Texas
Since 2008, providers and payershave been required to have the capability to receive medical billselectronically and to remit electronic payment advice. However, toease initial compliance burdens, providers and payers have beenallowed to receive eBilling waivers and to utilize various eBilling"clearinghouses" or agents. This is about to change. To pushenhanced system compliance, the Texas Division of Workers'Compensation (TDWC) recently published proposed changes to existingeBilling rule requirements that:

  • Remove "must be capable" (of receiving andremitting) language, replacing it with "shall submit andshall remit" language, making eBilling the exclusiveformat.
  • Update required formats for eBilling, in anticipation ofHIPAA-related changes to ANSI/ASC 837 and NCPDP (National Councilfor Prescription Drug Programs) formats.
  • Require providers and payers to show good cause for continualeBilling waivers.
  • Prohibit carriers from charging health-care providers to useclosed, proprietary, or "clearinghouse" eBilling systems, thusaddressing concerns of compliant providers.

The proposed changes highlight TDWC's desire to increasestakeholder eBilling compliance and push eBilling as the exclusivemethod of workers' compensation medical billing. It appears that inTexas, the grace period for eBilling non-compliance may be comingto an end.

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Minnesota
In July 2008, Minnesotaimplemented phased-in eBilling requirements for all health-careproviders and payers, including workers' compensation. Driven bylegislative order, the Minnesota Department of Health (MNDOH)adopted ANSI/ASC and NCPDP formats for their eBilling guidelines,creating similarities between Minnesota and Texas. Despite thesimilarities, there are striking differences. First, implementationwill happen over two phases (transmittal required July 15, 2009,and remittance required Dec. 15, 2009). Second, Minnesota requiresusage of adopted standards. Most importantly, Minnesota is notgranting eBilling compliance waivers. Lacking waivers, providersand payers are expected to exhibit day-one "compliance inpractice." Initial enforcement efforts and agency audits will becomplaint-driven.

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California
As successful eBillingimplementations take hold in Texas and Minnesota, California'sDivision of Workers' Compensation (CADWC) edges closer topublication of draft eBilling rules. In discussions with expertsfrom CADWC, it appears the division will institute eBillingguidelines in line with those required by Texas and Minnesota andrecommended by entities such as the International Association ofIndustrial Accident Boards and Commissions (IAIABC). Californiawill likely recommend or require utilization of national standardssimilar to Minnesota and Texas. Eventually, CADWC's desire is topush eBilling as the exclusive billing format for Californiaworkers' compensation system participants. Publication and adoptionof final rules are not expected until mid-2010, with an end-of-yearimplementation kick-off date.

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Going Forward
Adoption of eBillingrequirements in Texas, Minnesota, and eventually California, is nota random occurrence. Key regulators from these states (AllenMcDonald - TDWC; Dave Haugen - MNDOH; Sue Honor - CADWC) are allinvolved directly with IAIABC in efforts to advocate adoption ofeBilling efficiencies for workers' compensation. In fact, bothNCPDP and IAIABC have included eBilling as part of their generalmembership and committee discussions for several years. IAIABC'sMedical Pro-Pay and EDI workgroups/committees continue to influenceand assist numerous workers' compensation state regulators inimplementing eBilling guidelines. Several key IAIABC member statescontinue to advocate for creation of a model IAIABC eBillingimplementation guideline(s) -- sort of a playbook for stateeBilling implementation. At present, early drafts call foradoption/utilization of national standards such as ANSI/ASC andNCPDP formats.

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How Should You Prepare?
As entities suchas IAIABC and various state workers' compensation agencies continueto advocate adoption of eBilling standards in the workers'compensation marketplace, it appears that the days of paper billingare numbered. Successful implementation of eBilling requirements inhigh-profile states such as Texas and California will only augmentthe desire of other states currently contemplating eBilling. Withthree key states close to completing eBilling development and atleast a dozen or more seriously discussing the issue, it behoovesany workers' compensation provider or payer to be prepared foreBilling.

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The first preparation step is to realize that eBilling is hereto stay. The second step is to acknowledge that ANSI/ASC and NCPDPfile formats are being advocated as the national standards or anational solution for multiple jurisdictions. In doing so,organizations such as NCPDP and IAIABC are providing a simplesolution to a complex problem. The final step is to clearlyunderstand how utilization of ANSI/ASC and NCPDP national standardsor formats will impact your billing processes, and to move quicklyto enhance your processes or engage in relationships withclearinghouses or billing providers.

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Kevin Tribout is director of government affairs for PMSI. Hemay be reached at [email protected].

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