[This Transcipt is Unedited]
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
SUBCOMMITTEE ON STANDARDS
ADMINISTRATION SIMPLIFICATION UNDER THE
PATIENT PROTECTION AND AFFORDABLE CARE ACT
NATIONAL HEALTH PLAN IDENTIFIER AND
OPERATING RULES FOR ELIGIBILITY AND CLAIMS STATUS
July 21, 2010
Hamilton Crowne Plaza Almas Building
1315 K Street, NW
CASET Associates, Ltd.
Fairfax, Virginia 22030
P R O C E E D I N G S (8:43 a.m.)
Agenda Item: Welcome
DR. WARREN: Let’s get started with day 3 of our hearing on health plan ID and operating rules as we do with every one of these meetings, we start by introducing the staff and committee members. The committee members if you please tell us who you are and whether or not you have an conflicts with today.
I’m Judy Warren from the University of Kansas School of Nursing and have no conflicts.
DR. SUAREZ: I am Walter Suarez with Kaiser Permanente, and I have no conflicts.
DR. OVERHAGE: Good morning. Marc Overhage, Regenstrief Institute, Indiana Health Information Exchange, member of the committee, and I have no conflicts.
DR. FITZMAURICE: Michael Fitzmaurice, Agency for Health for Healthcare Research and Quality, liaison to the Full Committee, staff to the Subcommittee on Standards and the Subcommittee on Quality.
MR. HOUSTON: Good morning. John Houston, University of Pittsburgh, I am a member of NCVHS, chair of the Privacy, Confidentiality and Security Subcommittee. I have no conflicts.
DR. SORACE: Jim Sorace, ASPE, staff to the Subcommittee on Standards.
MS. DOO: Lorraine Doo, Office of eHealth Standards and Services at CMS. Lead staff to the committee and no conflicts.
DR. SCANLON: Bill Scanlon, National Health Policy, member of the committee, no conflicts.
DR. CARR: Justine Carr, Caritas Christi Health Care, chair of the committee, member of the subcommittee, no conflicts.
MS. TRUDEL: Karen Trudel, CMS, liaison to the committee and the subcommittee.
MS. AMATAYAKUL: Margret/A, Margret/A Consulting, contractor to the committee.
DR. WARREN: And again, we have quite a few people in attendance in the house, so please be sure that you sign in so that we can have your names for the minutes and can ensure transparency of the meetings. Do we have anybody on the telephone?
DR. GREEN: Larry Green’s here, in Denver, a member of the full committee.
DR. WARREN: Okay. So what we did was we took a look at everything that people did. So we followed the guidelines that we announced at the end of yesterdays meetings. We felt there was no need to change any of that agenda. So what you can tell from the published agenda is it has us until 10:00 o’clock called committee discussion. So that’s what we’re going to do. Our discussion is going to be about the health plan identifier and what we need to put together and want to use all of your expertise, those of you who are in attendance, to help us come up with some use cases so that we can really figure out how this identifier is going to be used.
For those of you who want to kind of track along, Margaret Weiker in her presentation Monday, in the back of her presentation, she has a listing of all the slots in the X-12 standards where the identifier would go. So that will help some people.
And then we had four people that got together last night and produced some slides trying to get a handle on terminology and where we’re using the words right, and their best ideas where some of these identifier might be used. And so they very nicely put together a set of slides. So, Karen Trudel and I have looked at those slides and decided that would be probably the best jumping off point for us to have to open our discussion about the use cases. And then Margaret has some of her wonderful tables, that as we talk about use cases, she’s going to be filling those in. So why don’t we go ahead and start and have you do the slides, and I think that will get us going well.
DR. SUAREZ: While you are getting ready I just wanted to make a couple of comments, if I may, Judy. I think we have several elements about the NCI that we need to define, several aspects, or features if you will. And so we will have to think in terms of several things. Of course, the scenarios that we’re going to look at are going to help us define one of those characteristics, and perhaps some more. But some of the characteristics I was noting as I was listening to the testimony was, of course, what is the actual standard itself, the number itself? We heard a number of consistent recommendations around it, and a few other ideas. Who is going to be eligible? Who’s going to qualify to obtain a number? There is that issue. What kind of entities will qualify to become enumerated?
And then, of course, the question of what is the levels of enumeration that we would want to do, or recommend to be standardized. And what are other levels that might be optional or available? And the we have a whole host of other things like the enumeration process, the information that could be available through a central repository, the issues around the pharmacy and applicability, Medicare and Medicaid considerations about the number, and the dual-use issue of being able to, during the transition, potentially both the use of the number and health ID cards.
So I just wanted to highlight a few of the various aspects that we are going to have to consider in terms of recommendations. And certainly I hope that through theses discussions we will be able to point to those. Thank you.
MS. POWELL: Good morning. This is the starting point. I wanted to let you know who the four of us were that got together last night. We got together in a fairly ad hoc basis. But as we started talking we felt the need to really try to deconstruct the problem a little bit. And one of the — just as we started discussing amongst ourselves we found the biggest problem was the terminology. And as we reflected on the discussion on the health plan identifier the previous day, a lot of where we saw problems were places where people were using terms in different ways, or people were looking at different levels of information.
So what we tried to do was start with at least identifying what the different pockets or buckets of information are. So we may not agree on what we call them, but at least if we can identify what pieces of information need to be grouped together, that might help us then look at where we need to point these different numbers.
So I’m going to go back to the beginning. So what you see here — and this is just taking it down to its most basic form — is a list of the kinds of things that we believe collectively one would need to know as you start the encounter. And again, you’ll notice that the names are bracketed because we weren’t trying to assign specific terms yet. We understand that different terms may be interpreted differently among different segments. And we’re not suggesting that these do or don’t need to be enumerated just yet. We just wanted to show where there were differences in things that you would need to know.
So first there’s the need to understand, there’s the entity itself. And that can take different forms, but generally there’s that larger entity. But then going below that, then there’s a need to distinguish between whether it’s medical, whether it’s property and casualty, whether it’s worker’s comp. So one term might be line of business, it might be market segment, but at some level you need to understand the difference in that in order to know how to process the claim, because it would be different depending on the segment.
Then there’s the need to understand what type of product it is; not the specific product, but the type. Is it an HMO, is it a PPO, is it indemnity, or is it something else? But again, just what type it is. Then below that there’s a need to understand, not just is it a PPO, but which level of PPO is it? It’s not enough just to know it’s a PPO; you’ve got to know specifically which PPO product it is because the benefits might be different and the network might be different. So you need to understand at the product level.
We also talked about rental networks. That was one of the questions that we had, and given that within a particular PPO offering that might be offered by a national health plan, that in some parts of the country they might use their own network, but in some other parts of the country they might need to rent the network out. So how do you distinguish that? So knowing that rental network, in some cases, would be important.
