[This Transcript is Unedited]
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Agenda Item: Welcome and Introductions
DR. WARREN: Welcome this morning to the meeting of the NCVHS Subcommittee on Standards. This is our working meeting, breakout session from the full committee.
We have a very packed agenda. So just a few rules. We do have timekeepers to try to keep us on line, because everything we have on the agenda is incredibly important to the subcommittee to hear and to act on.
I would like to start out with introductions. If you are a member of the subcommittee, please state that you're a member of the subcommittee and state whether or not you have any conflicts with any of the items that are on the agenda.
I will start. I am Judith Warren. I am from the University of Kansas School of Nursing. I am co-chair of the Standards Subcommittee. I have no conflicts.
Lorraine?
MS. DOO: Good morning. Lorraine Doo with the Office of the Health Standards and Services at CMS, lead staff to the subcommittee, and no conflicts.
DR. HORNBROOK: Mark Hornbook, member of the large committee, of Kaiser Permanente. No conflicts.
MR. BURKE: Jack Burke, new NCVHS member, no conflicts. I am here to observe this morning.
DR. FITZMAURICE: Michael Fitzmaurice, Agency for Healthcare Research and Quality, staff to the subcommittee.
MS. KLOSS: Linda Kloss, new member of NCVHS, and no conflicts.
DR. COHEN: Bruce Cohen, new member of the National Committee, no conflicts.
DR. CHANDERRAJ: Raj Chanderraj, member of the Standards Subcommittee, no conflicts.
DR. SCANLON: Bill Scanlon, National Policy Forum, a member of the subcommittee, no conflicts.
MS. WILLIAMSON: Michelle Williamson, CDC, NCHS, and staff to the subcommittee.
DR. SUAREZ: I am Walter Suarez with Kaiser Permanente. I am a member of the committee and co-chair of the Standards Subcommittee. I want to welcome all our new members, and I don't have any conflict.
DR. WARREN: And then I understand there are some people on the phone. Do you want to introduce yourselves?
MR. DOYSIMA(?)(via telcon): Austin Doysima, new member, no conflicts.
DR. WARREN: Is that the only person on the phone?
STAFF PERSON: Yes.
DR. WARREN: Then in the room?
(Intros around room)
DR. WARREN: At this point we are going to be hearing information about the status of the 5010 --
DR. SUAREZ: That will be at tomorrow's hearing. Just a brief update.
DR. WARREN: Then I am going to turn the mike over to you.
(Laughter)
You can see we are well rehearsed. Lorraine is going to do this.
MS. DOO: Good morning. Tomorrow we have an outstanding panel of individuals who are going to be talking to us from a wide swath of industries. So we will have health plans, providers, we will have associations. We are also going to be hearing from other parts of related industries such as workers' compensation and property and casualty because of the impact on ICD-10.
WEDI will also be talking tomorrow about their industry survey and a couple of other organizations that have done some surveys to really get a handle on where folks are. 5010, as we know, is coming up per the compliance date of January 1, 2012. ICD-10 has a little bit more time, in October of 2013. But you will be hearing about the kinds of issues that people are having, what they've done from a planning perspective, what they've done from a training perspective.
Yesterday was a big day. Medicare did a national test day, so hopefully we will be able to hear from them about how that went and what some of the initial results were. So it will be a very full day of a lot of information and probably a broad spectrum of where people think we are from readiness. But I think we will have much better information tomorrow.
DR. SUAREZ: Just a comment for our new members. This will be a great opportunity to engage in one of the most critical processes that we at NCHS undertake, which is these hearings. I am sure you have either participated in person or testified in front of some of these hearings. But this is our way to listen to the industry and to understand the issues and to formulate observations from that, and any recommendations.
Agenda Item: Review of Draft Letters on Standard for Acknowledgment Procedure/Role of DSMO
DR. SUAREZ: I think we are going to go to the next agenda item, which is the review of two letters, and these are draft letters, of the recommendations on acknowledgments and some of the observations on the standards development and maintenance process.
Just as a way of introducing this topic, I mentioned yesterday during our update on the administrative simplification of health reform that acknowledgments, this process for getting responses when someone sends a transaction to someone else, getting a response from that someone else, acknowledging the receipt and some of the aspects of that transaction that was received, was something that was not necessarily explicitly required or expected on the provisions of the Affordable Care Act, as were some of the other things that we are doing; for example, the operating rules, the health plan ID, EFT transactions.
But we always have other sources and mechanisms to receive feedback and requests from the industry to call upon the need for naming a standard for a new transaction; that is through our DSMO report process, about which we will hear later on.
DR. SCANLON: Walter, could I ask you a question?
DR. SUAREZ: Yes.
DR. SCANLON: I know you said that yesterday as well, but in the draft letter -- and maybe I have a problem because I am new to standards and their format, not really appreciating it -- section 1104 specifically calls for the adoption of standards and associated operating rules that provide for timely acknowledgment, which seems -- if I were a lawyer, I would say that's an open door --
DR. SUAREZ: Exactly. That is the other point I was going to make.
DR. SCANLON: So we are fully covered? All right. I didn't know what the handicap was.
DR. SUAREZ: Yes, exactly. So in addition to --
I just wanted to make sure that it is not an explicitly, clearly defined provision that says you must do acknowledgment the way --
DR. SCANLON: Well, but for lawyers, I think that is pretty explicit.
DR. SUAREZ: That is true, and yes, I point to that also, that indeed that is the case, that not only -- the industry had requested from us back in February of last year that we consider identifying these transactions, but also in the Affordable Care Act, there was this particular provision that you, Bill, point out.
So that is what this is, the source. We held hearings about this, and so after the hearings we always put together these letters of observations and recommendations.
We will go through, and the process we usually use is go through the letter paragraph by paragraph and ask if there are any comments or questions.
We will start with the first letter that is the observations and recommendations on the adoption of a standard for electronic acknowledgment of transactions in health care. That is the first letter. We'll talk about the second letter in a minute.
Let me start. We have the first paragraph that introduces, "The National Committee on Vital and Health Statistics is the statutory advisory committee with responsibility for providing recommendations on health information policy and standards to the Secretary of Health, Department of Health and Human Services, HHS.
"Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), NCHS is to advise the secretary on the adoption of standards and code sets for HIPAA transactions."
Then we go to mention, "The NCVHS Subcommittee on Standards held a public hearing on April 27, 2011, for the specific purpose of gaining industry and stakeholder insight into two subject areas: the potential adoption of a standard for electronic acknowledgment of transactions and the utility of the designated standard maintenance organizations (DSMO) on whether its role was still necessarily in facilitating the standard change request process."
So those were the two topics of the hearing.
DR. SCANLON: Right. Could I ask, in terms of the letter, in both the next paragraph in terms of what the second letter is going to be about, for again this cold reader, it doesn't seem to relate to the utility of DSMO and its role in the future. But then when I get to the second letter, I don't think we do that either.
DR. SUAREZ: Yes. I think the title -- so you are arguing that this paragraph that we just read, the last part that says, "and the utility of the DSMO," is not really what the subject of the hearing was, or at least what the subject of the second letter is, right?
DR. SCANLON: The subject of the second letter is just the utility of the DSMO. It doesn't say anything about its utility for the future in that setup. So I think we need to make the two consistent.
DR. SUAREZ: Okay, we'll do that. Thank you.
