Department of Health and Human Services
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
Subcommittee on Standards
Review Committee
Hearing on Adopted Transaction Standards, Operating Rules, Code Sets & Identifiers
June 16 & 17, 2015
National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782
The National Committee on Vital and Health Statistics Subcommittee on Standards convened a hearing on June 16 & 17, 2015. The meeting was open to the public and was broadcast live on the internet. A link to the live broadcast is available on the NCVHS homepage.
Committee Members Present
- Walter G. Suarez, M.D., M.P.H., NCVHS Chairman
- Raj Chanderraj, M.D., F.A.C.C. (via phone)
- Alexandra (Alix) Goss, Review Committee Co-Chair
- Linda L. Kloss, M.A.
- Vickie M. Mays, Ph.D., M.S.P.H.
- W. Ob Soonthornsima, Review Committee Co-Chair
- William W. Stead, M.D.
Staff Members Present
- Terri Deutsch, MS, RN, CMS, Review Committee Lead staff
- Debbie Jackson, M.A., Acting Executive Secretary
- Donna Pickett, RHIA, M.P.H., NCHS
- Jim Sorace, M.D., ASPE
- Michelle Williamson, RN, MSIS, CPHIT, NCHS
Absent
- Vivian Auld, NLM
- Suzie Burke-Bebee, DNP, MSIS, MS, RN, ASPE
- Betsy Humphreys, M.L.S., NLM
- Michael J. Lincoln, M.D., FACMI, VA
- James Scanlon, HHS Executive Staff Director, ASPE
Hearing Presenters List
- George Arges, AHA
- Stacey Barber, ASC X12
- Gary Beatty, AHIP
- Chris Bruns, HATA
- Rich Cuchna, CMA (via phone)
- Laurie Darst, WEDI
- Stephanie Eades, AHIP
- John Evangelist, CMS via phone
- Annette Gabel, ACAG Consulting/NCPDP
- Priscilla Holland, NACHA (via Phone)
- Raemarie Jimenez, AAPC
- Gail Kocher, BCBSA
- Gwen Lohse, CAQH CORE
- Heather McComas, AMA
- Benjamin Miller, PsyD, UC Denver
- Melissa Moorehead, MPHI
- Jean Narcisi, WEDI
- Dave Nicholson, HBMA
- Atul Pathiyal, CAQH
- Don Petry, BCBS TN
- Ruth-Ann Phelps, VA
- David Preble, DDS, JD ADA
- Sam Rubenstein, WEDI
- Rhonda Starkey, Harvard Pilgrim Health Care/AHIP
- Merri-Lee Stine, AETNA/AHIP
- Debra Strickland, Xerox
- Robert Tennant, MGMA
- Margaret Weiker, NCPDP
- Sherry Wilson, Cooperative Exchange
HEARING SUMMARY
TUESDAY, JUNE 16-17, 2015
ACTION STEPS
· A document outlining each topic that identifies themes from the two-day hearing will be prepared to make recommendations to the Secretary of Health and Human Services.
· The Review Committee will produce a final report later this year.
Tuesday, June 16, 2015
WELCOME, INTRODUCTIONS, AGENDA REVIEW
Alexandra Goss and W. Ob Soonthornsima, Co-Chairs
OVERVIEW OF THE REVIEW COMMITTEE AND PURPOSE OF THE HEARING
W. Ob Soonthornsima
The purpose of the meeting was to obtain information from the health care industry on the currently adopted standards, operating rules, code sets and identifiers used in administrative simplification transactions. The two objectives were to: a) review the adopted standards to evaluate whether or not they meet current industry business needs and if so, to what degree; and b) identify transactions that require changes, deletions or new versions in order to meet industry needs.
NOTE: For further information about presentations, please refer to transcripts and Power Point presentations.