Then there are some other pieces of information that we wanted to clarify. So one term that tended to be confusing is you’d hear the term benefit plan, and that gets confusing because the question is what’s the significance of that? Are you actually talking about delineating what the product is? Are you actually concerned about what the content is, what the substance is, what’s the deductible, what’s the co-pay itself? So we thought we needed to clearly define the name of the product versus the benefits, the attributes of that product, which we call benefits. Again, some consideration needs to be given to the names themselves. But the point is those are two different distinct kinds of information that would be needed in order to know how to work with that patient.
There’s also the employer group, which in some cases might be necessary. Now at least in our informal discussions it seemed that if you have some of these other pieces it might now be as important to know that, but we know that’s been something that’s been put on the table. There’s also been discussion about perhaps having information on the contract. There’s been discussion about having information on funding and fee schedule. Now, we weren’t able to get that far in our work, but we sort of started at the highest level and where we knew that we had agreement.
MS. DOO: Susanne, can I just ask, under the line of business — just so that I can get it out of my head — does that also include pharmacy?
MS. POWELL: That is a good question and I thought about that last night after we talked and we were putting that together. And I think I would sort of put that open to the group, because in some cases — Maybe I’d even ask Debbie — I mean in some cases when we look at — we have to think about it from the payer’s perspective. And when the payer’s processing the claim, would they have a different set of processes for a pharmacy versus the way they would process a workers comp claim or a medical claim? And I think they would.
MS. DOO: Okay. So then that would need to be separated out.
(comment off microphone by Debbie Meisner)
MS. POWELL: It is all about what they have to do within their systems. That’s the distinction.
(further discussion off microphone)
DR. WARREN: Maybe for clarity we need to add pharmacy up there, as well as dental.
DR. SUAREZ: I have another question, and that is the hierarchical relationship between these boxes.
MS. POWELL: There is none. That’s why they’re separate boxes.
DR. SUAREZ: I see that there are no lines. But I just wanted to see, because there are some possible lines, of course, between them. So there is the entity, which is in one or more lines of business. And within the line of business there might be product types. And within the product type, there might be specific product categories — up to that point, then the others ones kind of break. I don’t know that the product category has specific networks or maybe the product type has specific networks.
DR. WARREN: Does anyone have any other questions just about how we divided the lines?
MS. DOO: Then the only other question, in the benefit, is that where the HSAs and other payment programs go?
DR. WARREN: No.
MS. DOO: Okay. I just wanted to make sure I understood. Thank you.
MS. DARST: We’re trying to put our definitions behind because things were being discussed very differently yesterday, so.
MS. GREENBERG: First of all, thank you. We always are looking for ways to expand this committee, so we appreciate it. I wondered if you made any reference in your efforts here to look at the Source of Payment Typology that the Public Health Data Standards Consortium brought forward. I don’t know if you were here when that was presented. I’m trying to look at that against this. So where does Medicare go, under entity?
MS. POWELL: We had a lot of discussion about that very question. And so where we landed was that it really depends on the circumstance. If it were the case of Medicare Part A, you have an intermediary, which might be a Blue plan, so that would be the entity. So that entity might be Blue Cross Blue Shield of South Carolina — that may not be accurate. That would be your entity, but then it would really be down either at the product level that you would identify that it was Medicare. So you’d have Blue Cross, you’d have medical, and then under product type you’d have Medicare Part A.
MS. GREENBERG: When people are looking at high level trying to make comparisons among payers, a distinction like Medicare, Medicaid, governmental, these are sort of critical high level distinctions. So I guess that gets into the issue of hierarchy, but okay, fine. Thank you.
MS. POWELL: The challenge came in some cases you have the government who’s actually making the payment directly, like in the case of Medicaid. In some cases the state makes the payment. In other cases, in a Medicaid managed care organization it would be that entity. So that’s why at least drawing the lines, even if they don’t all line up as clear that we know what we’re talking about.
DR. OVERHAGE: Not being a payment side person, thinking about this from the provider perspective and being a inveterate lumper, it seems to me that we’re convoluting two concepts here. One is who are the entities? Who do I need to ask, Blue Cross Blue Shield of Virginia, or Medicare, whoever it might be? And then most of the things that are up here are it seems to me information we should be sending back from the plan in response to a specific query. In other words, most of this is description of a benefit design, which as we’re hearing in the discussion is a very complicated set of issues.
It seems to me that the complexity of how a health plan has decided to construct their benefits and so on with the employers ought to be a black box to the rest of the word. Now clearly we need some of these terminologies to describe. This is a visit for a vision encounter; is there coverage or not? It’s obviously a very different question if it’s a claim for a pharmacy service or something. Likewise, you want to get back information about how much of the patient’s deductible has been met. It seems to me that is a separate thing. That’s why I want to step back. So I’m worried a little bit that we’re convoluting the entity and the benefit design into one thing, which I think is risky.
MS. POWELL: The interesting thing about your question is the reality is we have to deal with both. But you’re absolutely right in the point that you’re making.
DR. OVERHAGE: I don’t know that you — well, you have to deal with both, but putting them together doesn’t make it easier to deal with them.
MS. DARST: I think – what is the information that the provider needs to have so they can communicate to the patient? You know, they don’t need to know all the details of your benefit design with the employer, but they need to know enough information to know how to interact with that patient.
MS. POWELL: I’m seeing heads that you don’t need to know that.
(comment off table)
DR. OVERHAGE: The provider can’t know that.
(comment off table)
DR. OVERHAGE: No, if that’s the assumption we are way off the — it’s not feasible.
(comment off table)
MS. MEISNER: This slide is not trying to say whether these need to be part of the enumeration. These were things that were thrown around yesterday. These were terms and concepts that were brought up yesterday. In some places it was saying that it needed to be part of the enumeration. I believe the AMA is looking for those other things — the contract, the funding, and the fee schedule — to be part of the enumeration process.
We’re not saying on this slide whether it should or shouldn’t be. We’re just trying to lay out the terms, because as four of us sat at the table and talked about this — and it happened in another meeting that we had — when I say line of business that means medical, dental, pharmacy. Other people think of it as property, casualty, group health. So we needed to come to terms to say when we’re saying line of business, what do we mean? So that box that we’ve got line of business or market segment is going to be different depending on who the organization is.
But for our discussions, to be able to make sense of what we’re doing, we have to agree on a term that in this room when we’re talking about this, when we say line of business we mean what’s in that box, just so that we can have a conversation without getting into, well that’s not what I consider that. Let’s forget what we consider it at home and say for these discussions, when we’re talking about this, this is what we mean. And then that will help facilitate.
This was not trying to say this is how it should be enumerated, that these even should be in the enumeration, or they must be in it. It’s just trying to lay out what are we talking about when we say a network? What are we talking about when we say benefits? That’s the deductible, the co-insurance, the HSA, the FSA, whatever benefit information that you need to know in order to collect from the patient.
