To: National Committee on Vital and Health Statistics

Presented by: James McNiff,Associate V.P, Montefiore Medical Center

Members of the Committee. Thank you for the opportunity to present. I would like to comment on standards and operating rules from the perspective of my institution, which has been an early adopter of electronic transactions. In fact, we consider ourselves to be a leader in working with health plans to advance administrative simplification.

I am responsible for the hospital Revenue Cycle activities at Montefiore Medical Center. The Montefiore delivery system offers a full range of healthcare services (preventive, primary, specialty, acute and post-acute) to the nearly 2 million residents of the Bronx, New York, and nearby Westchester County. Montefiore serves also as a tertiary care referral center for patients from across the entire metropolitan area, the nation and the world, and is known for advanced care in numerous specialties, including cardiology and cardiac surgery, cancer care, children’s health, tissue and organ transplantation, women’s health, surgery and surgical subspecialties. This includes registration, insurance verification, billing and collections. Our annual cash collections are approximately 1.8 billion dollars, which is achieved by a team of 400 full time equivalents. In addition Montefiore employs 1500 physicians for which the medical center performs revenue cycle functions.

Today, Montefiore has the ability to submit and receive all named HIPAA transactions. We were also a pilot hospital for CMS, when it was testing and developing the standardized claim attachment transaction (275). We were successful at the end of this pilot exchanging attachments electronically with Medicare.

Montefiore Medical Center was also one of the founding members of Linxus, which grew to include the three largest commercial national health plans (Aetna, United HealthCare, and WellPoint) plus seven major hospital systems and their faculty practice groups.

Through Linxus we participated in several work groups, where we have analyzed transactions in detail with an eye towards how we can increase automation and reduce the level of staff we depend upon in Revenue Cycle. The goal of each Linxus work group is to prioritize work with our health plans, because today the HIPAA transactions we exchange vary greatly by payer. This variation presents significant challenges to providers, such as Montefiore, to automate, because we have to account for each health plan’s unique way of implementing the standard transactions. We often refer to this level of variation in current standards as non-standard standards.

The main reason for this focus in Linxus was providing the ability for providers/hospitals to rely on the HIPAA transaction as the one source to drive the next work step. When an electronic response from a health plan is too vague, then we have to call the payer. By requiring the hospital to call the payer, we are unable to derive the cost efficiencies.

Ultimately, the vision at Montefiore is to create a NO-TOUCH revenue cycle, but the transactions are currently not yet specific enough or standardized enough for Montefiore to be able to do this. What we want is to automate work so that it minimizes manual labor and at the same time improves relations with our payers and, in particular, our patients. Linxus has been the vehicle to help make this happen for us. We believe, as Linxus does, that operating rules and standards must go through a standard process to prevent further delays in gaining the benefits of simplification.

It is now 13 years since HIPAA transactions have been established and yet there isn’t one payer or hospital that has in place all the transactions to reach the goals of administrative simplification. We are pleased to see that recent legislation has recognized the expediency of completing eligibility and claim status transactions. We must invigorate the vision through a committed partnership between providers and payers. Administrative simplification is in our grasp and the benefits will accrue to us all.