DR. WARREN: And just as a reminder, this is the purpose of this discussion, is do we have it in the right ballpark, the change? So we are not approving this letter at all at this meeting.
DR. SUAREZ: Yes. Thank you, that's good.
MS. GREENBERG: Excuse me. I am Marjorie Greenberg from the National Center for Health Statistics. Are you seeking subcommittee approval of the letter, though? Not that I mean we would have to have that formally but --
DR. WARREN: This is the first time the subcommittee has seen the letter.
MS. GREENBERG: Both letters?
DR. WARREN: Both. So this is getting their input. We'll probably then revise based on the input we have and then follow up with a phone call and get approval and then send it on to executive and the people.
MS. GREENBERG: Okay, great, thanks.
DR. SUAREZ: Thank you. Yes, that's a good clarification of the process.
So the third paragraph in this letter, "We offer observations and recommendations for the adoption of a new standard for electronic acknowledgments. In a separate letter, we provide observations of the review and update process for standards and operating rules."
Then we get into the standard for electronic acknowledgments. "The Patient Protection and Affordable Care Act (ACA), enacted on March 23, 2010, calls for the NCVHS to assist in the achievement of administrative simplification to ‘reduce the clerical burden on patients, health care providers and health plans' by providing advice and recommendations to the Department of Health and Human Services (HHS).
"Section 1104(4)(a)(III) specifically calls for the adoption of a standard and associated operating rules that shall provide for the timely acknowledgment, response, and status reporting that supports a transparent claims and denial-management process (including adjudication and appeals)."
The next paragraph: "Electronic acknowledgments between providers, payer clearinghouses, and their business associates is one of the most efficient and cost-effective ways to ensure that the correct message with the right information has been received by the appropriate party. These acknowledgments inform submitters as to whether their transaction has been appropriately received, if it can or will be processed, or if it has been rejected and why.
"According to a number of testifiers, this lack of information and feedback is often referred to as the ‘backhaul.' Without acknowledgments, the center does not know the status of the transmission and therefore often resorts to repeated queries to the receiver for information."
Stop me whenever you have any questions or comments, please.
"Currently, there are three types of acknowledgments used in health care: TA-1, which acknowledges receipt and acceptance status (applicable to all transactions); the 999 implementation acknowledgment, which is a notification that a transaction has been accepted with errors, so that part of the transaction can be used (applicable to all transactions)," and there is a period probably there, and then, "A 227-CA, health care claim acknowledgment, acknowledges receipt, acceptance, and rejection of a health care claim transaction and provides for an audit trail." Yes?
DR. CARR: So the first one is message received, the second one was acceptable but there are errors, and the third one was either we're accepting it or we're denying it?
DR. SUAREZ: Well, the third one is a specific acknowledgment to the claim transaction. It is called a 270 claim acknowledgment, I believe, CA.
DR. CARR: 277.
DR. SUAREZ: 277-CA means claim acknowledgment. So it is a health care claim acknowledgment and it is specific to the claim itself. The TA applies to all the transactions.
DR. CARR: So you know that it's received. And then 999 means accepted with errors. If you don't get 999, do you assume that it was fully accepted or rejected?
MS. GREENBERG: Then you get the TA-1, I guess.
DR. CARR: No, the TA-1 is message received.
DR. WARREN: It's one of the ways -- if you look at the TA-1 as an envelope, the TA-1 says yes, I received the envelope. Then you have to open the envelope and you get the message. The message can be that the transaction was accepted with errors, and part of the transaction can be used but the errors have to be corrected. Then the third one is you get information that it was totally accepted or that it was rejected and why.
MS. WEIKER: This is Margaret Weiker. I just wanted to clarify that for the 999, you can report accept, you can report accept with errors, or you can reject. So the 999 allows you to do all three, and it is just a matter of what is the error and the severity of the error and whether you can continue to process it, which is where you would get the accept with error. Then the 277-CA is only used for claims, and it can report acceptance as well as rejection.
DR. FITZMAURICE: Margaret, that doesn't give the reason for rejection?
MS. WEIKER: Yes. There are reason codes in both the 999 and in the 277-CA that explain why it was rejected.
DR. FITZMAURICE: We should probably add that to the definition there.
DR. CARR: And the TA-1 -- 277 refers to claims, and what does TA-1 refer to?
MS. WEIKER: TA-1 refers to any of the transactions, any of the X12 transactions, because I want to make that clear. These are only referring to ASC X12 transactions and not NCPDP transaction.
But the TA-1 is as Judy stated. It is just validating the outer envelope. Think of it like FedEx. You get a FedEx and it says yes, it was delivered. That is basically what a TA-1 is. It's, "I've got it."
DR. CARR: So what is being delivered besides claims?
MS. WEIKER: Eligibility transactions, remittance advices, prior auths, enrollment, premium payment, claim status, any of the X12 transactions.
DR. COHEN: So for claims you could get all three, but for non-claim transactions, you would only get the first two?
MS. WEIKER: Right. Now, in a lot of the transactions like eligibility or prior auth or claim status, there is a response transaction to that. So for like eligibility, you would submit a request, and depending on if it was done in batch or real time would impact the type of response you would get back. But, ultimately, you would hope to get back a 271 transaction, which is the eligibility response that says yes, you're eligible, and here's your copay, here's your deductible, et cetera.
DR. COHEN: So for the purpose of the completion of this listing, would it be important to include the types of transactions that are non-claim transaction responses?
DR. SUAREZ: They are already part of the standard, so when I send what is called a 270, an eligibility inquiry, I get a 271 eligibility response. Those two are already mandated HIPAA transactions, so they are not acknowledgments in the sense -- I mean they are acknowledgments but they are not acknowledgments in the sense of the acknowledgment transactions; they are actually a response transaction outbound to the inquiry.
DR. WARREN: So I think, to answer your question, there is a balance between how much detail to put in the letter where you confuse everybody. But we can put an appendix on here. We do have a nice graphic that shows the exchange of all these with all their numbers.
DR. CARR: I think for each of these letters it would be very helpful to use the same picture with a big arrow. Today we are talking about right here.
DR. SUAREZ: Good suggestion. We are becoming graphic artists. But a picture tells a better story always. So we will add that.
Right now we are focusing on these three transactions, acknowledgment transactions.
The next paragraph: "Though acknowledgments are used by some covered entities on a voluntary basis, and though there are standards available and referenced in the transaction standards, formats are often proprietary and unique to each entity. Perhaps adding to the lack of consistent use of available standards is that the original HIPAA legislation did not name this transaction as one of the standards to be adopted, and to date NCVHS has not made a recommendation to the secretary for its adoption."
So this was a totally separate transaction that HIPAA never, in the original list back in 1996, never added.
"In February 2010 NCVHS did discuss standards for acknowledgments, and the designated standard maintenance organization (DSMO), made a recommendation to the committee to consider the adoption of a standard. However, the committee did not act on that recommendation because of other priorities for the Affordable Care Act.
"The committee is aware that the operating rules under consideration for adoption for the eligibility and claim status inquiry and response transactions do include business rules for the corresponding acknowledgment transaction, and entities following the operating rules voluntarily already use the acknowledgments transactions.
"Furthermore, a number of other health plans and clearinghouses conduct these transactions with the providers on a voluntary basis outside(?) of the operating rules.
"Medicare has mandated the use of the acknowledgment for claims when version 5010 goes into effect in January 2012."