DR. WARREN: And for that we applaud it. What I just want to do is read from the law that defines a health plan includes the following singly or in combination — you’ll see all of these things mentioned: a group health plan, a health insurance issuer, and HMO, Parts A, B, or C of Medicare, the Medicaid program, the issuer of a Medicaid supplemental policy, the issuer of a long-term health care policy, employee welfare benefit plans, a health care program for active military personnel, the Veteran’s health care plan, also CHAMPUS, the Indian Health Service, and the Federal Employees Health Benefit Plan. So we’ve got a whole bunch of folks.
MS. GREENBERG: What are you reading from, Judy?
DR. WARREN: This is the briefing packet we have. And this is a direct quote of legislation.
MS. GREENBERG: Okay. All of those categories that you mentioned are also in this payer typology. So I’m trying to figure out how this —
DR. WARREN: I know. And that is kind of our task for today is to figure out what all of these words mean and how they’re related.
MS. AMATAYAKUL: I had two questions. Also, the definition of health plan varies from the statute to the regulation and has three additional things, including that group health plan we were talking about.
My first question I hope is simple. Where do the vendors like the clearinghouses, TPAs, repricers, and so forth, where do they go on this diagram?
MS. MEISNER: The TPAs would be in — it depends on the role the TPA is playing. If they’re playing the role of a rental network and doing the pricing, that would be in that rental network box. If they are actually the adjudicator, they would be in the entity box where it’s Aetna, Cigna, United, Blue Cross Blue Shield. Clearinghouse, in my opinion, doesn’t belong in this discussion because clearinghouse is just an intermediary in the middle that would be in the enveloping, because I’m Dr. Meisner to Embion, and inside that it says please forward this on to Aetna.
DR. WARREN: So we should probably have a use case about clearinghouse that says that they’re just passing —
MS. MEISNER: They would have nothing to do with the payer health plan identifier.
DR. SUAREZ: The issue is really the clearinghouse is not within the definition of a health plan.
DR. WARREN: No, but clearinghouse is talked about all over the place, and I want to be sure we understand where all of this fits.
MS. MEISER: They would be a trading partner.
MS. DARST: We see them just as the mailman.
MS. MEISER: Just as the mailman.
MS. DARST: A very important mailman.
MS. AMATAYAKUL: The second question I guess is probably a little controversial, sort of in line with the earlier discussion in terms of the entity. And when you said Medicare and Medicaid were the product types or categories, I can understand that there are health plan entities that provide those products. But Medicare and Medicaid are listed as health plans in the law. And so I’m not sure — I’m still fuzzy on the entity versus product distinction if you could help me there.
MS. DARST: I will try and answer that one. When we look at let’s say Medicaid, absolutely Medicaid — so I’m going to use Minnesota since that’s where I’m from. There are some situations that the State of Minnesota will pay the claim. There’s probably three-quarters of the time that they have delegated that to managed care companies. So in those situations where the State is playing the claim, they would indeed be the entity; it would be State of Minnesota. Otherwise it would be those managed care plans.
When we talk about Medicare, there isn’t this government entity that is paying all of those claims. It has been, again, outsourced to individual payers. That’s where we need to send the claims. It’s those rules that we need to understand. So that’s where we didn’t have Medicare B distinguished entity.
DR. WARREN: Are you thru Margaret?
MS. AMATAYAKUL: Yes. Thank you.
DR. W. SCALON: I think this follows on what Marc was starting. The issue is what do we need to know here to know everything else. And I think that it’s key that we know the entity. And then I think what we need to be focusing on is defining the product. And what you’ve got under specific product is probably the start of it, but I think it needs to be sort of more detailed. And if the product is a function of who’s paying the entity to do this, which could have be an employer, like Ford, it could be the Medicare program, it could be Medicaid, or it could be that the entity is offering individual insurance. And so that’s one part of it.
The second part of it is the benefit structure that’s involved. A third part of it, which is important even when benefit structures are constant, but is important for oversight, is what’s the population of people that are eligible for this product? Even though an insurer can offer an individual insurance product, they may not sell it to everybody. They may sell it to segments of the population, and we need to know that.
So it’s expanding that specific product list is the important thing.
MS. POWELL: The next slide shows that.
DR. W. SCANLON: Okay. As opposed to things like product type, which I’m not sure has become meaningful in today’s world. PPOs are very swishy. HMOs have become very swishy, you know, indemnity. And so it’s kind of like rather than focus on those kinds of things, I think we need to focus on the product type.
MS. POWELL: Actually I think we concluded that as well when we were looking at thoughts around enumeration.
MS. DARST: Actually that is what Jim Wicker and myself had testified as to what we’re really needing — although we didn’t want to get to that on this slide — is that specific product. And we only contract with maybe a few of the product lines under a certain payer, not necessarily all of them. So it is important for us to get to that product line. But that’s, that was part of our testimony. We’re just trying to keep this generic.
DR. POWELL: In this first slide we tried to just take a very generic example —
DR. WARREN: Excuse me. Excuse me. Karen’s next.
MS. TRUDEL: I just wanted to raise a little wrinkle that I happen to know about because it’s a Medicare wrinkle. And that is that while the MACs actually adjudicate our claims, our eligibility system is centralized and it’s run by CMS. So, I can’t imagine that we’re the only plan that outsources some things and keeps other centrally. So I’m not sure how that works in this model.
MS. MEISNER: I think when we get to the last slide that what we’re trying to do here is get the terms. So we’re all jumping back down into how are we going to use them. And we’re just trying to say where the brackets are. What do we want to call that entity that’s the Aetna, the Cigna, the Medicaid that’s paying — what do we want to call that? Is that the payer? Is that the adjudicator? Is that the information source? What do we think that high level being is? And what do we think the medical/property/casualty/workers comp, what do we want to call that? Do we want to call that line of business for this conversation? Is there a better term that we could use to represent that piece of information?
That’s what this conversation is right now is to just try to — and these are examples. They are not all-inclusive. They’re just kind of examples of what they are.
MS. DARST: Given our limited time that we really had to work on it.
MS. GREENBERG: It is the people who put forward proposals who get attacked, of course. But we’re not attacking you at all. And I would just say if this were easy we would have solved this a long time ago. And that goes without saying.
But just following up a bit on what Marc and then Bill and Karen were all saying, I think there are a lot of different questions here. But sort of the ultimate public policy question has always been — and a very hard one to answer — is what was the source of payment. That was the term that was always used. I don’t know if it’s really a term that’s used much anymore. But that’s where we get to what Karen is saying. The source of the funding is Medicare. And so it’s the source of payment.
There’s this other more practical question that I think needs — obviously the provider needs to have information on, and that is who is responsible here from the point-of-view of my getting paid? So, you’re not going to call up 1-800-Medicare as a Medicare beneficiary. You’re going to call whoever your intermediary is, or your — you know, Aetna, whatever. So obviously that information needs to be known or you’re not going anywhere. Who am I sending this claim to? These are important questions, but I think the ultimate public policy question is: what is the source of payment? And so, if it’s Medicare, it is Medicare and it can’t be buried somewhere. I think you need to know that.