PANEL 1 HEALTH PLAN ENROLLMENT/DISENROLLMENT AND HEALTH PLAN PREMIUM PAYMENT
Health Plan Don Petry, BCBS TN
Health Plan Gail Kocher, BCBSA
Employer Debra Strickland, Xerox
ASC X12 Stacey Barber
Pharmacy Annette Gabel, ACAG Consulting/NCPDP
Discussion
Separation between the enrollment and premium payment standard in commercial business versus the insurance exchange (HIX) has been an ongoing challenge. There are differences among the exchanges and industry business practices as to the requirements for tracking and reconciling data. One issue is that many group health plans and other industry participants are not HIPAA covered entities. Therefore, businesses are faced with the increased cost of customization and maintenance associated with using multiple channels to capture necessary data. Another barrier is that the uncovered entities do not have the technological infrastructure and are not well equipped to implement an EDI transaction. While some businesses use third party vendors to create the 834, there is a decrease in prioritizing the development for an 834 or 820, which presents issues with the adoption of the transaction.
The status of using 834 in the insurance exchanges was provided with several examples indicating where gaps still exist in the business processes (see transcript). Represented were logistical issues where specific data is not supported and therefore cannot be communicated in the transaction due to its structure in nature. Discussion ensued about the possibility of exploring a hybrid solution to align the transaction with industry demands. A question was raised with regard to opportunity in the future of using one 834 for the entire industry as opposed to making a distinction between commercial and insurance exchanges. Viewpoints presented included: reviewing approaches to the adoption of 834 and 820 transactions to minimize the business costs associated with customizing vendor tools; implementing greater standardization for enrollment processes; and examining the advantage of having a separate HIX guide for businesses given that various information has to be communicated via the transaction.
ASC X12 is in the development phase and revising the timeline for the next version (7030) of the transactions. The end of the year is the targeted timeframe for the base standard to be published. Discussion followed pertaining to the continued evolution of policies and regulations. There is a need for greater participation from industry in the standards development process to ensure that 7030 meets their long-term needs. The dialogue continued with responses as to how the Center for Consumer Insurance Information and Oversight (CCIIOO) is engaged with X12 and other stakeholders to make sure that changes are affected in the standards. Panelist stated: that exchange participants engage in regular industry-wide calls; there are designated individuals within their organization working with X12; consultations take place with smaller groups of issuers; and stakeholders maintain involvement with the associations and AHIP.
A conversation was prompted by a closing question regarding what steps were needed to advance administrative simplification over the next five to eight years. Different perspectives included: engaging covered and uncovered community stakeholders and industry partners by providing education on transaction standards that is initiated by HHS; having a focus on developing evaluation criteria that will concentrate on return on investment for the business industry to support the adoption of new transaction standards; and reducing the time it takes to adopt new standards.
PANEL 2 HEALTH PLAN ELIGIBILITY, BENEFITS INQUIRY AND RESPONSE (PART 1)
WEDI Laurie Darst
Provider George Argas, AHA
Provider Robert Tenant, MGMA
Billing Dave Nicholson, HBMA
VA Ruth-Ann Phelps
Mental Health Benjamin Miller, PsyD, UC Denver
Pharmacy Annette Gabel, ACAG Consulting/NCPDP
Clearinghouse Sherrie Wilson, Cooperative Exchange
Discussion
What is the differentiation between the clearinghouse requirements and the 270/271 for eligibility? Though many providers receive information via faxes, web portals, and clearinghouses, a combined review of studies discovered providers have a high volume of phone utilization. Further research is needed to determine whether the phone or transaction is the better value.
Changes in the industry, with respect to new forms of integrated care delivery and payment reform, have the capacity to affect the eligibility process. A question was raised concerning the outlook for a new eligibility transaction. There is a growing trend towards high deductible health plans and alternative payment models for provider reimbursement. Eligibility requests conducted simultaneously at the time of service is critical to establish patient financial responsibility to reduce the potential of increasing bad debt. Suggestions were made to: develop a real time eligibility transaction that promptly returns necessary information to providers; work collaboratively with WEDI and NCVHS to conduct a gap analysis linking business processes and real time response; and improve existing transactions to meet current needs and payment models. Although the billing model is different, the VA will continue to employ the 270/271 transaction as it is very useful in their business processes.
Recent studies found that integrating mental health providers into primary care affords patients the ability to have rapid access to a mental health provider. A question was raised to describe the vision of transformation in an eligibility transaction as it relates to mental health. Transformation would use an integrated model approach to address the issues where most primary care providers do not have the ability to connect to the specialty mental health system to care for their patients. Additional changes include, upgrading from the legacy systems which currently do not allow for essential electronic transactions and payment reform.
