Mr. Chairman and members of this committee, my name is Don Bechtel, I am the Chief Privacy Officer, for the Healthcare Data Exchange (HDX), a Siemens Medical Solutions company. I am also the current Chair of the Association For Electronic Health Care Transactions (AFEHCT) and I am here today to testify on behalf of our membership.
AFEHCT has strongly supported "administrative simplification" in general; and the development and implementation of the transaction and code set standards in particular since 1992. The strength of that support today is stronger than ever.
My remarks today are based on the comments and input from the vendor community both in and outside of AFEHCT membership.
I, and the vendor community are grateful to have the opportunity to appear before you today.
This morning I will share with you what we see as
I believe it is accurate to say that all the AFEHCT members are currently in the testing phase of implementation. Further, from our view of the industry, the clearinghouse vendors and the software vendors that provide solutions for the institutional providers have completed their development work and are in the external testing phase and some are even in production with claim and remittance transactions.
However, AFEHCT is certain that some vendors, mostly in the area of practice management solutions for the smaller provider practices, may have fallen behind in their efforts and others were simply late in starting their efforts.
Vendors that are falling behind will offer several reasons.
The AFEHCT membership believes the healthcare industry and the HIPAA community is not making nearly enough progress in the implementation of the required HIPAA transactions. For those of us who are in the testing phase, we are and have been experiencing a variety of problems, which seem to center on three fundamental issues: testing, data content, and overall project management.
Testing
Many of the necessary trading partners are simply not ready or able to test, even now after the April 16, 2003 dateline has passed.
In some cases, our members are hearing from some health plans they won't be ready to begin testing until early to mid summer or later in the case of some Medicaid programs.
Some of the issues that have prevented testing from starting are:
The volume of testing and available resources - Health Plans, in many cases, have thousands of trading partners to test and it is not realistic to expect they can test with everyone at once, and still maintain their production environment as well.
No one has the resources to do this level of work given the amount of testing that is required due to the complexity of the changes that are being implemented.
The complexity and scope of testing is significant. We're not just testing the new transaction formats and data content requirements, but we are also in many cases changing the technology to deliver and receive these transactions, and in some cases the trading partners are changing their underlying processing technology with new translators and other issues that are effecting the testing process and causing it to take longer.
Companion Guides - were late being delivered to the provider community and the vendors, and clearinghouses. This was partly due to health plans wanting for the Addenda to finalize their documents.
Companion guides have additional requirements that need to be coded to conduct the testing and production processing with the trading partner.
Trading Partner Agreements (TPA) - were late from many health plans because of the same issue, they were waiting for the Addenda to finalize their documents.
Re-enrollment - is an administrative issue that many providers and clearinghouses are being challenged with as well. This is also causing us to have more delays in starting, because this process needs to be completed first. These are complicating procedures and they are taking a lot of time. AFEHCT believes based on where we stand today, that we may not finish this effort by October 16, 2003. We believe that those of us who are in the process of testing and converting should not be penalized come October 16, 2003 if we can show we've been making good faith efforts to complete this work, that we have transactions in production, but not everyone is done. This transition period may need to consider several options, which we will describe later.
DATA Content
On the Practice Management side of our business, we are seeing a big gap between the data that is available and the data necessary to complete the transactions.
There seem to be many instances where the data necessary to populate the required fields is not available and the clearinghouses are not always able to provide this missing information.
Providers not capturing the required data
Other Obstacles to meeting the Compliance Deadline
ACSA required that all claims go to Medicare electronically
Embracing this requirement is potentially more work than original 837 transaction requirements of HIPAA. Implementers may have to make a choice between implementing this requirement and doing the implementation work they need to in order to get paid.
People Issues:
Training for new technology, new processes, and new requirements will take time. During the transition, support staff needs to support both current processes and new processes.