DR. OVERHAGE: I have a question or a comment about that, which is that in the world where I had to pick up the telephone that might be true. But in an electronic world, it shouldn’t be true. You should send it to 1-800-Call Medicare and Medicare should give it to whoever the right intermediary is for that beneficiary.
MS. GREENBERG: Right. That may be true, but I’m —
DR. OVERHAGE: The analogy — but part of what I was trying to say, though, is I think one of the things that I hear a lot of, putting a lot of complexity into the clinician practice, which is the least ready to manage that. So I’m trying to push any complexity to the people who are getting paid for what they’re doing and who have to weigh the complexity of what they create.
DR. W. SCANLON: I think if we define the products, we’re going to know the source of payment. It’s going to be a Medicare Advantage Plan, or it’s going to be Medicare Fee for Service. When I think of the identifier, I’m looking for the minimum information that gives me everything else. And I think that we can get it if we focus. And we need the address to where the claim goes, and so the entity is important. But beyond that, I think it’s the issue of what is the particular product we’re talking about.
DR. WARREN: Can I put it more simply? What we’re really interested in is who is paying and what are they paying for. Is that what we are trying to grapple with?
DR. W. SCANLON: Who is paying? What they are paying for? And for whom they’re paying? That’s the other part. There is the issue of the beneficiary —
MS. DARST: Can I add to that? What is the relationship of who’s paying with the provider? Without that relationship, we don’t even know if the patient shouldn’t even be at our facility. So we need to know: is this Aetna’s? We need to know if it’s Aetna’s. Is it their PPO gold product? Then I as a provider can figure out, do I have a contract. I know which one of those PPO products I have contracts with. If I don’t have a contract, I need to let the patient know you’re out of network and your benefits are reduced, or you will have no coverage at all. So it isn’t just that information. We need to be able to figure out the relationship between the payer and the provider, which is what we don’t have today.
DR. OVERHAGE: I continue to push on this, but the payer also knows whether they have a contract with you as a provider. They know if you’re in the PPO. So why should you figure that out instead of the payer saying this patient is seeing you, they’re not — you know here is the benefit under which you can see them. And it may be none.
MS. DARST: I did poll a couple of our payers; that’s a logical question. The majority of the payers I talked to said — in fact all of them said we don’t go back to our provider files. This is a relationship between the patient and the plan, not between the patient, plan, and provider. And what our recommendation is — or at least from the Mayo perspective — is if you give us enough information, we can figure it out without having the payer have to go and do that additional infrastructure to do that. I mean, that would be ideal, but —
DR. OVERHAGE: And again a small practice doesn’t have that infrastructure and that’s where 80 percent of the care is delivered.
MS. MEISNER: But I would like to just add to that, so keeping in mind that eligibility issues are a real-time transaction, and if they’ve got to ping multiple databases, you’re going to slow down that response. Having been a payer at one point, I know that the relationship with the provider to the plan is in my provider file. Where the relationship of the patient to a plan is in my eligibility file, and the eligibility file is what you’re pinging more than likely.
DR. OVERHAGE: That’s the whole problem.
MS. MEISNER: Well, so until you get into the actually adjudication process and marry those two things together, you don’t have that full picture. And so it’s kind of a catch-22. If the provider knows who they’re contracted with and has a list of — I’m contracted with PPO gold and bronze, and so if you come back as the payer and tell me it’s the PPO gold plan, I know I’m contracted in there. If you come back and say it’s the PPO silver, now I know I don’t have a contract with the PPO silver and I can have that conversation with the patient. I’ve been hanging around with the provider side too long.
DR. SUAREZ: I just want to emphasize that there is a series of elements that we’re trying to address here, not just — I mean not just who is paying, what are they paying for, for whom they are paying, what is the relationship between the patient and the provider. And then there’s other information that can be derived from being able to point to the right place, which includes things like deductible, co-pays, and other things that the provider also wants to know at the point of delivery of care.
So there is some information that helps us with a single number point to the exact right place. And then once in there, there is other information that can be derived by being in the right place.
MS. DARST: And that’s the eligibility transaction. So we have that. Again, we are kind of jumping ahead a little bit. We’re looking for that missing piece that’s just not there, and that’s the provider and health plan relationship.
DR. WARREN: Why don’t we go to the next slide.
MS. MEISNER: This slide simply does start to show some relationship between each of the pieces. So we just took a very simple example, we have a national payer. We go down to their health business. Again, HMO, PPO, and indemnity, and I think what we’re hearing and concluding is that middle level may not be terribly important, but we do need to get down to what’s below that. Then we get down to the product level. Say with a PPO you may have a gold and a silver option. And then within that gold option there may be multiple networks that might be rented out.
So potentially in order for the provider to be able to work with that patient, they may need to go all the way down at least to that network level, if not further. What we tried to do is to determine what was the minimum amount of information they might need, and what’s the best way for them to get it, in order to work with that patient at the time that they come in.
So this next slide we’re going to need to explain. So one of the disconnects that I had was thinking that at that very high level, and in the eligibility request that would be your information source, if we were going to be replacing that number, there’s a lot of work that would need to be done. I’m not saying if it’s the best thing to do, it shouldn’t be done. But touching that number at the high level, there are a lot of things around one number identifying Aetna as on organization, or Blue Cross of North Carolina as an organization. From the editing, from the enrollment process, providers have to enroll to send with a lot of payers. Would we have to redo all of that? And when I think of all of that, that scares the heck out of me that we could get that done by the time frame, at every desktop that would have to be touched and handled.
So you’ve got the entity known as the source. And then, again, it could collapse and get down to I am Aetna paying the HMO Medicare Advantage Plan, or I’m Aetna paying my PPO gold using this rental network. And they could be three distinct data elements, still enumerated in the same manner so that you’ve got one enumeration system they would all apply.
So I know Sagamore is a rental network that a lot of the national employers use as they go through the plans. A lot of the commercial payers rent those in areas that they’ve got national employers. So, Sagamore could be associated with Aetna, and it could also be associated with Cigna. Well, we don’t want to see Sagamore as two different numbers; we want to know Sagamore is Sagamore, that rental network 1 is rental network 1, regardless of what payer they’re associated with. So to me it’s a different data element.
So the analogy that finally worked for me is the national provider ID. If you look at the top one there would be Mayo Clinic, and by the time you get down to that rental network there’s a completely different data element within the transaction. That would be your individual rendering provider. There are two different data elements within the transaction, but enumerated by the same process.
So those three numbers that were showing — and this is a simple example; we did not try to find every example. We’re just saying it’s the same numbering system. Aetna might not be responsible, or the national payer up at the top might not be responsible for enumerating rental network one. Rental network one would go get themselves enumerated, but when they return the eligibility transaction, they would need to tell Mayo Clinic that it’s rental network 1 in a complete discreet, separate data element.