The impact of convergence of EHRs with administrative transactions has been a theme the National Committee has been considering. What is the future for the EHR systems having the capability to execute an eligibility transaction independent from the practice management systems? Responses were unique to industry segments. Whether running one vendor product for EHR and a different vendor product for PM, or using the same vendor product for both EHR and PM, practices experience the same outcome. Challenges with EHR and PM systems continue to exist as they do not interface well. A focus on how best to transport clinical information using automation to support eligibility will help transition from faxing, which is a prominent method used in the industry. Clearinghouses are currently incorporating the convergence of clinical and administrative transaction in the workflow process. Further adoption of the attachment standard will support the industry requirement.
PANEL 2 HEALTH PLAN ELIGIBILITY, BENEFITS INQUIRY AND RESPONSE (PART 2)
Health Plan Merri-Lee Stine, AETNA/AHIP
Health Plan Gail Kocher, (BCBSA)
Long term Care Stephanie Eades, AHIP
Medicare Rich Cuchna, CMS telephone
Medicaid Melissa Moorehead, MPHI
Practice Management Vendors Chris Bruns, HATA
Operating Rule Authoring Entity Gwen Lohse, CAQH CORE
ASC X12 Stacey Barber
Discussion
Testifiers asked if it is possible to consider in a transition process to new versions as one of the early steps? Others believed externalizing code sets would allow for updating when the transactions are updated.
The upcoming standard version 7030 addresses the gaps that currently exist in 6020 (which was never released). ASC X12 is progressing towards externalizing code sets for ease of maintenance and providing regular updates. While developing technical solutions continues, it was noted that ASC X12 is working on a process within ASC X12 whereby they will own the created codes eliminating the use of a third party. Relative to time and speed, ASC X12 expects some of the transactions to be implemented rapidly and then gradually move to incremental changes.
One testifier stated that the speed at which implementation for new standards takes place warrants caution with regard to Medicaid agencies. IT resources in these State agencies have limited resources. Providers experience barriers to EDI with respect to connectivity and cost. EHR systems consume the bandwidth and the challenges increase with the addition of practice management systems.
Discussion continued with a recommendation to take a collaborative industry approach by considering operating rules to use as tools to ensure appropriate resourcing. Additionally, in light of changes that have taken place of the past few years, industry should re-engage in discussions prior to responding to the question posed to the panel. Taking into consideration the value of blended concepts of incremental change and externalization of code sets enables the industry to respond to changes more quickly.
PANEL 3 PRIOR AUTHORIZATION
WEDI Sam Rubenstein
Health Plan Rhonda Starkey, Harvard Pilgrim Health Care/AHIP
Health Plan Gail Kocher (BCBSA)
Medicare Connie Leonard, CMS telephone
Medicaid Melissa Moorehead, MPHI
Provider George Arges, AHA
Provider Heather McComas, AMA
Provider Robert Tennant, MGMA
Mental Health Benjamin Miller, PsyD, UC Denver
Pharmacy Margaret Weiker, NCPDP
Clearinghouse Sherry Wilson, Cooperative Exchange
Practice Management Vendor Chris Bruns, HATA
ASC X12 Stacey Barber
Discussion
A question was raised pertaining to the complexity of the 278 transaction and its impact on the likelihood of the industry to increase its adoption, or whether a re-evaluation is needed to design a streamlined process followed by a standard. A lengthy discussion followed with perspectives from the various industry segments.
The complexity of 278 transactions and operating rules are not achieving intended benefits. Testifiers indicated there is a cumbersome workflow process resulting from having to provide additional required information through manual intervention directly affects patient care. One suggestion was made to take a three pronged evaluation approach which is to step back, assess the barriers and areas of improvement for streamlining the business process, and review standards including attachment needs.