What we are arguing in this paragraph, of course, is that there is already a lot of usage of these acknowledgment transactions, but there are a lot of proprietary formats or inconsistent adoption of it, I guess is the way to put it.
DR. CARR: I am sorry, I am still on a previous paragraph. But I think it might be helpful in terms of framing what we're trying to do in that paragraph to begin by saying the original HIPAA legislation did not name this transaction as one of the standards to be adopted. Today, acknowledgments are used by some, but not all, covered entities on a voluntary basis, and then when they are used, there is not a consistent format, to just sort of frame -- it is not required, some but not all are using it, and when it is used, it is not consistent. So therein we have three problems. Then you can say NCVHS has not previously made a recommendation to the secretary for adoption.
DR. SUAREZ: So, "During the April 2011 hearing, virtually all testifiers were very supportive of a mandate to use the acknowledgment standard because of the clear time-and-cost-saving benefits. Simply put, there is a significant and tangible business case for the use of acknowledgments. Providers should be informed as soon as possible about the status of their inquiry, claim, or other transaction. Without timely, relevant information, manual intervention is necessary.
"Based on the testimony and commentary, NCVHS has developed observations and formal recommendations for the secretary with respect to adoption of an acknowledgement standard under HIPAA."
So we start with our observations from the testimony.
Number one: "Current use of the acknowledgments transaction. Although not currently mandated under HIPAA, the acknowledgment standard appears to have a fair amount of voluntary use within the health care industry. Nevertheless, the lack of standard implementation specifications and operating rules that define the specifics of which, when, and how the transaction might be used underscores the need to define and mandate a consistent standardized use of acknowledgment. A regulation will resolve inconsistencies and ensure the avoidance of any unnecessary burden on (word garbled)."
Number two: "Support for the adoption of existing acknowledgment transaction standards. There was across-the-board support for the adoption of the three main acknowledgment transactions noted earlier in this letter, as developed and validated by ASC X12."
Number three: "Support for the regulatory rulemaking process to assure transparency. Testifiers indicated overwhelming support of continuing with the current process for adoption of a new standard by going through the proposed rule (NPRM) process. This will assure transparency within the health care industry as well as allow time for consideration of the impacts on organizations that are not yet taking advantage of this standard.
"Though the proposed rule process was favored, there is understandable concern about the length of time it takes HHS to produce, clear, and publish regulations. There was strong interest in finding ways to accelerate the NPRM process for the adoption of the standard to ensure that the benefits of the new transactions can be achieved sooner rather than later."
DR. SCANLON: Walter, several points about this. First of all, when I read it the first time, I guess I was thinking we were shifting gears and we were talking about, when we adopt standards, we want to use NPRM. I think this is within the specific context of this standard. So I think changing "a" new standard to "the" new standard would prevent --
DR. SUAREZ: Process for the adoption of the new standard.
DR. SCANLON: The new standard, okay.
Then there is the issue -- and this is an issue that has come up almost the entire time I've been on the committee, which is the NPRM process and how long it takes. I am one who has been arguing it doesn't have to take that long. There is a question of will as well as requirements.
So this "strong interest in finding ways" -- I mean I guess I am leery of that because we've had discussions here, we had a draft letter that never went anywhere, there has been legislation proposed. So this is kind of a big hole we could be falling into. I think maybe a statement more about that we really hope that it is expedited, that it is vetted most quickly, is a safer thing to say as opposed to -- "finding ways" opens up a lot of options of things that you can think about.
The last point was if this is part of the ACA, why doesn't -- isn't there something expedited in the ACA that is applied here too?
MS. DOO: No. The challenge has always been the Administrative Procedures Act or the APA, which you know very well, requires that a new standard go through notice of proposed rulemaking, and we don't --
DR. SCANLON: And the ACA doesn't override that?
MS. DOO: Not in this. The reason we are able to do the interim final for most of the regulations under ACA is because it says you may do so through interim with final comment. It does not say that for acknowledgments because it doesn't specify that we adopt the standard for acknowledgments. So it is an unfortunate situation.
DR. SUAREZ: Thanks for those comments.
Number four: "Conditions for submission of the acknowledgment transaction. Each of the three acknowledgment transactions being recommendation for adoption on this letter would have its own separate condition for submission. Testifiers agreed that the TA-1 acknowledgment should only be required when the submitter of the transaction -- for example, i.e., a provider submitting an eligibility inquiry -- has elected to receive the TA acknowledgment back. The 999 acknowledgment should be required when the transaction submitted has been found to have errors, and the 277-CA health care claim acknowledgment should be required in response to each claim submitted."
Any questions about that?
DR. CARR: Why? Why would you --
DR. SUAREZ: Maybe Margaret can join us.
DR. CARR: Just why wouldn't you want the 999, the receipt that it was received?
DR. SUAREZ: That is probably one thing --
MS. WEIKER: That was going to be my point as well. You said just with errors, and I think that is incorrect, that you would want the 999 in any case, whether it was accepted, rejected, or accepted with errors.
DR. SUAREZ: That is a better way to put it. In any case, whether it was accepted or rejected or accepted with errors.
MS. WEIKER: Yes.
DR. CHANDERRAJ: Are we not duplicating the 277CA where the claim is being accepted, or the claim is being stated as accepted or rejected? Is it the same as 999?
DR. CARR: No, because there can be a multitude of transactions. Now that I've had two sentences, feel free to expound on that, but I get it. There are multiple transactions, all of which you want to know about. When there is a claim issue, you get a separate --
DR. CHANDERRAJ: So the 277 only is for claims, but 999 is for all other transactions?
MS. WEIKER: Yes, it is for all the transactions, and the 999 has different types of errors than a 277-CA would report, because the 999 can report you're syntactically incorrect or you violated a situational rule or a mandatory rule. But the 277-CA can then say you're missing procedure code, you're missing diagnosis code, or those types of things. So it goes a level further than just the base standard and implementation guide.
PARTICIPANT: One clarification. For the 999 does it go beyond ASC X12?
MS. WEIKER: No. These are just all ASC X12-related transactions, because in regard to NCPDP, most of those transactions are done in a real-time mode, so you get that immediate response back, whether it was paid or denied or rejected, so because most of it is real time, you get that response back.
DR. SUAREZ: Okay. Number five: "Differences between acknowledgments in real time versus batch situations. Testifiers agreed that in cases when transactions are conducted in real time and resolved in an instantaneous response, an acknowledgment transaction is not necessary. However, for most batch transactions, an acknowledgment is needed to inform the submitter has been received, accepted, or rejected."
Number six: "Use of acknowledgments specifically for batch remittance advice. In a batch transaction for remittance advice sent from a health plan to a provider, testifiers agreed that the 999 functional acknowledgments be used." Again, this would be from the provider back to the health plan.
And number seven: "Pharmacy exclusion. Pharmacy transactions are conducted in real time. Therefore, testifiers stated that there was no need for acknowledgments to be used with the pharmacy claim transaction."
In here, I think -- go ahead.
DR. CHANDERRAJ: With e-prescriptions, I have a problem when I send a prescription and I don't get an acknowledgment from the pharmacy saying that it was received. I don't know where it went, and some of the patients come back to us and say there was no prescription for me waiting there.
DR. SUAREZ: Yes. E-prescribing is actually outside of HIPAA in the sense that it is not a HIPAA transaction, so this would not have an effect on other types of transactions like e-prescribing or even a submission of an electronic health record message to another electronic health record. Those are clinical transactions that are sort of outside of the HIPAA.