That’s when it clicked for me that this was okay and we got to a better place. So on this one we’re kind of just really high level saying — and these are not the right qualifiers; we didn’t have the time to do that sitting at the restaurant on a paper napkin I didn’t have the transaction with me at the time.
So your information source would be whatever you consider that payer plan ID to be. And that might be the Medicare, if that’s who — if it’s the Medicare central system that you do your eligibility through, that’s the payer’s source ID. The subscriber or patient has a reference number in it that you could include all of these reference number with the — and actually those two exist already, where you could say and here’s the products plan ID that’s been enumerated, and here’s the network plan ID that’s been enumerated.
In some of the other information — and we certainly did not have time to research it — there is a place for a contract number, and there is a place for all of the benefit information to go in that could actually carry the information that’s being asked for by some of the providers, and not necessarily in that enumeration process.
DR. SUZAREZ: This is very good to understand. In this case, in my mind, is different than with an NPI where one would hope that you would be submitted the lowest granular level in terms of say place of service and things like that. Here, even if you send the lowest granular level let’s say, which is network plan, you still need to send a product plan, because a network plan doesn’t tell you specifically which product they belong to.
MS. MEISNER: Think of it more as the type I is your organization there, and then all of these other thing are components of that organization, but not necessarily type. So the individual rendering provider number is not a subpart of the billing provider. It’s another number unto itself. Both issued by NPES, but a separate number. And that’s where it clicked for me when we started —
MS. DARST: And we were using the analogy, again, with NPI. Let’s say that we have a rendering physician that works at Mayo Clinic, but he moonlights at the University of Minnesota. It would look different. So if it’s Mayo Clinic asking us for the rendering provider, it’s going to look one way. But if it were the University of Minnesota, same position or same network here, it would just look different. And that distinction is important.
DR. WARREN: Do we have anybody in the audience from Blue Cross Blue Shield or any of the other health plans? Can you come up to one of the microphones up there? And I’d like to hear a response to what they’re talking about with the three numbers.
MR. FISHER: My name is Greg Fisher, United Healthcare.
MR. KELLY: John Kelly, Harvard Pilgrim Healthcare.
MS. KOCHER: Gail Kocher, Blue Cross Blue Shield Association.
MR. FISHER: I think there are a couple of things. One is, I appreciate the work that’s being done. I think it’s very educational. I think that’s where we should be going, educating ourselves on what the requirements are and what the relationships are. And I think we should go a little further in two areas. One is, what can the transaction actually hold? If we invent something that doesn’t fit the transaction, it doesn’t matter what our definitions are. You can create a whole bunch of definitions, but if they don’t fit in the X12 transaction, we’re sunk.
Secondly, we need to understand in the real world what can be done and can’t be done. I’ll just give you an example of the real world right here. We don’t know the network when we get the eligibility transaction. We don’t know what network we’re going to use. That’s not known until the adjudication time. So, while we think it’s a great idea to know the network, and identify the network, and enumerate the network, you can’t put it on the 271. So the issue is, you know, decide what the definitions are, what your transaction can hold, and then support it.
And one more thing: if you decide for instance to create a definition — any definition — then you look at the transaction, the transaction can help you with relationships. I can take this definition and I can associate it with a product, associate it with a contract, associate it with funding source, associate it with administrative. So there’s the associations can actually be done in the transaction. The associations don’t have to be done in the number.
MR. KELLY: I’d like to say a couple of things. One, with regard to network, when it says rental network up here, does rental networks apply to the network contracts that we would use to actually reimburse the provider, what fee schedule we use. That is not the same as the network the patient is in. That’s two completely different concepts.
So, when it comes to what is available in the 270 and 271, ironically I’m going to cross over a little bit here, but this is exactly where operating rules come in. Right now people say stuff doesn’t come back in 271. Well, a providers sends in a type 30 270 request, which means what are the benefits for this patient. If the provider was to send in a request that said this patient wants to see me for an office visit consultation for cardiology, then I would be able to respond, or should be able to if the operating rules mandated that I did make that available. Then I should be able to respond to the provider for this service, for this patient, on that day, yes, this patient is in network for you.
Now that would be different at the end of the day about which network contract I apply to that when the claim is actually presented. But as far as saying are they in network or out of network so the physician can respond to the doctor, that information could be and should be all available in 271.
MS. DARST: I think that is our issue, John, is that’s not communicated today — I mean, that relationship.
MR. KELLY: Absolutely. But I guess what I’m saying is it’s confounding this conversation about enumeration to talk about product plan ID or network plan ID, to make a part of the enumeration rather than to say straight — to use binary, yes/no — they’re covered or they’re not, for you to see this patient on this date for that visit. That’s really what you need to know if you’re talking about having a conversation with the patient about whether they’re in or out of network.
Now, when I pay you, should I be able to tell you and give you some kind of fee schedule ID or something on the 835 that says here’s the network contract that I used when I paid you, to that you know what to put in your AR system and that you can reconcile appropriately and automated. That is perfectly reasonable.
Again, I’m not trying to say that we are providing you with all of this information today. There’s a lot of information that you need that we could have, and that we should provide. And we’re not doing that. But I don’t think that putting it in here is the way to do it. Now, what I will say is —
DR. SUAREZ: I’m sorry when you say “putting it in here” what do you specifically mean?
MR. KELLY: Creating the network plan ID as part of the payer enumeration scheme is a lot different than saying here’s a fee schedule ID, or here’s a contract ID and this is the ID that I’m paying you and put that in the 835 so it could be auto-posted basically when it came back. As Greg said, I don’t know what that ID is at the point of visit when the patient presents in. I might know, in certain products I might know —
DR. WARREN: One, they have not proposed to create a network plan ID. All we’re trying to do is — because I didn’t even know about rental networks until Monday. What we’re trying to do is clarify the words so that we know what we’re talking about. I mean, we’re in a taxonomy/terminology exercise here, without looking at how they’re used yet. Because I do think that we’ve started putting too much into the conversation before we have clarity. And once we have clarity, what we mean by the words, then I think we can get into some use cases, which you’re already beginning to uncover some very interesting use cases about what needs to go in these cases, et cetera. And then at some point this morning I plan to call Margaret to make sure that these things fit in the slot of X12. So I’m not even worried yet about does it fit with X12; let’s wait until we’re further in the conversation and then find that out. I just want to be sure we’re all talking on the same page.
MR. KELLY: I agree. I should not be implying that that’s where this is going. What I really want to address though, is that this typology, you will find a lot of payers that might disagree with this typology, not because in all cases it’s wrong. But as one of the members of the committee said, you know, the definition of these products is changing constantly in this market. I’m in a small plan and I’m releasing 10, 15 brand new products every year. I have no idea about Greg or the Association. But I will say this: if this committee moves in the direction where all of that stuff is enumerated, I have hundreds of thousands of dollars worth of algorithms in my organization that deal with this. If you want to push that on other providers and have them fill in all of these numbers and solve my headache, go for it.
DR. SUAREZ: Thank you. That’s very good.