Feedback regarding automated approval systems versus manual intervention presented differing viewpoints. There are some payer organizations that are using systems that have auto-approval rules. This contributes to high approvals and minimal manual intervention. In such case, the ROI for the 278 transaction also increases. One example of how the 278 services everything, including phone and portals was given. The participant explained the results of a ten year iterative examination procedure that successfully developed into an automated process using a rules engine; a combination of the 278 and a utilization management system. Other feedback indicated that there were more manual interventions. The WEDI representative stated that mixed provider perceptions illustrate a need for additional research.
A question regarding what opportunities exist with simplifying prior authorization requirements, was presented to the panel. The payer is using prior authorization as a cost savings tool in providing health service. Some States have standardized prior authorization forms that use their own criteria. Plans find that difficult because they require additional information, which can be burdensome. Discussion continued with commentary on pilot studies that had a focus on pharmacy formulary, the types of attachments required, and the need to have flexibility for questions in order to address the variabilities in the transaction.
Suggestions were made concerning converging eligibility and prior authorization transactions. Benefits presented for coordinating these transactions involve capturing information in the initial phase of the process. This will support streamlining the end-to-end workflow automation. Moreover, there was acknowledgement that providers may encounter some challenges.
A forthcoming change that involves moving to an emerging value-based care business model was described as one that may require a completely different type of transaction. In order to understand this new development, a full examination of trend data comprised of the number of negotiated contracts, how many plans no longer require prior authorization for providers, and an evaluation of the work flow analysis will better equip the committee to make recommendations. While there was agreement for further research, additional suggestions included: beginning the recommendation process with a medical and clinical policy conversation followed by a review of EDI transactions.
PANEL 4 HEALTH CARE CLAIM OR EQUVALET ENCOUNTER INFORMATION (Part 1)
Health Plan Gail Kocher (BCBSA)
Medicare John Evangelist, CMS telephone
Medicaid Melissa Moorehead, MPHI
Provider George Arges, AHA
Provider Heather McComas, AMA
Provider Robert Tennant, MGMA
Dental David Preble, DDS, JD ADA
Mental Health Benjamin Miller, PsyD, UC Denver
PANEL 4 HEALTH CARE CLAIM OR EQUVALET ENCOUNTER INFORMATION (Part 2)
Pharmacy Margaret Weiker, NCPDP
Clearinghouse Sherry Wilson, Cooperative Exchange
Practice Management Vendor Chris Bruns, HATA
ASC X12 Stacey Barber
Coders Raemarie Jimenez, AAPC
Discussion
A discussion ensued about the deadline for change requests for the next version. Members requested additional time to ensure it was inclusive of all changes, which provides more time to accept changes. Therefore, the cut off will be February 2017 with release some time in 2017. Piloting should be integrated into that timeline to gain a better understanding and validate success prior to releasing new standards. Establishing ROI should be another component to rally support from providers and practice management vendors who have to incur the expense of moving to a new standard. Also, the outcomes from the testimonies afford the committee a chance to look at opportunities that improve utilization of the transaction standards prior to adopting new standards.
On the subject of modifying the covered entity provision with HIPAA, a recommendation was made to take an educational approach for employers, workers comp, and other partners. The messaging should entail the value add sustained by: a) adopting new standards; and b) adhering to a communication process with health plans while simultaneously establishing their own business practices. One participant, speaking on Worker’s Compensation, mentioned that working with WEDI on the X12 standards over the last eight years has allowed them to use the 837 transaction for all lines of healthcare business, as well as standardize and automate the workflow process. Other comments suggested taking a holistic approach when thinking about transactions, consider the impact to providers on meaningful use, and review the continuum of end-to-end or automation rather than analyzing transactions separately.
The ONC is publishing additional EHR certification with new standards frequently. With development being a very rapid process, the intent for administrative simplification is to look for middle ground using small incremental enhancements. What are some other improvements in the standard that can be adopted faster for HIPAA transactions? Implementations are costly and they take time. Feedback from the industry stresses adopting changes that are needed instead of waiting for a major version comprised of accumulated changes. After this next release of the TR3’s, the expectation is that updates will occur more often.
The value of the incremental approach is that the initial investment is less risky. This is a key issue for Medicaid agencies, as they are impacted by a political process. Changes, though small in nature, may present challenges. Addressing potential difficulty can include: having a dialogue and communication process which is key to testing, managing various IT developments, and collectively working with stakeholder continuum participants. The discussion continued with reference to meaningful use and the intersection with the HIPAA transactions.
