The National Committee on Vital and Health Statistics

Subcommittee on Standards and Security

Geographic Perspective on the implementation of Administrative Simplification standards that will be required under HIPAA

New England Healthcare EDI Network
(NEHEN)

Presented By:
Computer Sciences Corporation

July 14th, 2000

First, I’d like to thank you for giving me this opportunity to testify to your committee this morning. My name is Eric Bartholet and I’m a healthcare consultant with Computer Sciences Corporation. I’m here today representing a regional perspective on the implementation of the HIPAA Administrative Simplification EDI transactions based on our experience as the program managers for NEHEN, or the New England Healthcare EDI Network.

In my comments this morning I hope to provide the committee with an understanding of the challenges and issues we’ve faced in implementing the HIPAA transactions. The focus of my comments will be to provide you with an overview of who NEHEN is, the status of our implementation, and the technical and process related issues that we’ve had to overcome. I’ve also submitted a brief White Paper that discusses in greater detail the history of NEHEN, how we’re organized, and the specifics of our technical approach for anyone who may be interested.

NEHEN Background

NEHEN, or the New England Healthcare EDI Network, is a consortium of payers and providers located in Eastern and Central Massachusetts who are collaborating on the implementation of the HIPAA Administrative Simplification EDI transaction sets. Started in 1997 from a subgroup of the Massachusetts Health Data Consortium, headed by my colleague and fellow panel member Elliot Stone, NEHEN is currently comprised of most of the regions largest provider networks and two of the regions largest managed care organizations. The founding members of NEHEN include Partners Healthcare, Care Group, Lifespan, Harvard Pilgrim Health Plan and Tufts Health Plan but membership has rapidly grown to now include Boston Medical Center, Boston Children’s Hospital, and UMassMemorial Medical Center. It is an open organization and any payer or provider is welcome to join for a low monthly fee (there are no transaction fees). Additionally, NEHEN provides connectivity to Medicare and Medicaid in a seamless and integrated manner, so that the provider members have access to all four payers through a consistent user interface. In all, NEHEN membership represents over 25 hospitals, over 6,300 licensed beds and over 2 million covered lives (not including Medicare and Medicaid).

The primary objectives of NEHEN are:

• Address HIPAA compliance issues. All transactions currently flowing over the New England Healthcare EDI Network are HIPAA compliant
• Improve service efficiencies through EDI. Exchanging HIPAA mandated transactions lets participants realize significant improvements in the speed and uniformity of many core administrative processes.
• Shorten the elapsed time to achieve wide scale use of EDI in payer and provider organizations.
• Reduce the costs of EDI implementation through coordination and standardization.

Implementation Status

NEHEN went live with the Eligibility Verification (270/271) transaction in 1998 and has recently gone live with the Specialty Referral (278) in a pilot project starting last week. The next planned transaction is the Claims Status Inquiry (276/277) which is scheduled for August of this year. Although it took about a year to develop the necessary infrastructure, new members are now able to begin trading transactions within a few months of joining NEHEN. Our current transaction volumes are approximately 220,000 per month and are expected to triple over the next year.

Key Implementation Challenges

There are two key implementation issues that have affected our progress that I would like to make this committee aware of:

• First, the providers have typically required significant redesign of their patient access processes prior to implementing the eligibility transaction. For example, there is considerable value in moving eligibility verification to the front of the patient access process, or verifying eligibility at time of appointment rather than waiting until the patient arrives for service. Currently, this is not done in a consistent manner due to the time required to manually verify a patient’s eligibility. By significantly reducing the time it takes to verify eligibility, NEHEN members have greater flexibility in determining when the eligibility verification occurs in their patient access process. As a result, schedulers are now able to resolve any eligibility discrepancies while the patient or physician’s office is still on the phone. The effect of this redesigned process has been higher quality data and fewer rejected claims. The challenge has been that the scheduling function is often supported by individual departments and is highly decentralized. Since the new verification process adds to their existing workloads and requires additional training, our provider members have found it necessary to at a minimum develop education programs for their staff and on occasion have decided to develop new organizational models that centralize the scheduling function. Although these redesigned processes add considerable value, they also take time and affect the speed in which providers can effectively implement the HIPAA transactions.
• Second, we discovered early on that the key to maximizing the value of the Eligibility transaction for providers is to integrate the function within their core information systems. One of the greatest challenges that our provider members have had is that our regional payers all offer unique technologies for accessing their member data. The current local access methods include card swipe devices, PC dial-up technologies and IVR. The promise of HIPAA’s Administrative Simplification is to consolidate all of these unique communications methods into a single standards based approach, allowing the providers to access all payers from a single user interface. However, what we’ve learned is that providing a single user interface does not go far enough. What is really necessary to maximize the value to our providers is to fully integrate the HIPAA transactions into the core application workflows, thereby eliminating the need for multiple data entry. For example, someone registering a patient in a high volume ambulatory clinic often does not have time to capture the patient information in their core registration system, then re-key the data into a separate system in order to verify eligibility and key the response back into their registration system. Instead, the eligibility transaction must be integrated into their core systems and become a natural extension of the registration process. The challenge we’ve had at NEHEN is that very few vendors fully support the HIPAA transactions. This challenge is further compounded by the fact that a typical large IDN often has multiple registration systems from multiple vendors that need to be integrated.

Overall, I would like to emphasize that NEHEN’s experience with the implementation of the Eligibility and Specialty Referral transactions has been very positive. Both payers and providers in the network have seen significant financial and operational benefits from their early implementation. Some of the benefits achieved include:

• Reduced telephone based customer service support requirements for the NEHEN payer members
• Reduced average eligibility verification time from seven minutes to one minute, allowing staff to verify nearly 100% of all patient visits
• Reduced claims rework by as much as 20% to 25%
• An audit trail of all transactions is created, facilitating better management of the verification process

In conclusion, while we recognize that there is little effect that this committee may have on the process redesign issue, we would like to recommend that you explore ways to encourage vendors to make their products HIPAA compliant sooner rather than later in order to reduce the costs and time associated with implementation. One potential way to encourage vendors might be for HCFA to compile and disseminate information on vendor compliance efforts.

Once again, thank you very much for allowing me to share with you our experiences at NEHEN.