MS. MEISNER: Just to respond to that if I could. This was just one example, and we did struggle with this because we do know that there’s — it’s not a one to one. It’s not as linear as we’re showing it here. This was just to kind of represent the simple, simple, simple relationships. And the need that I heard from the providers was when you’re talking about rental network 1 and Aetna, I need to know that that’s rental network 1 when I’m talking to Cigna, because my contract is with Sagamore Health. And so as a rental network, when they rent that network to one of the other providers automatically in that network, they need to be able to identify that it’s that network and that I do have a contract with them.
So there was a need to get a standardized way of recognizing those rental networks and recognizing some of the product offerings across the different organizations. And this is very simplistic, and we understood that.
MS. DARST: I just want to make my comment to John. John, I understand what you’re saying and we would love to have that. The reason we came forward with this is we desperately need the information and the payers that I have talked to said it would cost hundreds of thousands of dollars. We said, we know who we contract with. If you can give us enough information this seems to be the easiest path to go — and I would even especially point out that product line. We can figure it out from there and we can serve our patients and subscribers better. So we were trying to go the easiest path. The information is the critical part.
DR. WARREN: Do you have a comment?
MS. KOCHER: With 39 different plans that do business 39 different ways in some cases, I share a lot of the concerns that John and Greg have shared. Judy, I really like that you were taking us back to let’s go back and just do the definitions with trying to not get wrapped up into — I get a little concerned with the hierarchical view, because with MPI we found a lot of difficulty in an embedded hierarchical approach with no relationships built into a database. And at the end of the day those relationships are really built based out of the provider and payer systems as they coordinate and didn’t necessarily need to be in that system. So I’m not sure we even want to consider the hierarchical approach. I think we need to go back and do the definition, and then do what you suggested, and let’s look at what can we accommodate, because we don’t want to break the transaction I don’t think either.
DR. W. SCANLON: Since I only heard about rental networks on Monday too, I guess I’m wondering if we really shouldn’t really have PPO copper here. You can’t be selling a gold product in my mind and have to different networks.
MS. MEISNER: Yes, you can.
DR. W. SCANLON: Well, you shouldn’t be because if I’m on the buying side I’m concerned about that.
MS. MEISNER: For example, with a national company — let’s use Home Depot. Home Depot wants to offer their employees a PPO. They go with — we’ll use ABC Insurance Company. ABC Insurance Company owns a couple of PPO networks in two or three major cities, but they don’t have networks in all the little remote cities where their employees are. And so they will hook up with a network, a PPO — it’s a standalone PPO. And that’s what they do. They reprice the claims, they have the relationships with the provider, and they sell their network to insurance companies who want to have national employees, but they don’t have networks in all of the cities where their employees live.
DR. W. SCANLON: I understand that. We’re not talking about local markets here.
DR. OVERHAGE: This brief comment gets back a little bit to our discussion yesterday about representation. And we’re hearing a lot of comments from very sophisticated provider organizations. And when you go to the two-physician practice, it’s a whole different world. And that’s where 80 percent of the care is delivered.
DR. SUAREZ: The comment I want to make is really about the difference of what information can be placed in the eligibility transaction, versus later in a claim, versus later in an 835. I think we might by trying to think of everything goes in every place, and it doesn’t necessarily work that way. So, at the point of care I see a patient, the patient comes in and I know a number of things about the patient, but I know that they have perhaps a card, or they have something that identifies the patient enrolled in some plan.
And if we have some level of enumeration, that identifier that says the patient’s enrolled in the PPO gold at that level. Trying to ascertain more information about exactly which things like rental networks or even lower levels, at that point — this is my question I guess: It might not be so much necessary as to the fact that I at least know the name and ID of that person, enrollee, dependent, whatever in a plan and the PPO gold. And I can now send that information into eligibility so that the payer can then say, yeah, this is this person and he is enrolled in this PPO product. I have all of that information that they are assigned to this particular network. Then I can tell the provider that submitted that inquiry of eligibility that, yeah, they are in that network, or no they are in an out-of-network situation. I just wanted to test that and make sure that if in eligibility that’s enough, then later in the claim processing and all that other information can be placed out of the payer sending back on a 271 more information. Is that-?
MS. DARST: As long as that relationship — I guess I go back to what John was saying — as long as that relationship between the payer and the provider is also reflected. Today it’s only the payer and the beneficiary. So we need to know if we can get that product line information. We need to know is the patient at the right place, because a lot of times they don’t know if they’re at the right place. That’s what we don’t have today.
DR. SUAREZ: Is that something that gets reflected with additional information in the 270?
MS. DARST: No. Usually it will be a rejection on the back end or a reduced reimbursement or something, which creates lots of phone calls. We need to know up front, and it gets — again, we don’t want to solve it here. The two avenues are maybe enumeration or it does indicate a lot of money on the payer’s part to try to tap into their provider enrollment system to give us that kind of information. So, one of the two options we need to take a look at.
DR. WARREN: Can you put your first slide back up? Okay. So what I’d like to do now is kind of push us into trying to create some use cases. But before we do that, is everybody comfortable that when we do the use cases we use these names: entity, product type, line of business, specific product, rental network, benefits, employer group? We may decide later to change those words.
MS. MEISNER: I would like a different word for entity. It seems too generic for that box up there. That would be my suggestion. But we didn’t want to put payer up there. We didn’t want to put — I mean, I’m okay — that could be the source, information source. Who’s going to supply this information? Who are you sending this eligibility transaction or claim to?
DR. WARREN: I want to be careful, because in X12 they have a slot called information source name. And that’s what we’re trying to uncover, right, is what goes in that slot? So, if we call this information source, we’ve already closed out everything else. I’m not willing to come to closure yet.
DR. W. SCANLON: I might combine the product type and the employer group and eliminate PPO, HMO, and indemnity, and put in, you know, employer as a category, and individual as another category. And I think we’re mixing different types in what we have there now when we put Medicare, and PPO, and HMO.
MS. POWELL: Could we perhaps just eliminate that box and just have one that says product that simply lists the products themselves and doesn’t try to categorize them, place artificial categories on them that maybe aren’t as clear anymore?
DR. WARREN: Wait just a second. So the way I’m reading the boxes — back to step 1 — what’s in the colored bar is what we’re calling it. Below it is a definition by example of what we mean by the name. So don’t get hung up on the definition by example.
DR. W. SCANLON: Right, but I am saying that in terms of definitions under product type, that it’s not a consistent set.
DR. WARREN: I have a funny feeling it probably isn’t.
DR. W. SCANLON: Well, right. And I think we’ve got an issue that there’s a big distinction between self-insured, which the national plan we talked about would be a case of, okay, which is not subject to state rule, versus individual insurance or small group, which will be.
MS. MEISNER: That would be down in the funding, I would think.