One suggestion was made to explore moving in the direction as meaningful use. A subsequent comment highlighted the difference between end user involvement in meaningful use standards and ASC X12 development. ASC X12 led a collaborative effort into problem discovery to develop the next version. Another recommendation stated that increasing provider participation in ASC X12 development can be achieved by holding focus groups at MGMA meetings. This qualitative approach provides immediate feedback on what improvements are needed.
A question was posed about group perspectives on the future of claims. Emphasis on more of the clinical variables becomes essential as the process moves away from the fee for service to more of a quality component for pay for performance. In essence, the claim is a summary of the type of resources expended for the patient. As the most reliable source of condensed data, the question becomes whether or not the data set used in the claim, should be expanded to separately capture information for research purposes.
The future vision of the claims process may involve having a system where multiple approaches can accommodate those using the PQRS and those who are capturing data from EHR without the use of codes. Instead of developing new attachments, it may be possible to use an information identifier to indicate where to go for more information. However, to maintain data quality, security barriers are needed to prevent inappropriate access.
Once a standard is in place, what are our mechanisms for ensuring that it is being properly implemented? Providing proper training and education for industry partners emphasizing the benefits of following operating rules, and having consistency in establishing the requirements for the companion guides. A remaining issue is trying to hold people accountable. Since the first $4.3M fine levied against a health care system, issuing fines for non-compliant entities have been sporadic. Although these incidents have raised awareness, not having strong enforcement has contributed to non-compliance. Reluctance to filing a complaint is a barrier to the process. However, CMS has a published process where they provide education outreach to industry regarding how to achieve successful complaint resolution.
Questions specific to mental health were raised referencing mental health clinicians not being included in the HITECH Act with regard to incentives. Also, where are we in terms of those symptoms in the EHR and are incentives needed? What is presently seen in the mental health systems is insufficient data in comparison to other providers. This is the result of financial restraints that do not allow them to purchase technology for the EHRs that are inadequate. The method in which data is collected involving narrative fields versus discrete fields poses ongoing problems with determining ways to dismantle what exists for mental health. Continuum of care should address following up care as part of the process. Additional statements indicated that psychiatrists were not excluded from meaningful use. Psychiatry and mental health purchase EHRs that are specialty specific therefore, it posed a challenge for them to meet the requirements.
PANEL 5 COORDINATION OF BENEFITS
CAQH Atul Pathiyal
Medicaid Melissa Moorehead, MPHI
Provider George Arges, AHA
Medicare Supplemental Carrier Gary Beatty, AHIP
Provider Robert Tennant, MGMA
Clearinghouse Sherry Wilson, Cooperative Exchange
ASC X12 Stacey Barber
Practice Management Vendor Chris Bruns, HATA
Discussion
A question directed to the ASC X12 representative referenced the balance between the effectiveness of the coordination of benefit transactions for communication with payers and providers. There are two models; the payer model of coordination of benefits and the provider-to-payer model. Although majority is Medicare payer-to-payer with crossovers, a large volume of duplicate claim submission continues as providers use electronic and paper along with Medicare Explanation of Benefit (EOB). From the provider’s perspective, a barrier to efficiency is lack of confidence in knowing that crossing the claim over is creating the 837. Suggestions for improvement include having a larger adoption of payer-to-payer model to simplify the providers’ process, improving primary information in a consistent manner to health plans, and sending a status message to providers.
What would be the reasons why there isn’t more coordination of benefits between payers of dental benefits? A representative from the Dental industry noted that in the case when providers have information on primary and secondary to submit on the 837D, the provider assumes the responsibility in determining which is the primary and secondary. Consequently, there are two outcomes: a) a payment without coordination is received; or b) a denial. Additionally, the issue that exists with vendors and practice management systems is that payers are not conducting claims process using an electronic method. However, HIPAA structure provides a strong compliance message.