Most of the discussions thus far have dealt with getting into compliance. While the computer systems are ready, it will take time for each organization to develop the support and troubleshooting processes and techniques in place as they do today with the older transactions. This learning curve is effecting both current processing as well as new test and production environments.
State Medicaid programs are having their own set of problems; some due to their special funding circumstances.
Elements of a solution
No one, to this time, has developed or adopted a plan for what the industry can agree is a reasonable amount of time to complete each of the steps involved in testing. Consequently, there is no project management discipline being applied to any of this among the trading partners. There is no timetable or set of milestones to indicate where entities need to be in the process to complete this work on time. We have no real view of how large and complicated the process is, most large develop and implementation projects like this have milestones and dependencies identified and they are managed. With a project management discipline, problems are managed. But, in the case of HIPAA resolving problems is time consuming because there are not quick answers, we often need authoritative answers from policy makers or Standards Development Organizations, but these answers are slow and often challenged, we really need a solution in this area.
Testing related solutions:
Our industry has been almost completely focused on two transactions, claims and remittance, and rightly so. As these two transactions will have the effect the cash flow in health care, we need to do this part right without disruption; but, what about the other transactions?
We need a plan and process for rolling these out too, some sort of sequencing with milestones is needed and again the implementation issues will need to be managed.
Regarding the implementation issues, questions about content or implementation guide ambiguities need a process that will help resolve these questions quickly. We believe the WEDI Issues Data Base can be used for this purpose more effectively to manage some of these more difficult implementation questions, but the answers need to be provided quickly and from authoritative voices.
Data related solutions
For those situations in which an X12 format is used but the data is not compliant but is such that the payer can process it to adjudication, AFEHCT believes this "operational compliance" is a good first step toward full compliance. Additional time should be granted to providers and vendors to who are making good faith efforts to come to full compliance.
For some types of claims, we anticipate that some providers - particularly providers who submit professional claims - will simply not be able to meet the full data requirements of the HIPAA-standards. Enforcement of the full data requirements against these providers will only cause them to revert to paper submission, which has never been the purpose of HIPAA.
Last, we also recognize that Operational Compliance may require extra work for the providers, the clearinghouses, and/or the health plans. So, we also suggest that in the cases where neither full compliance or operation compliance can be achieved, that we still permit health plans and providers to exchange the existing electronic formats until the party at fault can come into compliance.
Enforcement.
We recognize that some penalties might be appropriate to those who have not met their own obligations of either full compliance or operational compliance and some incentives, such as additional penalties, should be applied to those entities so that their efforts to complete the conversion is not delayed or deferred. But, these penalties should not be crippling either.
Conclusion
These changes are complicated and require time, planning, and careful project management. All of which are extremely difficult when so many disparate organizations must participate in a coordinated implementation effort that is not being coordinated by any one entity other than the individual organizations themselves. We believe that some form of sequencing is necessary and we believe that HHS should get behind such a process and lead the industry through this process by providing the implementation management leadership that has been missing.
Full more detailed report:
Mr. Chairman and members of this committee, my name is Don Bechtel and I am the Chief Privacy Officer for Healthcare Data Exchange (HDX), a Siemens Medical Solutions Company. I am also the current Chair of the Association For Electronic Health Care Transactions and I am here today to testify on behalf of our membership.
AFEHCT is dedicated to identifying and advocating the effective use of standards to promote the efficient exchange of health information among members of the health community, in a secure but open architecture, that promotes better healthcare services, and reduces costs while improving the quality of patient care. We have strongly supported "administrative simplification" in general; and the development and implementation of the transaction and code set standards in particular since 1992.
The following remarks are a collective statement from our members that we believe best represents the issues we're currently struggling with while trying to complete our implementation efforts for the HIPAA Transactions and Code Sets. Our statement also includes several suggestions that may help us to move forward towards the completion of this incredibly complex and most significant technical implementation in the history of healthcare.
I, and the vendor community are grateful to have the opportunity to appear before you today.