DR. WARREN: And those transactions are handled under the NCPDP standards, not this one, which is an X12.
DR. GREENBERG: But what I hear Raj saying is that it is not true necessarily that there is no need for acknowledgments to be used with the pharmacy.
DR. SUAREZ: One thing is the pharmacy administrative transactions; a different thing is the eprescribing from a physician to a pharmacy.
MS. GREENBERG: Oh, Okay.
DR. WARREN: So maybe we just need to clarify that, that there is no need for an X12 acknowledgment?
MS. GREENBERG: Yes.
DR. SUAREZ: There is one exception, though, which is actually noted in the comment on the side, which was discussed at the hearing. In cases where the pharmacy is sending a batch of transactions to a payer, that there might be a need for a remittance advice response. I think that was actually noted, that health plans in the hearing noted that to them it would be helpful to receive an acknowledgment back from the pharmacy when they send a batch remittance advice.
So, basically, a health plan sends the pharmacy a batch of payments, and the health plan never receives back from the pharmacy an acknowledgment. That is one instance where the acknowledgment in the pharmacy transactions would be helpful. Is that accurate?
PARTICIPANT: That's in the appendix, and it is also still an X12 standard.
DR. SUAREZ: It is an X12 standard. Pharmacy transactions, as you know, use the NCPDP standard, but HIPAA required that for payment the pharmacy as well as the medical side use the 835 X12.
All right, so that is the observations, and the recommendations are very straightforward. So, "Based on the testimony and our observations of all, the committee makes the following recommendations:
"1.1 The secretary should adopt the TA-1, 999, and 277-CA as HIPAA transactions.
"1.2 The secretary should adopt the X12 standard, version 5010, as a standard for the three acknowledgment transactions being recommended.
"1.3 The secretary should adopt these transactions and standards using an expedited rulemaking process as permissible by law."
MS. GREENBERG: I thought it wasn't permissible by law.
DR. SUAREZ: When we say "expedited rulemaking process," we don't mean entering final rule in this, we mean whatever the secretary could do to expedite the rulemaking process.
DR. WARREN: So some of those could be to say that there only needs to be a 30-day comment period instead of a 90?
DR. SUAREZ: Good point.
DR. WARREN: And look at effective dates and stuff like that.
DR. CHANDERRAJ: Walter, "should be adopted and mandated for people to be using these transactions" would be better.
DR. SUAREZ: Yes. Well, by adopting it as a HIPAA, it will include the mandated. We don't need to say adopted and mandated because adopting it makes it required transactions for the industry. So it is intended to.
MS. DOO: But he may be thinking in terms of utilization, and any new standard requires the industry to be given 2 years to do it.
DR. SUAREZ: Yes, that is an important point because this is a new transaction and a new standard being adopted by the secretary. Under the original 1996 HIPAA law, the provisions of the law said that the secretary must give 2 years to the industry for any new standard. So this is brand new, this is not a new version of an existing standard, like 5010, or a modification of an existing standard. This is a totally new transaction, totally new standard, so the secretary needs to give 2 years to the industry.
MS. DOO: That's why we put the question out as "Would you want to encourage industry to use it voluntarily between willing trading partners?" to make that point strong, that you don't have to wait the 2 years. But that's for the committee to decide.
DR. SUAREZ: Yes, I think that was one of the comments clearly from the testimony, that the industry is already engaged in this transaction, that the industry wants to move it fairly quickly, and so the opportunities to -- even though the secretary has to still provide the 2 years, the industry can voluntarily adopt that standard.
DR. WARREN: Do we want to make that as a recommendation to the industry, I mean just explicitly state it in the letter?
DR. SUAREZ: Yes, I think we should.
DR. WARREN: There was someone on the phone?
MR. DOYSIMA(?)(via telcon): Yes, real quick. Walter, did you mention that you wanted the NRPM period to be 30 days? What is the normal period?
DR. SUAREZ: The normal period is 60 days for an NRPM to be commented, but the secretary has the leeway to shorten that time frame.
MR. DOYSIMA(?)(via telcon): Is part of your recommendation for this particular one to shorten to 30, or you are just saying that in general --
DR. SUAREZ: We didn't explicitly say it. We just said in the 1.3 that the secretary should adopt these transaction standards using an expedited rulemaking process, as permissible by law. So by saying it that way, we leave it open to the secretary to find the various ways, including things like reducing the comment period. I don't know that we needed to be that explicit necessarily.
MR. DOYSIMA(?)(via telcon): Exactly. I mean we're not suggesting that the secretary changes the NPRM period, the normal period, right?
DR. WARREN: What we are suggesting is that the secretary look at the options that she has for expediting approval and use those, but we don't want to tell her which ones of those to do, because she may come up with a better solution than what we've recommended.
MR. DOYSIMA(?)(via telcon): All right.
DR. SUAREZ: Do you want to introduce yourself?
MS. LOHSE: Sure. Gwen Lohse from CAQH. I just want to make a quick comment. With the CORE participants, for some of you that are new -- welcome -- they represent about 75 percent of the commercially insured as well as a mix of public and private and then vendors and providers. So within the CORE operating rules on a voluntary basis since 2005, they have been supporting the use of the X12 acknowledgments in a voluntary way, specifically both in batch and in real time where appropriate, so it is not repetitive.
So there is tremendous industry support for the use of these acknowledgments, and I just wanted to reiterate that. And there is a certification process behind it to demonstrate that there is true commitment. Thank you.
DR. SUAREZ: Thank you for that. Indeed, I think that is part of the reason why this transaction would be adopted sooner than the 2 years that the secretary has still to give the industry.
So I think we are in agreement generally of adding a recommendation with respect to the --
DR. WARREN: I just captured the idea, not the wording yet.
DR. SUAREZ: We don't have the wording specifically right now.
Any other comments?
I guess I have a quick question back to all of us here, and it is about the version itself. We have talked about version 5010 because right now the industry is actually going to be moving to 5010 in January, and the expectation is that, well, if they move to 5010, the acknowledgment that will come through that will be adopted by the industry voluntarily, would be probably 5010, so the question was whether we -- by the time this gets implemented, which would be probably 3 years maybe from today, we might be getting close to implementing the next version of these transactions, the next version from 5010.
So the question was whether in the letter we still recommend version 5010?
DR. WARREN: I was just conferring with Lorraine. In a previous letter, we had the same issue -- this letter was like about a year, year and a half ago -- where we did not specify the version, we said "current version." That way we didn't have to write another letter specifying the new version. That seemed to be well accepted by the secretary. So maybe that's what we want to do here.
DR. SUAREZ: I think that would be a great idea.
DR. WARREN: All right.
DR. GREENBERG: The only thing is if you said the current X12 standard, and this is a letter dated next month or something, the current one is the 4010. What you want to imply is the --
PARTICIPANT: Whatever is in place.
MS. GREENBERG: The one that is current at the time of adoption.
PARTICIPANT: Prevailing.
DR. SUAREZ: The one that is current at the time of adoption. I think that would be --
All right, and then just to finish up the letter, "NCVHS believes there is an opportunity created by the Affordable Care Act to improve the effectiveness of the health care system through improved adoption of standards. NCVHS embraces opportunities for such improvements while believing that there are some serious and significant challenges that must be addressed and monitored. NCVHS continues to stand ready to provide additional guidance or assistance to the secretary as requested."
