The Amazing Maze of US Health Care » Administrative Simplification

Amazing seems a most appropriate word to describe the financing and delivery of health care services in the United States of America.
James L. McGee, CEBS--On Health Care Reform

Administrative Simplification

Sometimes people are magically teleported outside of their health care silo.

This happened to a group of our participants every month for several consecutive months.

At the beginning of each month one of the members of this group would call our office – “The doctor won’t treat me because he/she was told I have no health insurance.”

Our Plan had recently approved coverage for domestic partners.    Somehow, the computer system of one of our carriers could not properly interpret the code for a domestic partner.    The computer saw this adult as a child.   Sound like Alice in Wonderland?  One computer makes you larger and one computer makes you small.

The carrier told the doctor’s office that this member had no other adults on their plan, only a dependent child or dependent children.    In at least one case, the domestic partner was 52 years old and the couple had no dependent children.

Now this should not present an insurmountable challenge.  The Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191, includes provisions for what is referred to as Administrative Simplification.   This rabbit hole of  regulations details in excruciating detail the requirements for transmitting electronic files (Electronic Data Interchange or EDI), including enrollment files, first appeared in 2000.

The implementation guide for the enrollment file, ANSI ASC X12N 834, lists the acceptable individual relationship codes.    They appear in the INS02 Segment in the 2000 Loop.  The primary card holder is represented by the number 18, a dependent child is a 19, a spouse is a 2.    You may argue that the codes don’t make sense.    But they don’t need to.    After all, they are being read by a computer.    The code for a domestic partner is 53.

Notice that it does not include any of the digits used in any of the other codes.    So how does a 53 get confused with a 19?   Is our group the first to cover domestic partners?   How is a fifty two year old interpreted as a dependent child?

But as confounding as computer systems may be, they are at least constrained by laws of logic, laws that most of us find baffling, but laws nevertheless. How logical is it that every month, in some cases, every week or day, countless thousands of group health plans must send their updated enrollment and eligibility information to their respective health insurance carriers -  m ost of the time electronically, but far too often, on paper.

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