As the members of this committee knows, AFEHCT has long been a proponent of using HIPAA transactions, because we believe they will improve the efficiency and quality of our healthcare system.
But at this time, the healthcare industry as seen by the AFEHCT membership is not making nearly enough progress in the testing and implementation phase of the required HIPAA transactions.
We believe there are two fundamental compliance issues, testing and data availability.
AFEHCT does not feel confident that we can complete the necessary testing with all our various trading partners in time to have everyone implemented and exchanging HIPAA compliant transactions by October 16, 2003. Nor do we believe that all providers are implementing the changes necessary in their workflow and systems to be able to send our clearinghouse members all that data necessary to create HIPAA-standard transactions by October 16th.
Many of the necessary trading partners are simply not ready or able to test, even now after the April 16, 2003 dateline has passed. In many respects, Health Plans have become a bottleneck, as all their trading partners (submitters) need to test with them. So, today some submitters are not yet realizing an opportunity to test. In some cases, our members are hearing from some health plans they won't be ready to begin testing until early to mid summer or later in the case of some Medicaid programs. This allows very little time to test and implement the transactions with the quality that is required by our respective customers.
Some of the issues that have prevented testing from starting are:
While Companion Guides and Trading Partner Agreements are not extensive issues, they are limiting issues, because most often testing cannot begin until these items are available. Our experience to date is that until recently, many health plans had not made these guides or agreements available to their submitters. This issue was been exacerbated by the late delivery of the Transaction Addenda, version 4010A, as many health plans were waiting for these changes to come forward before they could finalized their documentation. Within the last month we have begun to see more of these guides and trading partner agreements being offered, but this delay has been costly.
AFEHCT members also recognize that Health Plans are not the only parties not ready. We're certain that some clearinghouses and some vendors may be struggling. Some say their reasons are due to the addenda and Companion Guides or other documentation being delivered late, which delayed their work. While others are simply struggling with development issues related to the changes. But, the lack of testing with Health Plans and the absence of Companion Guides would seem to be a key issue that has threatened our ability to complete implementation on time. A survey just completed by WEDI SNIP Transactions Testing Sub Work Group, has highlighted that this is considered to be the number one issue confronting 79% of the providers and 69% of the vendors and clearinghouse that responded. Although the WEDI SNIP Survey was limited in the number of respondents, the AFEHCT members believe it accurately reflects what we have been experiencing.
AFEHCT also agrees with WEDI's concerns about the lack of data captured by providers. AFEHCT's clearinghouse members can assist providers by reformatting data into the format of standard transactions, but some data that the X12 standards require simply isn't available from providers who use legacy practice management systems and legacy formats.
AFEHCT realizes that a number of Practice Management vendors will not be creating the X12 transactions. That they have always relied on clearinghouses to provide the electronic claim formats required by the various health plans and they will continue to rely on clearinghouses to provide this function for X12 formats. However, some practice management systems may not be providing the necessary content requirements or the providers may be having problems implementing the procedures necessary to key in the necessary content. Subsequently, we believe there may be a need to extend the transition time to allow for these adjustments to be corrected or improved. For these situations, we believe the "Operational Compliance" solutions described by PriceWaterhouseCoopers would be a good alternative, where the format is using X12 as required can be accomplished by the clearinghouse, but the content may not be fully HIPAA compliant. If the health plans can accept these transactions and process them, then we believe this is a good first step towards full compliance and we should permit some additional time for the transition to be completed if the providers and practice management system vendors affected are making good faith efforts to come into full compliance.
Other issues confronting small provider systems, as Dr. Braithwaite stated in the PriceWaterhouseCoopers document on 'Operational Compliance', there are 35 claim types inside of the 837 4010 format for claims. Many providers are submitting their professional claims electronically while submitting most other claim types including UB92, DME, and many other types of less voluminous claims on paper. ACSA required that all claims go to Medicare electronically if the 837-transaction format supported the transmission of the claim. Embracing this requirement is potentially more work than original 837 transaction requirements of HIPAA.
