Advances or absences in e-technology are often the engines driving ever-new considerations in healthcare business from the drawing board to the workplace to the bank.

In the case of the business of complementary and alternative medicine (CAM), the matter that has been holding it in economic quarantine is not belief or philosophy. Those forums are still buzzing away under the hot lights of the media, but much closer to the bottom of the business food chain. A tool for accurate and legally compliant claims processing has been missing e-commerce link preventing CAM's full integration into healthcare business - until now.

Recently, a small privately funded family firm in Las Cruces, N.M., Alternative Link has created a model for CAM claims processing and reimbursement which is being considered for the national standard for electronic processing of CAM claims for payers and providers.

Demand for CAM
It would be tough to grasp the potential impact of this little company's invention without some update of CAM business and the factors surrounding its integration into mainstream medicine.

For some time now insurers have been lined up to meet the public's demand for CAM services in health plans. A study done by David Eisenberg, director of Harvard Medical School's Center for Alternative Medicine Research, was published in the Nov. 11, 1998, issue of the Journal of the American Medical Association. It describes Americans in the 90s making more visits to CAM practitioners than to primary care physicians - and spending $27 billion out of pocket to do it.

A 1999 survey of HMO executives funded by Landmark, a CAM services organization and specialty health plan in California, showed that 38% of the respondents reported that they offered CAM because of patient demand.

Consumer demand for CAM is further evidenced by the growth of Discounted Fee for Service networks, smart cards and legislative mandates over the last two years. So why aren't CAM claims 'business as usual' for payers?

It turns out that CAM business has its own specific administrative and legal demands, separate and different from those of conventional medicine.

Existing payer systems, Medicare and Medicaid can't add CAM benefits without the descriptions of treatments performed by CAM practitioners put into a standardized vocabulary, identified with training standards, and given corresponding codes with relative value units. Further, each states' licensing and scope-of-practice laws (different in every state) must be part of that vocabulary. Finally, the capture of outcomes data such as cost-effectiveness and treatment efficacy - critical for payers to underwrite the cost of adding CAM - have been nonexistent.

The electronic procedural billing codes such as the ones used for conventional medicine are not adequate for the requirements of CAM.

Payers throughout the country are having a very difficult time processing CAM claims, according to Jan Thorpe, executive director of Alternative Healthcare Systems of Maine Ltd. "We will never integrate CAM nationally until we can validate and process claims nationally," Thorpe says.

According to John Weeks in the July 1999 issue of The Integrator - for the Business of Alternative Medicine, "The question was not if somebody would develop a set of procedure codes for CAM, but who and when."

The "who" in Weeks' question was insurance visionary Jo Melinna Gianinni, president and founder of Alternative Link. The "when" was June 22, 1999, when Gianinni's electronic CAM billing codes (ABC) and accompanying CAM-designed database system (CAM-net) received a U.S. patent provisional in 90 foreign countries.

The best minds consistently work from an acknowledgement of the future. The most visionary of them devise solutions.

Gianinni perceived this simple truth: Codes equal payment. After 4,000 codes and three years of sweat, the result is a database system providing legal, regulatory and educational support to payers and providers for CAM claims processing.

Even before the patent became final, Gianinni's system was voted into the American National Standards Institute's Implementation Guide For Electronic Standards, and accepted into the National Library of Medicine's Unified Medical Language System. Gianinni's system is being considered for a Level One national standard for billing codes by the Department of Human Services, which administers the Health Care Financing Administration, which in turn governs Medicare and Medicaid.

Alternative Link's ABC codes are the only CAM code set being considered. If selected as the standard, this would mean that by 2002 the billions of potential electronic CAM transactions would each generate fees for Alternative Link.

Motivated by a desire to see CAM practices and treatments available to consumers in all health plans, Gianinni has been an insurance innovator from her early days with New England Financial Group in Albuquerque, N.M.