DR. WARREN: My timekeeper tells me that we are already 4 minutes over and we haven't even hit the second letter.
DR. SUAREZ: I think we are going to probably have to do some adjustment on that second letter.
Mike, do you have a quick comment?
DR. FITZMAURICE: Yes, a very quick comment, and that is on observation 3. You might consider breaking it up into two observations: one, support for the regulatory rule, and a second one, support for accelerating the process. They seem to be two separate thoughts.
DR. SUAREZ: So maybe is that 3.1 and 3.2, or are you saying 3 and 4?
DR. FITZMAURICE: I would say 3 and 4.
DR. SUAREZ: Okay, so breaking observation 3.
DR. FITZMAURICE: There is a natural break spot in the paragraph.
DR. WARREN: Oh, the observations.
DR. SUAREZ: So breaking the observation 3 into two separate observations. Yes, that will be --
DR. FITZMAURICE: I have some wordsmithing stuff, but I will just pass it in to --
DR. SUAREZ: That will be very good. Thank you.
DR. WARREN: We have a recommendation that we hold off on the second letter and continue with the agenda. Then if we have time at the end, we can pick it back it up.
DR. SUAREZ: I think that will be very good.
So we are going to hold off on the second letter if there are no objections from the members of the committee. The second letter was a letter with observations on the standards and operating rules development process.
DR. CARR: Will the concept be presented to the full committee?
DR. SUAREZ: No. The next steps are basically we are going to redraft or edit the letter we just went through. We will convene a conference call of the subcommittee of standards and review and finalize the two letters, and then we will present those to the executive committee, and then they will be presented to the full committee.
DR. CARR: So these will be for the September meeting?
DR. SUAREZ: We might be moving it a little faster by phone, and we might be able to finish up this sometime in August if possible, but if not, yes, we will just push it to September for the full committee.
DR. WARREN: On today's agenda at 11 we have a report, and so we intend to give a report on the activities of where we are and our time line.
DR. CARR: So just to preview that?
DR. WARREN: Yes.
DR. CARR: Then your thought would be to convene the full committee in August to approve the letter?
DR. SUAREZ: It might be that if we are so close to the September meeting that that makes sense, to convene it for 2 weeks --
DR. CARR: Is there any time sensitivity about this?
DR. SUAREZ: Not to that level.
DR. GREENBERG: If there isn't, I would rather that you hold it until the September meeting.
DR. SUAREZ: Sure. We should probably just do that.
MS. GREENBERG: During the summer, quorums can be a bit difficult.
DR. SUAREZ: But in between we will get the clearance through the conference call.
We are going to go to our next agenda item, which is the DSMO report. I will turn it back to you.
DR. WARREN: So Margaret, you are on. Do you want to come over here and use one of those microphones. You have to watch Lorraine because she is going to be vicious with her signs.
MS. WEIKER: Which I think is fine to do.
(Laughter)
MS. WEIKER: I am Margaret Weiker. I am with Hewlett-Packard Corporation, where I serve as a director for the business exchange service and our health care payer services products. I am also chair of the Insurance Subcommittee in ASC X12. I serve on the Standardization Committee at NCPDP, and I also represent NCPDP on the DSMO or the Designated Standards Maintenance Organizations. I was the first chair of that organization and have served a couple of terms as we rotate that through the cycle of the organizations.
On behalf of the members of the Designated Standards Maintenance Organizations, we would like to thank the National Committee on Vital and Health Statistics for the opportunity to present our 2010 Annual Report on the Changes, Challenges, and Opportunities Affecting the HIPAA Transaction Standards. The 2010 report is for the period November 2009 through December 2010.
As you know, the DSMO includes three ANSI-accredited standards development organizations: ASC X12, HL7 International, and NCPDP, as well as three non-ANSI-accredited data-content organizations: the ADA's or the American Dental Association's Data Content Committee, the DECC; the NUBC, or the National Uniform Billing Committee; and the NUCC, the National Uniform Claim Committee.
Collectively, the DSMO reviews change requests to the HIPAA-designated standards and for new standards and code sets to be adopted. A change request can be made by anyone. All they need to do is complete the change request form found on the HIPAA DSMO Web site. Each organization can opt in to review the change request and discuss the merits of the request within their organization. Normally, each organization has 90 days to review change requests. However, there is an opportunity to request a 45-day extension if any organization requires additional time.
Once the organizations complete the review, we collectively meet to discuss the action that each organization has made toward the change request. As the DSMO review each of the responses, a final DSMO recommendation and response is made and then published on the DSMO Web site.
For complete background in regard to the formation of the DSMO, as well as the complete process that the DSMO goes through, I refer members to the background testimony that was given on April 27. I would also like to mention that CMS, in particular OESS, serves as an observer on the DSMO as well. They are a nonvoting observer.
For the period November 2009 through December 2010, there were 21 change requests that were entered. Five were withdrawn by the submitter, nine were withdrawn by the Web administrator because they were not valid DSMO requests, and seven were subsequently reviewed by the DSMO.
Of the seven change requests reviewed by the DSMO, only one was approved for adoption. The approved change request pertains to more than one HIPAA transaction standard. It seeks to increase the consistency across the transactions for allowable values in a data segment. The DSMO approved the change and requested that ASC X12 make the values of the PWK02, which is the report transmission code data element, consistent across the HIPAA TR3 guides for future versions.
The remaining six change requests were disapproved for a variety of reasons. Enclosed you will find an attachment containing the detail of these change requests under category D, no change.
During the past year, the DSMO discussed provisions of the health reform legislation, particularly the provisions in the administrative simplification sections calling for the creation of operating rules to go along with the HIPAA transaction standards. The discussion included whether the operating rule entity should become part of the DSMO.
The DSMO submitted to NCVHS a letter dated November 23, 2010, in response to several NCVHS-proposed recommendations. In our response we recommended that the operating rule entity not be designated as a DSMO member but, instead, urged a partnership with greater coordination and collaboration between the DSMO and the operating rule entity or entities.
We also recommended that the current review process be followed when changes to the standards or operating rules are incorporated into rulemaking; that is, the DSMO must continue to review and evaluate all changes prior to being brought forward to NCVHS for incorporation into rulemaking.
The DSMO as a collaborative organization continues to demonstrate its ability to merge both the business and technical perspectives of the transaction standards, as well as the modification processes.
The DSMO remains well positioned to assist the NCVHS and HHS in recommending changes to the HIPAA-adopted standards, new HIPAA standards not yet adopted, and operating rules associated with the standards.
We are encouraged with the NCVHS recommendations that outline greater collaboration and engagement between the operating-rule entity or entities and ASC X12, NCPDP, and HL7 International.
Another recommendation that we support is to provide a greater and broader level of participation and input as operating rules are developed. We intend to provide timely input and feedback.
The DSMO presented process-improvement recommendations on April 27, 2010, and stands ready to further collaborate and discuss with NCVHS, OESS, and HHS.
Thank you for the opportunity to submit our 2010 Annual Report.
DR. WARREN: Let me just comment for the new members. One of provisions in the HIPAA legislation that designated NCVHS with certain activities is that we receive an annual report from the DSMOs and then act on recommendations that they come in. So there is their annual report, and you can see we need to wait for them to finish their annual sector, and then we need to find a time for them to give the report. So sometimes there are several months, like this one there were five months before we could get them into the agenda.