Plus, there are answered questions still outstanding regarding the need to send secondary and tertiary claims to Medicare. Nearly all secondary and tertiary claims were submitted on paper. Modifying systems to collect all Coordination of Benefits information, ramping provider systems up to receive electronic remittance, and implementing secondary / tertiary electronic claims is a large effort.
Similarly, some health plans may be able to take in the X12 format, but still require some of the old content be provided so they can process the transactions. Again, if the health care providers are willing and able to submit the additional data and there is a place for this data to be placed in the X12 transaction, then it may be a good transitional step to permit this extra data to be sent for some additional time while the health plan completes their remediation effort. We believe these Operational Compliance steps will also be helpful to the implementation process.
Last, we also recognize that Operational Compliance may require extra work for the providers, the clearinghouses, or even the health plans. And, so we also suggest that in the cases where neither full compliance or operation compliance can be achieved, that we still permit health plans and providers to exchange the existing electronic formats until the party at fault can come into compliance. We recognize that some penalties might be appropriate to those who have not met their own obligations of either full compliance or operational compliance and some incentives, such as additional penalties, should be applied to those entities so that their efforts to complete the conversion is not delayed or deferred. But, these penalties should not be crippling either.
AFEHCT members also realize that a number of Health Plans and CMS in particular, have been testing with their Trading Partners. And that a number of Health Plans have had their Companion Guides and Trading Partner Agreements ready for some time, but overall the number doing so are not sufficient.
AFEHCT does realize that some testing can be and has been accomplished in the absence of payers being ready, that is, internal testing and certification or compliance checking to the standards and the implementation guides, and that clearinghouses can and do provide a means for many providers and those payers which use clearinghouses to do this testing of their transactions. But the critical testing is the external end-to-end testing between trading partners. Clearinghouses can do much to help offload this testing from the payers as well, by verifying that payer specific requirements are being met in their compliance checking software when testing their customer's test files/transactions, but again this level of testing can't be done without the Companion Guides, which define the Health Plan's transaction requirements for successful processing in their production environment.
We also recognize and suggest that testing tools and certification organizations can be a highly effective means to validate that the transactions being produced satisfy the rules of the X12 Standard and X12N Implementation Guides. And they can also help with much of the trading partner specific testing if they had the Health Plan's Companion Guides. However, acceptance of this kind of validation needs to be more widely embraced by the Health Plans to reduce the amount of unnecessary testing. And, the Health Plans need to be more willing to provide their guides to all of these certifying entities. We could be doing much more testing without the direct payer's involvement than is currently being done with this approach. We believe this would greatly help to reduce the payer bottleneck and the time required to complete this process. We have also noted that many of us are encountering situations where payer specific requirements and/or other business rules are not always documented in the Companion Guides, these things are generally not found until trading partner testing is actually started. Which implies some amount of payer testing will always be required between the trading partners or with the clearinghouses and the testing and certifying entities to ensure we are capturing all the payer specific editing requirements.
Due to the reasons listed above, the testing and implementation process has been stifled and significant queues are beginning to build up. It is very difficult for the industry to complete the tasks of external trading partner testing that ensure that the use of transactions are accurate and deliver what was promised with administrative simplification. Each party involved in the testing and implementation process has only so many resources to conduct this work effectively. Every day this problem continues it is less likely that everyone will be able to complete their work for full implementation by October 16, 2003.
AFEHCT would like to suggest that the industry needs a process to define a common implementation plan on how to proceed with these conversions that benefits all trading partners and provides assurance that production processing of the transactions will be successful. As an industry, we must recognize that Health Plans are the keystone to making all of these transactions work. If the Health Plan is not ready, and the provider or clearinghouse is, then the implementation and configuration testing really can't begin.