Primary barriers within 837 Coordination of Benefits (COB) are being addressed in the next standard version. Having the ability to have the reason code, remark code, and the adjustment amount to be reported simultaneously is a future enhancement that may increase electronic submission of coordination of benefits claims. An effort to create a central COB database is active. Receiving data from all industry partners is encouraged. Standardizing the secondary payer questionnaire furnishes the most recent information.
How can we make the process for capturing and collecting secondary payer information from the patient side more effective? From the dental provider viewpoint, accepting the responsibility of submitting patient information on the 837 COB is equally as important as getting the transaction processed in a timely manner so the patient will know their out-of-pocket expense. A variety of suggestions were proposed: having the transaction processed automatically to relieve provider from the burden of using a web portal to reconcile bulk transactions; using a standard methodology for industry partners to determine the payer sequence; helping the provider access secondary information when available without asking patient; and having a national patient identifier.
In order to assess the risk aspect, panelists were asked to comment on pay for performance and transactions that are currently in place to determine if there is an emerging business function that the committee should be exploring. A distinction was made between two issues; the payment model and coverages. Complications will stem from adopting different payment methods and understanding how to coordinate benefits with various health plans. A concern was raised about the absence of having a mapping process that would begin with standard terms having computable contract terms, and lead a way to re-conceptualize which transactions are essential versus those that are non-scalable. Codifying in a manner that can be used in an electronic process environment proves challenging as SNODENT has 7000 diagnostic codes and SNOMED CT has 60,000. Other contributing factors to consider is cost and maintenance of such a system. The all-inclusive new models are a reminder that continuum of care dictates how health records need to be coordinated, which in terms prompts the committee to re-evaluate what that process workflow should be.
PANEL 6 HEALTH CARE CLAIM STATUS
Operating Rule Authoring Entity (ORAE) Gwen Lohse, CAQH CORE
Provider George Arges, AHA
Provider Robert Tennant, MGMA
Health Plan Rhonda Starkey, Harvard Pilgrim Health Care/AHIP
Health Plan Gail Kocher, BCBSA
Medicare John Evangelist, CMS telephone
Clearinghouse Sherry Wilson, Cooperative Exchange
WEDI Jean Narcisi
Discussion
Health care claim status was discussed relative to how it is used in the industry and its capabilities. An industry representative stated that their organization uses the 277 transaction and the information it provides extensively. As a result, they have experienced significant cost reductions by conducting routine follow-up to prevent aging account receivables. Supporting comments indicated that the value of the response from the transaction is dependent upon how well it is entrenched in the practice management or accounts receivable system. This is fundamental in managing the results from the transaction.
To what extent is the next version already taking into account changes to improve the information in the actual standard and is there a need to expand the content? The transaction does support the data. However, the level in which a plan responds to the information drives its effectiveness. Minor changes from the 276/277 perspective such as predetermination of benefits are taking place. A consistent message from this hearing to add the pay date is a change request that can be presented. The 277 claim acknowledgement is currently supported.
The discussion continued concerning the level of granularity in the transaction. It was noted that granularity is directly related to the response from the code set as well as effectively using the specific information. Differences were noted between the two levels of granularity in the claims status inquiry response: a) status of the claim at the claim level; and b) reporting on each individual service line. The capability currently exists in the 5010 version for the claim status codes and tracking, but is not required. As a result, there is no consistency in its use.
In response to the question as to whether or not there was a need to increase granularity, a participant pointed out that the current version supports the ability to report down to the service line. The transaction is rich with many capabilities. Codes can be updated three times a year, as the change requests sent to the codes committee can be initiated by anyone. Concern pertaining to complications with granularity emphasized how institutional claims are adjudicated at a claim level. Therefore, there is no ability to report at a line level.
Recommendations for improvement included working collaboratively to conduct a gap analysis from the various perspectives within the industry to provide a uniform communication tool. An additional suggestion was to have WEDI, CORE, X12, and others provide educational outreach for industry users. A representative for WEDI acknowledged that their organization would be the ideal consortium to facilitate that process. The CORE certified vendors who effectively use the claim status inquiry transaction would make good partners in the educational outreach effort.