With that, are there any questions about the report for Margaret?
MS. DOO: I actually want to make a clarification, Justine, which Marjorie had sent a note for the new members. Unfortunately or fortunately, the concept of this DSMO, which is a designated standards maintenance organization, there are also named DSMOs with an S at the end, which are designated standard maintenance organizations, which are the three standard-setting, HL7, NCPDP, and X12. But then there is this umbrella mother DSMO, which is the grouping of -- I know it sounds --
PARTICIPANT: We need a graphic.
MS. DOO: I know. We had one someplace.
PARTICIPANT: We have a graphic. Trust me.
DR. SUAREZ: Maybe a way to distinguish them is there is the dsmo's, lowercase, and then there is the DSMO, uppercase. The DSMO itself is a convened, defined organization.
DR. GREENBERG: Except when you look on the Internet, capital DSMO says it is a plural. So I don't know. I find it confusing.
MS. DOO: It is, and it is an unfortunate nuance. But the capital-letter DSMO, if you will, is made up of more than just the standards maintenance organizations. It is also the NUBC, NUCC, and ADA.
DR. SUAREZ: Just a quick clarification, because you mentioned that the DSMO concept was in the law, but it is really in regulations, as I understand it, or is it in the law?
MS. DOO: The naming of the designated standard maintenance organizations is in the law, and then the addition with the DSMO is in the regulation.
DR. SUAREZ: That is an important distinction.
MS. DOO: It adds to the confusion.
DR. WARREN: Just to clarify, I have Justine, Bill, Linda, and Raj. Anyone else?
DR. CARR: I have a question. Thank you for that nice report, actually, and for all the great work that you do.
When we held hearings last summer and in the fall, we heard issues raised that had not come through the DSMO, that appropriately should have come through the DSMO, by your assessment. My question is where we are with that today. Is there any kind of outreach to ensure that, or enhanced communication, or somehow a response to that observation that the information was not getting to you in a timely manner?
MS. WEIKER: What we have found through the years since the DSMO was first formed is a lot more entities are coming directly to the standards organization groups and asking for their modifications there, versus submitting a DSMO request.
As part of the hearings that we've held in the last year or so, where I have sat around a table much like this and said, people complain about the standards but yet we don't see any DSMO requests. We don't see them coming forward to the SDO and asking for those change requests, and we encourage people to do that.
So we have been trying to do more outreach through WEDI. Lorraine has graciously sent things out through her listservs, which are much broader listservs, as well as just the testifying here and the subsequent cutoff date that we established for the next version in regard to ASC X12 standards caused a high uptick all of a sudden in DSMO requests. So actually having these hearings and saying, hey, people, bring them forward, do it now, actually helped, and we did see an uptake in the requests.
DR. CARR: Great. That was the other question I had, is how many requests, let's say for '08, '09, and '10, did you get? And is the number that you identified here, number received, number acted on, more than, less than, equal to previous --
MS. WEIKER: No, this is more than, I would say, the last 3 years that we had. Then the next report, which will include January of this year, basically for all the year, you will see almost triple this size because of the cutoff date, the cutoff date of this report and then the cutoff date in regard to the next version. So we will see a whole bunch more DSMO request numbers next year.
DR. CARR: I think a graph, a cumulative graph, year over year, showing the number of requests coming forward and the number acted on, is an interesting way to observe the effectiveness.
MS. WEIKER: We can produce that and I can send it to Lorraine and then she can distribute.
DR. WARREN: Bill?
DR. SCANLON: I was confused by the plural and was watching the verbs kind of switching back and forth. The reason I wanted to bring it up, it really relates to the other letter, and it's the whole idea of a super DSMO, and since Margaret is here, maybe you have some reaction. But I don't know how a super DSMO is different than a mother DSMO.
PARTICIPANT: The mother will decide.
MS. GREENBERG: I'm sorry I started this.
DR. SCANLON: In preparation of that other letter, what do we do? What are we proposing?
MS. WEIKER: I need to know what is being proposed before I could react.
DR. SUAREZ: Well, let me take it. We are not proposing anything --
DR. SCANLON: We observe.
DR. SUAREZ: We are observing what the industry reported during the hearing as ideas and possibilities of how to structure a relationship between the standard development organizations, which is another term, SDOs, the data content committees, and the operating-rule authoring entities and anybody else, because there is vocabulary, maintenance entities, there are code maintainers, there are all sorts of other entities.
During the hearing, Minnesota had a nice graph that showed a whole host of entities where one organization has to belong to in order to work through all the standard process. It is a very complex one, a very expensive one, and it requires a lot of resources.
So we are trying to find, as we add yet another, third stool to this process, a new way to facilitate that oversight of the whole standards development and maintenance process.
DR. SCANLON: Right. Let me just observe. I think one of the concerns I had was that this if is an issue of burden, that if you create an umbrella organization and you say everybody is part of this umbrella organization, you spend the time at the umbrella organization sort of idling while people are talking about issues you don't care about.
You've raised in your report about the fact that your component organizations don't all necessarily look at a proposal. I mean there is this issue of specialization. We look at what matters to us, and then when it's appropriate we come together. There was this question of whether the burden is going to be solved or the burden is going to be increased.
DR. SUAREZ: Good observations there.
DR. WARREN: We need to consider that.
I need to accelerate this because of time. I still have Linda, Raj, Lorraine, and Marjorie. So Linda?
MS. KLOSS: I have a question, and if we don't want to wade into it now in the interest of time, it's fine.
I wasn't clear on what the rationale was for not having operating-rule entities as part of the DSMO and how that helps or doesn't help the coordination particularly, with the greater emphasis on operating-rules.
DR. WARREN: Probably what we need to do is send you the letter chain because it is all spelled out in the letter chain.
MS. KLOSS: Thank you so much.
DR. WARREN: And that's good. We'll send the history out and then we'll probably have some phone calls over the summer, and so after you see the letter chain, you can look at that.
Raj?
DR. CHANDERRAJ: I had the same issue with the operator entity, and I want a definition of that, what that is.
DR. WARREN: Okay. And Lorraine?
MS. DOO: I got to actually say my piece, but I will add since you called on me.
I think what is interesting is -- and obviously no offense to the DSMO or Margaret -- but the sad thing is that the supra or super DSMO is supposed to be the DSMO, and the industry needs to come around. So what is this thing now? How is it supposed to have grown up? That is kind of the issue, that if the DSMO is not allowed to fulfill its function, people are saying, well, we have to have some other solution instead of making that work or changing it. So I think they didn't want another other thing, they wanted this to work. So I think that was a way of differentiating it.
Just to clarify on the operating rule, the NCVHS, I think, did recommend that operating-rule entities become part of the DSMO. The DSMO did not agree with that recommendation.
DR. WARREN: And I got that sense from the report but with no explanation as to why.
Marjorie?
MS. GREENBERG: In regard to the statistics, 21 change requests, at the end of the day one approved -- I actually sit on the data content committees on behalf of public health. So I see these DSMO requests, and I know -- I am not sure I have that, but that there are different reasons why they weren't approved. A number of them never even made it to that.
But it seems to me the bottom line is people don't understand more than not what actually is appropriate to send to the DSMO, what they should be going directly to the standards maintenance organization with.
