was to define standard formats and best practices in advance of specific direction from federal regulators, says Ogawa, who is a voting director of the consortium. The standards were developed with help from integrator Computer Sciences Corp.
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