Two questions were directed to the Operating Rule Authoring Entity (ORAE) participant (CAQH CORE): a) To what extent would the operating rule modify data content of the standard adopted; and b) To what extent does that create conflict within compliance under HIPAA standard transaction rule versus operating rule compliance? Consider the investment made to adopt the standard in the national health care system. The construct of using a balanced multi-stakeholder voting process, and examination of business needs and cost reductions to determine which of those items in that tool would generate the most benefit, is not viewed as conflict but rather complimentary. It was noted that the providers would prefer having a standard versus using a portal. Many aspects of that investment can be implemented within the current operating rules. Therefore, looking at it as an advantage point presents the question, “Where do we want to put our investment within the national health care system…IT.”
PANEL 7 HEALTH CARE PAYMENT, REMITTANCE ADVICE AND ELECTRONIC FUND TRANSFER
WEDI Jean Narcisi
Operating Rule Authoring Entity (ORAE) Gwen Lohse, CAQH CORE
NACHA Priscilla Holland telephone
Provider George Arges, AHA
Provider Heather McComas, AMA
Provider Robert Tennant, MGMA
Dental David Preble, DDS, JD, ADA
Long Term Care Stephanie Eades, AHIP
Health Plan Merri-Lee Stine, Aetna/AHIP
Health Plan Gail Kocher, BCBSA
VA Ruth-Ann Phelps
Medicare John Evangelist, CMS telephone
Medicaid Melissa Moorehead, MPHI
Pharmacy Annette Gabel, ACAG Consulting/NCPDP
Clearinghouse Sherry Wilson, Cooperative Exchange
ASCX12 Stacey Barber
Discussion
Health Care payment, remittance advice and electronic fund transfer was discussed at length. As the largest, most diverse panel at the hearing, the discussion yielded insight into practices and challenges encountered in the industry. One participant commented that as the committee moves forward, to be conscientious of the burden on end users and providers as they move toward adherence to new regulations. In response to the low adoption rates, Healthcare Administrative Technology Association (HATA) is working on a nationwide awareness campaign to remove provider adoption barriers by sharing ERA/EFT best practices, hosting an ERA/EFT summit, and partnering with NACHA. Providers have a paper preference resulting from the electronic payments rollout. There is strong support to have a roll out with full transparency about provider costs as well as giving them the opportunity to opt out.
A suggestion to improve administration simplification is to identify: a) what is working well; and b) where are the provider success stories. Such partners can be included in an educational outreach to support those who are struggling with embracing compliance. The CAQH Index highlights provider benefits, yet as the decrease in cost continues, it affords providers additional opportunities to help their patients.
A discussion ensued regarding fees and provider hardship. Conflicting messages regarding fee charges exist with CMS rules versus what vendors are charging a health plan using a credit card payment method reduces the provider payment by 4%. What compounds the issue is that providers accept discounted fees from health plans and face additional fees associated with the use of (health plan) credit card payment. Providers argue that in a patient-to-provider credit card transaction, an interchange fee is charged for the purpose of shifting the risk of non-payment from provider to card issuer. This same fee is associated with the health plan-to provider credit card transaction. However, the non-payment risk does not exist even though the provider still incurs the charge for the fee. It was noted that there are provisions in the rules that prohibit charges for standard transactions.
A consensus among panelists advocated for working in a collaborative environment to find a solution to help entities that fear retribution for sharing their compliance inadequacies. The WEDI representative offered to take the lead in educational outreach while providing next steps. Further recommendations included: being creative in using social media for awareness campaigns and leveraging limited resources; and inviting compliance officers and Healthcare Financial Management Association (HFMA) representatives to participate in review committee discussions. A final suggestion was made to utilize the same strategy that is used in Medicare Fraud, by which the whistle blower or person who brings the complaint forward shares in the reward from the fine. However, anonymity poses a barrier to that approach.
Review Committee Discussion of Key Themes, Findings, and Next Steps
Specific consistencies derived from the panel discussions over the two day period are as follows:
- Concerns with standards adequacy versus usage and implementation
- Conflicting regulations and business models
- Moving toward a new business model
- Providing sufficient information for conducting business versus using alternative venues, such as portals
- Compliance, educational outreach, and awareness
- Compliance versus choice
- Collaboration
- Making Administrative Simplification work
Adjournment 4:00 p.m.