But I can tell you, it takes up time for every one of these organizations within the DSMO, every one of these DSMOs or whatever, to have to go through the process of agreeing that this isn't appropriate because it is not something that can be done or it came to the wrong group. There are a lot of people spinning their wheels over this, and actually Margaret is agreeing with me; her head is going up and down.
So when you're looking at trying to reduce burden all around and to streamline the process, I just wanted to add that, that it's like I know that you don't want every appendectomy to end up to find a hot appendix, but if there were 21 appendectomies and only one was a hot appendix, you would say we're doing too many appendectomies. That might be a poor analogy, but there is something missing here, there is something wrong.
DR. WARREN: So maybe we can do that.
MS. GREENBERG: There is a need for education, big time.
DR. WARREN: So we could do that in our letter, make a recommendation that the DSMOs provide guidance on what things need to be handled at the SDO level or the committee level and which ones need to be brought up to --
MS. GREENBERG: I think they tried to do that, but maybe the Department has to do it also.
DR. WARREN: So we could also do that. We could recommend to the secretary that --
MS. GREENBERG: Because a lot of people are spinning their wheels in the wrong direction.
DR. WARREN: All right.
We need to move our agenda along. Our next report is not on your agenda, but we wanted an update from CAQH CORE on what they're doing. So Gwen, you are up.
MS. LOHSE: Lorraine asked me to make this very brief, but I thought it was important to update the committee where we are in just two seconds for the new members. I am Gwen Lohse from CAQH. I am the deputy director at CAQH and work on the CORE project.
Just a quick update. Two things that I'm going to focus on. One is the EFT/ERA operating rules update and the other one is the CORE Transition Committee.
The EFT/ERA operating rules. You had all requested CORE write a set of operating rules for delivery on August 1. The CORE participants are working very, very diligently on that.
Then the Transition Committee is a committee that is being formed to look at what -- CORE right now is sponsored by CAQH. The CORE participants vote on the rules, but the CAQH board manages the budget, sets some priorities, and so we are looking at how we can change that.
With the EFT and ERA operating rules, the time line for August 1 is very tight. I just want to express that. So the team is working really quickly and really fast.
There are a few things. Who is involved? The CORE participants as well as the non-CORE participants. So we have over 150 organizations that have been actively involved. For instance, one survey we did on prioritization, over 130 organizations responded to the survey. There were many, many comments. There is a very focused effort on this with a lot of people involved.
There are also a number of new CORE participants. Just to highlight, that is the U.S. Department of Treasury, as an example, Allina Hospital Association out in Minnesota, and Washington State HIE. So you are getting a mix of different types of entities that are looking at this because of the payment and also the remittance and the concept of supporting more standards and the business rules.
Significant surveying I mentioned is occurring. Additionally, open discussions. There are public town hall meetings that are open. There are weekly calls that are about 2 hours long that you have over 60 organizations actively participating in. Then you have significant research that is occurring. The research is based on doing things like comparisons between one topic that different states have handled differently, so you have one topic. There isn't one solution. You want to solve the problem. We're having to look at multiple ways. Each of the states looked at it, as well as other national initiatives that looked at it differently, comparing and contrasting those and trying to find a common place.
You had asked us to reach out to the states as one of your letters. We have actively been reaching out to the states and getting them involved. Many of them have directly submitted ideas and are actively speaking up on the phone calls and submitting comments and ideas. So I think that is a really positive process.
Additionally, working with the other national initiatives, we've been highlighting some of the work that WEDI has done in the different areas and highlighting that, providing links to educate the community.
And then working with the SDOs. A few things there. We recently signed an MOU with NCPDP to make sure within each of the operating rules we have a discussion as to whether or not there is pharmacy covered and how it may be covered, whether it is not applicable because we haven't done enough research, whether they have something that we can just reference to, or that it is included. So I think that MOU is very, very positive.
Additionally, NACHA, which writes the operating rules, they are the recommended standard-setting organization which you all recommended, for the new folks, back a few months ago. They write the standard for the EFT. They have been actively collaborating on this process and very involved. We have done a white paper with them that came out, that was published, and a number of educational sessions, including ones with WEDI that are on line and then others that are in person.
Then X12 has been actively involved in the discussions as well. In several places the research highlights that the standard already covers the requirement and we need to all educate about what the standard already needs to do. So suggestions on that.
We are down to a focus on about five areas where these participants are writing operating rules. One of the difficult parts will be what is appropriate for the financial industry, because they have their own set of operating rules, and we have no desire to repeat that at all, and collaborate how we make sure that the carveouts from medical, like pharmacy, are appropriately addressed.
Then, additionally, because people have strong opinions about tackling the same issue differently, getting down to that detail, we are trying to make it as fact-based as possible. For instance, to just give you an example, CMS was nice enough -- I thought this was an extremely positive thing. They went back and they shared with us their top ten on the whole fiscal year of Medicare, whole fiscal year for 2010, the denial codes and the acceptance codes, the CARCs(?) and ARCs. I don't want to go into detail as to what those are. But they shared those, and that is a high volume. Those are facts you can actually use to make really good decisions.
So we appreciate -- people are really sending in things; we are reaching out; and it is a fantastic dialogue. But a lot to do within a very short time frame given how many people are at the table.
I am going to move on to the Transition Committee. I could go on about the EFT/ERA for quite a long time.
The Transition Committee, again just a reminder, CAQH has been sponsoring CORE since 2005, so it covers about 95 percent of the costs. The CORE participants pay a minimal fee, those 130-plus entities, but the CAQH members cover the cost for the research, the outreach, things like that.
As the Transition Committee meets, they are looking at different models for both the voting for the rules, which is done by all the CORE participants, as well as the actual governance of CORE. Who is sitting on the Transition Committee? I can give you the direct list, but these are executive-level people who are responsible for line-item budgets within their organizations.
For instance, you have the CFO from Montefiore M edical Center. I think we are all familiar with how large Montefiore is. He has a lot of responsibilities. You have the CIO from WellPoint, and you have a practicing physician who also happens to serve on the AMA board. So you really have an executive-level group of people saying what is right for the industry to take on the responsibility to make these types of decisions and also do it in a multi-stakeholder way. The state of Minnesota has someone on, and the National Governors Association has their health IT person on, so that you are having fantastic dialogue.
Where they are, they've met four times. We at CAQH retained a funding expert that did research that shared information with the committee, and also we have a governance expert that we retained that is going to support the committee as it looks at models.
The committee is debating key things like should vendors and clearinghouses vote on the rules, or should it just be the health plans and the providers? They are going to be making a number of decisions and coming out with some potential models and asking for comment from the CORE participants as well as external bodies.
We have been updating CMS as the group moves forward because it is clear from the committee it is going to be a public/private effort as it moves forward, so involvement from the government is going to be absolutely essential.
With regard to the funding, there obviously the committee is going to be updating the CAQH board since they are covering 95 percent of the cost right now. If we transition that, there is going to be probably a need for seed funding and then a need for a long-term budget. So the committee is looking at what is appropriate for seed funding and also realistic and what is appropriate for the longer term when you want to involve public/private, states, the SDOs, and voting on the rules versus voting on things like budget, priorities, management.
That's it. I tried to make it super-quick.
DR. WARREN: I just have to say one thing. Having been on this subcommittee now for 6 years, one of the highlights for me in being on this committee was when we did e-prescribing. What we saw is we had multiple hearings on e-prescribing, and we actually saw industry come together while we were doing the e-prescribing and fill in all the gaps that we were identifying for the process, and they worked together.