According to a March 1999 article in Physician Manager, "Alternative Link has created the first independent third-party coding system for alternative medical treatments. The system of 4,000-plus codes has attracted government attention, and if widely implemented could make insurance coverage of AltMed routine."

"There has been no legal or regulatory infrastructure upon which CAM business can develop," Thorpe says. "Gianinni, with her CAM-net and ABC codes, has resolved a host of thorny issues for CAM."

The Alternative Link codes will be useful to all healthcare players that process claims, according to Brian Klepper, president of Health Performance Inc., specializing in the construction and repair of MCOs, such as clearinghouses, router, utilization management firms and health plans.

"Gianinni's work is the key to the administration level of the integration of CAM and existing healthcare systems," Klepper says.

"We don't want to anticipate disaster, but between 1997 and 2007, it is estimated that the costs of healthcare will double," The Integrator's Weeks says. "There will be segments of the mainstream payment delivery system that will be ready and willing to investigate CAM more thoroughly as an answer to their cost problems. Those that do so will find Alternative Link's codes and database a handy tool."

The Health Insurance Portability and Accountability Act, passed by Congress in 1996, mandates standardization for coding systems and electronic claims transactions, and imposes civil and criminal penalties for misrepresentation. The goal is to reduce insurance fraud, but well-intentioned violations of their rules are easy to make.

"HCFA forms now include a backpage notice that each of 10 billing line-items can be separately charged as fraudulent acts, with penalties as high as $10,000 per line-item. That's $100,000 per page in maximum penalties, a daunting prospect for alternative providers who may be just trying to do the right thing by using conventional code approximations of treatment," said an article published in the Feb. 1998 issue of Advance, Health Information Professionals.

Payers will make it a priority to meet legal compliances regarding their electronic commerce, consequently expediting Alternative Link's market acceptance and implementation, says Jack Scanlon, vice president, EDI-USA, routers for about 95% of claims for Blue Cross and Blue Shield, as well as claims for private payers. EDI and Alternative Link have a contractual agreement for future claims delivery.

Opportunities for big payers.
"Alternative Link offers a great opportunity to the big payers," Scanlon says. "The final compliance guidelines for the mandates of HIPPA are due out this year. Therefore, payers will be focusing on compliance with electronic billing code standardization. Enter Alternative Link with a resolution, a most fortunate incentive for the huge payers like Aetna, Blue Cross and the big TPAs to implement CAM-net and the ABC codes."

According to John St. George, president of St. George Consulting, "Alternative Link's products perform a service to CAM. CAM business now can take advantage of the cost-saving electronic advantages that other healthcare providers have. E-commerce for CAM will reduce costs of doing business and introduce more resources for healthcare delivery."

The best advice for healthcare players wanting to enter the alternative medicine marketplace is "know the legal parameters in your state or find somebody who does," Gianinni says.

She says beware of "CAM grafting," a phrase coined by Weeks referring to programs like Discounted Fees for Services (DFS), which tack CAM onto programs but fail to integrate them on a legally compliant administrative level.

"DFS is a quick fix devised to market CAM services in exchange for referral volume for providers," Gianinni says. "It is not insurance coverage and it creates more problems than it solves. Foremost is the absence of outcomes data in the DFS model. This is counter-productive to the future of CAM business. Without accurate descriptions of the patient encounter, there is no way to evaluate the CAM treatments you've added to your plan.

"As long as underwriting experience is the measure of treatment protocols, a method is required to connect CAM treatment plans to coded procedures," she says. "When cost is attached to the CAM codes, conventional data can be used as a benchmark to allow or disallow treatments. You must have the data underwriters require for integration of CAM."

Overall, Gianinni says, "the well-conceived plan including CAM must be merged with network development, contracting, coding, pricing, medical management and experience to integrate CAM services into a productive interface with conventional medicine."

Alternative Link's system has been designed to plug into conventional claims processing systems without the need for extensive and costly changes in software.

"It is much less costly to have a system that allows all stakeholders to continue 'business as usual' without revamping current systems," says Judy Lee, director of research for Alternative Link.