Infusion coalition seeks to shape new EDI regulations


HHBR Washington Correspondent

ALEXANDRIA, Va. — Home infusion representatives are developing a strategy to help shape emerging federal regulations that will standardize the coding of healthcare claims and other requirements for electronic data interchange (EDI). These regulations, which will be finalized this year, will have a major impact on home infusion providers, according to members of The National Home Infusion Association (NHIA; Alexandria, VA), the National Alliance for Infusion Therapy (NAIT; Washington), and the Home Infusion EDI Coalition (HIEC; Phoenix).

"When these standards are finalized, we will have a situation where if you want to do business through EDI you will have to conform to these standards," said NHIA Executive Director Lorrie Kline Kaplan. "We have a very short window of opportunity to work together as an industry to influence these regulations. We must take action early in the first quarter of 1999."

HIEC, composed of home infusion providers and associations, was developed in 1994 and since that time has worked closely with insurers and electronic networks to promote electronic claims and EDI for home infusion providers. HIEC has already developed a national system for encoding home infusion claims that codes drugs with NDC codes. It now hopes to promote this system with federal regulators as the baseline for the new federal regulations. The coalition has also worked closely with the Accredited Standards Committee, the country’s predominant EDI standards setting organization.

The regulations HIEC is focusing on are required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The centerpiece of that bill was a set of protections that guaranteed workers could maintain their insurance when they changed jobs. However, it also requires the secretary of Health and Human Services (HHS; Washington) to develop and enforce national standards for health insurance EDI. This includes electronic claims and other health insurance transactions, healthcare coding systems, as well as confidentiality and security standards. Also included are national entity identifiers for payors, employers, and patients.

The full impact of these changes will be felt by home infusion providers and the rest of the healthcare industry in the year 2000 with large-scale implementation of standardized EDI taking place in 2001. The law requires the compliance of all payors including Medicare, Medicaid, managed care organizations, and other private health insurers.

The goal of EDI is to minimize the manual entry of data and enable healthcare providers to transmit clinical, demographic, insurance, and service information to carriers electronically for timely adjudication. The majority of institutional health claims are now submitted electronically as well as many physician claims. Many durable medical equipment (DME) claims are also submitted electronically as well as some home care agency claims.

"Unfortunately for home infusion providers," said Kaplan, "virtually the only payor accepting claims via true EDI is Medicare." Some infusion providers submit a certain number of applicable claims electronically to the durable medical equipment regional carriers, (DMERC) but most other payors do not accept any of their claims electronically. Some payors may accept portions of certain claims electronically, but home infusion companies must key-in the claim in a very detailed fashion. "This is definitely not EDI," said Kaplan.

HIEC members see both positive and negative developments in the proposed regulations for implementing the requirements of HIPAA that have so far been published in the Federal Register. On the positive side, the regulations proposed that the coding system for drugs be based on NDC number rather than the HCPCS codes that are currently used. "HCPCS codes are not nearly inclusive enough to specify the wide array of drugs supplied by the infusion industry and most payors already require NDC number," Kaplan said.

However, the proposed rules also stated that the systems used for coding claims will be HCPCS, CPT, ICD-9-CM, and NDC codes. "None of these systems adequately describes the full scope of services we provide or includes specification of our professional services. "This challenges HIEC to get our coding system incorporated into the federal regulations somehow," said Kaplan.

The home infusion representatives are also concerned that the proposed rules do not clearly define exactly what type of claim a home infusion claim is—retail pharmacy, professional service, or institutional claim. "We hope to eliminate the need to split’ our claims — where we have to submit one claim for drug products and other for supplies and professional services — maybe even to two different places," said Kaplan. "Infusion providers are having a terrible time getting paid lately, and this only makes it worse." In addition, said Kaplan, there is currently no real way for infusion providers to bill explicitly for professional clinical pharmacy services. "If we can gain national recognition for a coding system that addresses these issues, it will be a giant step forward for the infusion industry," she told HHBR.

While HIEC, NHIA and NAIT have already formally commented on these aspects of the proposed regulations, the coalition believes that opportunity still exists to help shape the final regulations if the industry is adequately united in its recommendations.