DR. W. SCANLON: But we have got Medicare up there in the product type. We’re confusing —
MS. MEISNER: The reason Medicare was put in there is if you take a payer, like WPS was a good one that we were able to do because we know our WPS folks. But they have an indemnity line of business, a commercial line of business. They are also a Medicare FSA intermediary. They have a TRICARE business and they have a TRICARE for life business. So, those are product lines within their — it’s different based on the payer and how they’re structured. But initially you send it to WPS, and then they route it internally to whichever product they’re doing.
PARTICIPANT: My suggestion would be just as a person who’s done this a long time, leave the definitions the way they are, leave the little pieces the way they are now, discuss your X12 situation. If you’d like to combine them later and say, you know, it makes a lot of sense to combine three or four of these, do it later. Leave the definitions simple for now. Each categories kind of simple, and worry about the other things.
DR. WARREN: So are you suggesting that we haul Margaret up here? Okay, Margaret. Why don’t you go over there and sit next to John and use that microphone.
DR. CARR: Judy, before we begin, could we just state what are the problems we are solving this morning?
DR. WARREN: We are solving the problem of Congress –
DR. SUAREZ: Like I said in my introductory remark, there are a number of aspects of the plan ID that we have to address.
DR. CARR: Can we get really specific and say we’re trying to decide —
DR. SUAREZ: At this point we are trying to decide the types of categories for which a number will be issued. That’s the main issue we’re trying to address here.
DR. CARR: It would help me to say in the big picture, beginning with administrative simplification, we’re trying to make the experience of a patient going to an office — the experience of the patient, the provider, or the payer more efficient. And to do that we will fix this gap or —
DR. SUAREZ: The highest level – the key element we are trying to do is simplify and make more effective the processing of eligibility, to claim submission, to claim payment. The whole thing from the start, when a patient shows up at a clinic or a site, and is going to be taken care of. So we’re trying to address who the patient is, who is the payer, and what are the benefits that are eligible to be covered, and what me as the provider I’m going to expect to get.
DR. CARR: Also identifying crunch date. The crunch date is X, the gap is Y, and we are trying to address it with the following tools, which are the 271 or whatever they are.
DR. SUAREZ: Sure. So the current state is that there is a level of complexity in the processing that creates situations where the patient wasn’t supposed to be covered, or the coverage wasn’t supposed to be good enough and all of that.
DR. CARR: There is insufficient information. I just think we have to get back to very definable tasks. So, the information in the current is either insufficient or it comes too late.
DR. WARREN: The back office picks up the phone and calls and tries to find out. There’s an opportunity to automate that by having a plan identifier in the 270, 271 exchange.
DR. CARR: So we want it timely, and we want it at the beginning of the visit, not the end of the visit. And we want it to be sufficient for the provider to know as well as the patient.
DR. SUAREZ: And the payer. And it’s not just eligibility; it goes all the way to claim, because when I’m now ready to issue the claim, I have the information from eligibility that I can use about this patient, about this coverage, and about this service, and about who I need to send this claim to. And so it automates the whole process from eligibility. I just want to make sure that we see the whole EDI cycle from eligibility, to claim preparation and submission, to claim payment.
DR. CARR: I just think we need to identify this is the current state, this is the gap, this is what’s broken, and we’re focusing today on this gap and this broken thing. Our tools to use it are A, B, and C, and we will therefore, you know, do X, Y, and Z.
DR. WARREN: Margaret, we need to put formal words around that, which should probably go into the letter in our introduction. Okay, Karen?
MS. TRUDEL: I am just writing down some — following up on what Justine said — I’m trying to write down some questions that I heard that we’re trying to answer. So the first question is, is the patient at the right place? Another question is where do I send the transaction, whether it’s a claim or an eligibility query? How much are you going to pay me? What’s the patient going to owe? And how do I coordinate the benefits if there’s a secondary payer? So I think those are some of them.
DR. CARR: Right. And we were formally doing that on the back end. And we’re moving that to the front end; is that the idea?
MS. TRUDEL: Sometimes we weren’t doing it at all.
DR. CARR: Okay. So understanding which we weren’t doing at all and which we’re moving would just be helpful.
MS. MEISNER: I think there are two very high level problem statements. One is, today there is not a standard identifier for where do I send the transaction. And so what happens in a COB situation is if you send it to payer A and payer A has to cross it over to payer B, payer B may not know the number that you put in there, because they know that payer writing out the number.
So the first problem statement is we need to standardize that number. That was up at the very high level that we were talking about. Who am I sending the transaction to? And just in clarification, where you’re sending the eligibility transaction apparently — and this was an aha moment for me — may not be the same place that you’re going to send the claim transaction.
So standardizing that number is one thing. The existing number, a one-to-one match, if that’s all we did in the first phase of this, you would be accomplishing the COB problem solved.
And then the second problem is — I think you kind of said it — I’m talking to the patient and I need to know what do I tell the patient based on what I got back in an eligibility transaction. The providers need enough information coming back to know are you under contract with me. Are you out of your network and you should either not be seeing me or you’re going to have to pay a lot more money than you thought, and what are your out-of-pocket expenses that I can let you know right up front.
So, I think that’s what I’ve heard as the two problem statements.
DR. W. SCANLON: In addition to what Karen said in terms of the questions, I think it’s important to also keep in mind that one of the things that we have is the ex-post usage of this information. And the best example probably today is the Medicare advantage program. There’s a contract for every product, and that requires a net contract. And it’s the ability to sort of at the end of the day to aggregate the information to know whether or not those contracts are being fulfilled.
I don’t think we have to have that preeminent in our discussion, because I think that if we can answer these questions about the real-time encounter that Karen has posed, we will get to the point where we can also do the ex-post analysis that is needed by not just Medicare, but it’s going to be much more expensive in the future with the reforms or changes. But I think we shouldn’t forget it, because if we do decide we can sacrifice this, you have to ask about is it going to have an implication for this ex-post analysis.
MS. GREENBERG: Bill pretty much said what I was thinking, but I do think there’s a question about — and it may have to do more with process of enumeration and the database that’s associated with the number. But at the end of the day will the way that we enumerate allow us to aggregate data to answer some basic policy questions? I think if it doesn’t it will be a lost opportunity. So, as I said, I just think we should have that on our radar screen.
DR. WARREN: Okay. Does anybody in the back want to weigh in with any comment before we have Margaret do her thing? Okay, Margaret, do you want to tell us about the slots that need fixing?
MS. WEIKER: It depends on which transaction we’re talking about in regard to the slots.
DR. WARREN: Let’s talk about 270, 271.
MS. WEIKER: Okay. The 270, 271, which is the eligibility request and response, in the request, which is the 270 transaction, there is a slot for what’s called an information source. And that is usually the payer or the plan ID; it’s where I’m sending it to.
MS. DOO: Margaret, are any of those up there that?
WEIKER: It could be entity. In some instances it could be rental network, as I understand rental network.
