[This Transcript is Unedited]

Department of Health and Human Services

National Center for Vital and Health Statistics

Meeting of

Subcommittee on Standards

June 16, 2011

Double Tree Hotel
300 Army Navy Drive
Arlington, VA 22202

Proceedings by:
CASET Associates, Ltd.
Fairfax, Virginia 22030
(703) 266-8402

TABLE OF CONTENTS

P R O C E E D I N G S (8:32 a.m.)

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)

Agenda Item: Status of 5010

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 277 CA 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 e prescribing 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)

Agenda Item: DSMO Report

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.

Agenda Item: CAQH Update

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.)