We know that as this work continues to backlog, when the floodgates do burst this summer we will be flooded with testing requests in the eleventh hour. We are soon going to run out of capacity (system, people resources, and hours) to respond to the volumes that will be needed to complete this testing and conversion effort. To illustrate our point, CMS shared with AFEHCT last month some startling numbers about their readiness, (perhaps the same information shared today - on May 20th), and we're certain that other payers are experiencing problems that are just as severe, if not worse, as clearly CMS is leading the health plan segment of the health industry in its efforts to be ready. We would like to complement CMS and Janis Nero-Phillips on their efforts to get this testing done and their efforts to improve this situation. AFEHCT has been bringing its members to several conference call meetings with CMS to discuss some of the testing and implementation issues they and we are being challenged with today. We've shared a number of issues, to which CMS has been trying to help, for example:
These are the very same concerns that were identified by AFEHCT three years ago during our December 1999 meeting, which led to the writing of several white papers, including the WEDI SNIP Sequencing White Paper. AFEHCT still believes that some sort of ordered sequence needs to be considered. We also believe that some amount of additional time is going to be necessary for this transition, as we cannot see how everyone will be converted on schedule any longer. We would offer that several things should be considered:
Many of these concepts were described in the WEDI SNIP Sequencing White Paper, and they still seem valid, we believe an implementation plan needs to be defined. As things now stand, the industry is fragmented, it is mostly working on claims and remittance as they should be, but work on the other transactions, which are also all due to be implemented on October 16, 2003 has barely begun. The closer we get to October 16, 2003, the more likely we are to see any sense of order and quality be abandoned in an effort to make the dates, an effort that will surely lead to much difficulty and certain failure.
As to the problems raised by the availability of data elements, we support the notion of Operational Compliance that has been articulated by Pricewaterhouse Coopers and discussed by WEDI. For some types of claims, we anticipate that some providers - particularly providers who submit professional claims - will simply not be able to meet the full data requirements of the HIPAA-standards. Enforcement of the full data requirements against these providers will only cause them to revert to paper submission, which has never been the purpose of HIPAA.
Risks:
What is the industry risking if the transactions are not handled appropriately? This implementation with hard and fixed deadlines is putting the healthcare providers at tremendous financial risk if payments are delayed or denied due to processing problems caused by lack of quality testing. This implementation needs to be defined in a way that will minimize this risk. The proposed schedule above with an extended implementation process will help to accomplish this goal. Everyone knows these financial applications for billing, adjudication, remittance, and accounts receivable are complicated and because of this resolving test problems takes time. AFEHCT believes that we have all under estimated the effort that is required complete the testing and implementation phase of HIPAA.
We believe that allowing health plans and health care providers and clearinghouse to use the older formats of electronic transactions during the full transition period, until everyone can get implemented will also go a long way toward minimizing the risk and cost of implementation.
One final note, even if all testing was completed, it will take time for each organization to have the support and troubleshooting processes and techniques in place as they do today with the older transactions. While the computer systems are ready, there are still people issues and we still have a learning curve. As one AFEHCT member reported to CMS, they had passed testing and submitted 30,000 claims in production, but they were unable to get the experts needed at the payer site for assistance when a production problem was encountered. We're going to need time to ramp up our skills, as those who support our older systems today, learn how to support these new implementations as we go forward. Implementation is not going to be a simple process of testing is okay, now start production, new production problems are bound to become just as troubling.
The bottom line is, as everyone knows, we don't want to disrupt the necessary cash flow between health plans and providers where financial strains are already causing many providers large and small to close their doors. Health care represents one seventh of the nations economy, and HIPAA as we have all stated for years, is the largest operational and technological change in history to affect our healthcare system. These changes are complicated and require time, planning, and careful project management. All of which are extremely difficult when so many disparate organizations must participate in a coordinated implementation effort that is not being coordinated by anyone entity other than the individual organizations themselves. We believe the sequencing solution is necessary and we believe that HHS should get behind such a process and lead the industry through this process by providing the implementation management leadership that has been missing.