This part of the Health Care Reform Bill, section 163 of HR3200 bothers me almost as the End of Life clause. I have a friend, Shadow, who sent this to me. Please read every word of this. It is a license to steal.
This post’s movie selection is dedicated to Nancy Pelosi and Harry Reid.
SEC. 163. ADMINISTRATIVE SIMPLIFICATION.
(a) Standardizing Electronic Administrative Transactions-
(1) IN GENERAL- Part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.) is amended by inserting after section 1173 the following new section:
‘SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.
‘(a) Standards for Financial and Administrative Transactions
(1) IN GENERAL- The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph
‘(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS– The goals for standards under paragraph (1) are that such standards shall
‘(A) be unique with no conflicting or redundant standards;
‘(B) be authoritative, permitting no additions or constraints for electronic transactions, including companion guides;
‘(C) be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications;
‘(D) enable the real-time (or near real-time) determination of an individual’s financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card;
‘(E) enable, where feasible, near real-time adjudication of claims;
‘(F) provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary;
‘(G) describe all data elements (such as reason and remark codes) in unambiguous terms, not permit optional fields, require that data elements be either required or conditioned upon set values in other fields, and prohibit additional conditions; and
‘(H) harmonize all common data elements across administrative and clinical transaction standards.
‘(3) TIME FOR ADOPTION- Not later than 2 years after the date of implementation of the X12 Version 5010 transaction standards implemented under this part, the Secretary shall adopt standards under this section.
‘(4) REQUIREMENTS FOR SPECIFIC STANDARDS– The standards under this section shall be developed, adopted and enforced so as to–
‘(A) clarify, refine, complete, and expand, as needed, the standards required under section 1173;
‘(B) require paper versions of standardized transactions to comply with the same standards as to data content such that a fully compliant, equivalent electronic transaction can be populated from the data from a paper version;
‘(C) enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice;
‘(D) require timely and transparent claim and denial management processes, including tracking, adjudication, and appeal processing;
‘(E) require the use of a standard electronic transaction with which health care providers may quickly and efficiently enroll with a health plan to conduct the other electronic transactions provided for in this part; and
‘(F) provide for other requirements relating to administrative simplification as identified by the Secretary, in consultation with stakeholders.
‘(5) BUILDING ON EXISTING STANDARDS– In developing the standards under this section, the Secretary shall build upon existing and planned standards.
‘(6) IMPLEMENTATION AND ENFORCEMENT– Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section. Such plan shall include–
‘(A) a process and timeframe with milestones for developing the complete set of standards;
‘(B) an expedited upgrade program for continually developing and approving additions and modifications to the standards as often as annually to improve their quality and extend their functionality to meet evolving requirements in health care;
‘(C) programs to provide incentives for, and ease the burden of, implementation for certain health care providers, with special consideration given to such providers serving rural or underserved areas and ensure coordination with standards, implementation specifications, and certification criteria being adopted under the HITECH Act;
‘(D) programs to provide incentives for, and ease the burden of, health care providers who volunteer to participate in the process of setting standards for electronic transactions;
‘(E) an estimate of total funds needed to ensure timely completion of the implementation plan; and
‘(F) an enforcement process that includes timely investigation of complaints, random audits to ensure compliance, civil monetary and programmatic penalties for non-compliance consistent with existing laws and regulations, and a fair and reasonable appeals process building off of enforcement provisions under this part.
5) BUILDING ON EXISTING STANDARDS– In developing the standards under this section, the Secretary shall build upon existing and planned standards.
(6) IMPLEMENTATION AND ENFORCEMENT- Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section.