This is another opportunity where we were doing something no one had really thought about well yet and how it all fit, back to Walter's three-legged stool of being able to bring these groups together.
So I just want to applaud everybody who has a part in this. We have come so far and got over a lot of hurdles about different business models, people's versions of what they thought the future was going to be, and now we have kind of changed the whole mix of that.
CAQH CORE is to be applauded for trying to be so inclusive of everybody and working together. I was thrilled when I saw the press release with CORE and NCPDP. So I think we are well on the road for this.
We have probably a moment or two for questions. Justine?
DR. CARR: I want to add my applause. We hadn't even met this time last year.
MS. LOHSE: Right. It has gone fast.
DR. CARR: What has happened just really demonstrates, when there is the will to problem-solve, what can happen. So a great job all around.
DR. WARREN: Any questions from the subcommittee? Marjorie? None? Oh, wow, okay.
PARTICIPANT: Go forward.
MS. LOHSE: If you do have any questions, feel free to reach out. We are happy to send things in writing or in detail to you. So thank you.
DR. WARREN: And we have multiple times to meet again as we finish this trek on operating rules.
Agenda Item: Tenth HIPAA Report
The next agenda item is our tenth HIPAA report. Walter is going to cover that.
DR. SUAREZ: Yes. We only have 10 minutes. The way I think it is going to be helpful to the committee, if it is up to me to do it, if you go to the book for the committee and tab number 6 for members of the committee, that is the presentation that we will be giving a little later this morning. It is only four or five bites. So let me just go through it with you first and see what your reactions are.
As was mentioned, this is our tenth HIPAA report to Congress, and we wanted to take advantage of that kind of event to make a special report, if you will, in which we would take a look at the journey that we have gone through on administrative simplification.
The first slide just says take advantage of this year's tenth report and where we started, where we are today, where we are going, especially the fact that there is an upcoming major transition to the next versions of 5010 and ICD-10 which are enhancing this view of the journey and the significance of the journey, and then build upon certainly the previous reports, HIPAA hearings, all the different activities that we have had over the last several years, which is an amazing array of activities when you put them all together in a report.
We don't expect certainly to do a collection of new data. There is enough data and there are more data coming down the pike later this year on assessments of where the industry is with respect to HIPAA. We will have a hearing tomorrow. So there is a lot of information that we will be able to use on this.
On the second page or the second slide, third slide I guess, the outline of the report that we put together is listed there. So we have a transmittal letter as a cover, we will have an executive summary, and then we divided the report into three sections. Section one will be the journey, the overview, the HIPAA standards, what is administrative simplification, the description of the various components of administrative simplification and how they fit together, and really how has NCVHS served as a catalyst in this journey; what has been the role of the committee.
Section two is the implementation of HIPAA administrative simplification. So now it's talking about where we are today, the destination and where we are today: How well have the HIPAA transaction codes as identified been implemented? How well have HIPAA privacy and security standards been implemented? So we have a connection to our Privacy and Security Subcommittee, and they will be involved in helping us draft and review this report.
What has been the effect of HIPAA administrative simplification implementation? So what is ultimately the effect? Do we have some evidence out there that shows the benefits of the value that HIPAA administrative simplification has brought in? What are the doubts and issues that remain?
Section three is the future of administrative simplification, the next version of standards. We are now engaged in the discussions of that. The opportunities for additional standardization, which we will be talking about later this year in this subcommittee, links to EHR standardization and HIE adoption. So all these we are doing in the administrative side of the health care world, and then at the same time there is this major movement towards the use of electronic health records and how the two at some point in the future will come together. I mean they are coming more and more together, but EHRs, which is where we capture and maintain all the clinical information when we see patients and when we interact with patients, are used to generate the administrative side where we send claims and when we receive payments and all that. So at some point the merging of those two worlds will continue. That is one of the views or visions out there is how the two come together. So that is section three of the report.
Then we will have a set of attachments, basically, referencing material.
The task and the process in slide number 5 is basically -- this is a work of research and drafting, and we have been fortunate to be able to engage a very knowledgeable and expert person in the industry, Margaret A(?), whom many of you probably know from other engagements. She has been working with us on a number of other projects. She has been helping us with the environmental scans of the industry on all these areas. We are working with her on the drafting of this section, so there is research and identification of sources and collection of information for each of the three sections, and we are putting all this together.
Lots of resources. This sample of resources includes NCVHS previous letters, reports, hearings, industry-published data, CMS data on the implementation of transactions and codes on privacy and security from OCR, for example.
Then the time line you see there. We have completed a significant part of the data gathering, and we have already started the drafting of the various sections. We have initial drafts of at least sections one and two and we are working on section three.
So what we want to do over the next month or 2 months basically is to engage the subcommittee in the discussion now of the draft. We did not want to present to you a very rough draft yet, so we wanted to put together a decent draft that can be then shared with you, and then you can provide the feedback.
So the expectation is that between July and August, we will be presenting to you that, presenting to the Executive Subcommittee, and then by September we will bring to the full committee a report.
There might be one or two options. The report is pretty much ready and the committee will approve it, which is unlikely. So we expect that it will probably need a second round of reviews. So we expect that, as it points out, we intended to really finish the report in September, but I think the time line is going to be more the November meeting of the full committee is going to be when we finalize, approve, and publish the revised final report.
So that's a very brief overview. Any questions or comments about that?
DR. GREENBERG: I applaud you on this work, and Margaret A, and look forward to seeing the drafts.
I just wondered, because I know I was involved in some early discussions since we were planning it, and one of the issues, the main issue, was the extent to which there was extant data or information that you could begin to address these questions.
So have you found what you consider a reasonable amount of evidence to address all of these questions?
DR. SUAREZ: I think we have. I think there are holes certainly and there are gaps in the information. There is more information coming out later this year from other sources as well. But yes, I think generally we have.
DR. WARREN: Plus our hearings tomorrow we are hoping will add more information, and there are two surveys that are going to be published this summer.
MS. GREENBERG: Okay, great.
DR. WARREN: So we will be getting those as well.
DR. CARR: I really applaud this endeavor. I think this is phenomenal. I think the fact that we are finding that this data exists underscores the fragmentation of the story. I think we owe it to Congress, we owe it to the public to really tell the story of where we are today. So it is fantastic.
DR. WARREN: And then, much as I hate to, Walter, we are out of time, because Justine wants to start her meeting on time.
So what we will do, there is a time line for what the subcommittee is doing. We will send that out on email. It is pretty self-explanatory. And if it's not, you can email Walter and me back and we'll try to explain it better.
DR. SUAREZ: One important quick comment is we will be convening a number of conference calls of the subcommittee over the summer basically because we have a number of important issues, like the letters that we have to approve before September, review the HIPAA report, and other things. So we will send you a display of the time frame of the work plan over the next several months and then some expectation of your conference call time.
DR. WARREN: I would encourage the new members that have attended the subcommittee meeting, if you could let Walter or me know sometime today whether you are still interested, and so we add you to our mailing list, or whether you are committed to joining the party, and we will definitely add you to the list.
DR. SUAREZ: There are going to be prizes and also some other incentives.
(Laughter)
DR. WARREN: Yes. So come in and you can help plan the party and be part of it.
I think on that note we will adjourn the meeting so that Justine can start hers on time.
DR. CARR: Thank you.
(Whereupon, at 10:00 a.m., the meeting was adjourned.)