DR. OVERHAGE: So what you just started to identify, it seems to me, is a set of options, which is one of the things that’s problematic in lots of places. And so I’d be curious on people’s thoughts about that. It could be A, or B, or C, or D. We’re saying it could be any one of three or four of those; that suddenly gets —
DR. WARREN: So what we may be talking about is identifying the granularity of what this plan ID number should be about. And it may not correlate to what we currently look at. It may have to encompass all of the optionality, or as Walter was just whispering in my ear and made kind of shiver, is it might go under the operating rules for the standard.
MS. WEIKER: That would make me shiver too.
DR. WARREN: Thank you. That makes me feel really good.
MS. DOO: Just to help Margaret, that’s sort of the point, is that the text in the standard is obtuse. So it can be the — and that’s where we are today is figuring out so what’s that number, because we don’t even know who it is.
MS. WEIKER: The standard will support the fact that, if you all say it’s an entity, if you all say it’s a rental network, if you all say it’s an employer group. So it comes back to there’s a slot in the standard to say who is the health plan? Now, that can be however you want to define it here, but the standard doesn’t say, oh, it’s an entity, or it’s a rental network, or it’s a —
DR. WARREN: But does your standard define specifically what a health plan is?
MS. MEISNER: Can I jump on that for a second? I think it will help you out. The information source definition is you use this to identify an entity by name and/or identification number. This is used to identify the eligibility or benefit information source, for example, insurance company, HMO, IPA, employer. Whoever is the source to be able to tell you when I’m eligible and what my benefits are.
MR. FISHER: I was going to add to that, we call it plan administrator — whoever is responsible for administrating the plan. And that usually, 99 percent of the time, is the insurance company. Sometimes it’s a TPA. Sometimes it’s the employer. But whoever holds the responsibility for that plan. And that’s the thing we normally call payer. We call the payer, you know, you’re administrating. And so the plan administrator normally is the insurance company or the employer, but can also be a TPA.
DR. WARREN: Okay, so if we go with plan administrator, then to me that says we’re talking about entity, product type, and rental network.
MR. KELLY: We are talking about who are you going to call, regardless of what you label it.
DR. WARREN: Right. And so if we say the administrator is who you’re going to call —
MR. KELLY: It’s who is responsible? The patient has someone that they call their plan, and on the card it says if you’re seeing this patient, call this thing. How they incorporate, how they enumerate it, how they’ve done it internally to service the patient, that’s what it is.
DR. WARREN: So when I think about my own healthcare, I have TRICARE Prime. They’re not going to call the military health administration to find out, and yet that’s the entity. They’re not going to call TRICARE Prime, which is the product, because there are other TRICARE products that have different eligibility and different payment. Okay? But I may be out of network, and so I have a rental network that’s going to cover me and step in. Do I have that right, or am I still way off base?
MS. POWELL: If you talk about TRICARE or any of those similar arrangements, they’re still going to be contacting whoever the intermediary is or the administrator. So the Blue plan or whoever it is that’s responsible is where the calls going to go. It will be whoever administers TRICARE for that region. There is no TRICARE office; it’s the plan that administers it, right? Is that right?
MS. MEISNER: Right. So, for example, if WPS is the administrator — if you were to put administrator in that green box, it depends on the role the entity is playing. It could play both. So a TPA could show up as the administrator, the TPA could show up as the repricer, the TPA could show up as a funding situation. A TPA could play many roles and wear many hats, which is why we’re trying to give examples and not concrete, because it is not the same for any given…. So if you took, for example, the Medicare Advantage also has a Medicare Advantage Plus or Gold or whatever. And if you want to pay a little extra, you don’t have to go to just the Medicare Advantage plan. So HealthSpring in Tennessee has two plans. It’s the Medicare Advantage plan, and then the Medicare Advantage Plus plan. So those two plans are administered by HealthSpring.
MS. AMATAYAKUL: I would just like to just clarify, is this in the 4010? And could you tell us if something’s different in the 5010 when you get there?
MS. WEIKER: I am just looking at the 5010 at this point because the 5010 will be the version that will be mandated when this goes live.
DR. SUAREZ: What we have is what is written in 5010 right now in terms of what should we put in there. And right now it’s very generic in terms of, you know, put the plan ID. So I don’t want to bring again the operating rules, because I don’t want to give you shivers. But I do think that we will have to think about, in the regulations of the NHPI, the specific instructions on what should be put in the different segments might need to be defined. I’m just throwing that out. Otherwise, we would have to write out operating rules.
DR. WEIKER: Or depending on how you enumerate, how you ultimately enumerate, it may be clear-cut, or it may not be.
DR. SUAREZ: I don’t necessarily see that it will be clear-cut, so it will be probably necessary to include in the regulations, in my mind, instructions on what it’s to go. So each of these 30-plus instances where health plan ID is to go, it will be better off to define it unequivocally.
MS. MEISNER: And, Walter, I just would like to clarify something with maybe Margaret on this, but it would seem to me that the operating rules couldn’t contradict what’s in the guide, and right now the guide says you have to use this once it’s mandated, and you have to use it in this place. So I would suggest that there might be either coupling it with 5020, fast-track 5020 a little bit if we have to change the rules. Or perhaps look at an emergency errata to fix the guides to do. But I don’t think we should box ourselves in to what the guides say.
DR. WARREN: Right. Lorraine.
MS. DOO: And so this is a question both for Debbie and perhaps Margaret. Given that there are three or four options in that field, then how does the provider know what to put there? Who gets enumerated, but how does the provider even know what to put since there’s three or four options for information source? How do they know who to ask?
MS. MEISNER: National ID card should help with that. You’ve identified the problem, and no matter how we enumerate this, that problem’s not going to get solved.
DR. WARREN: Let me propose this: what I’d like to do is try to walk through one use case, and then for us to take a break. Everybody think about what else we need to do. But I think the use case to me that is probably the most compelling is the one that Marc keeps coming back to. And so we’ll let Marc generate it. So it’s his physician practice office, and so you have someone walk in. What do you need to know from them? So, go from there. How do you currently do it, and how would you like to do it?
DR. OVERHAGE: Well, and obviously primary care and specialty are different. In the primary care you don’t; it costs too much money to do, to figure out eligibility and things. You do the care, and then you get paid, maybe. No, I mean that’s the reality in primary care.
DR. WARREN: Right. And I think that needs to be the use case. That’s the current state of where we are.
DR. OVERHAGE: Right. And what you’d like to do is be able to — and as you say one of the challenges is even know ing where to start asking. But being able to send an electronic transaction that returns to you information that — and I think all the comments that were made earlier today are exactly right — that let’s you inform the patient about what their financial responsibilities are if you provide whatever the care is for them, and that you know you’re situation. In other words, are you going to be trying to collect from the patient, or are you going to be trying to collect from a plan, or are you going to be trying to collect from your local rental network.
DR. WARREN: If you were only allowed one health plan ID, what information would you want to get back when you query that ID?
DR. OVERHAGE: I think the comments that you heard earlier are exactly the right ones. I think that the practice should provide enough information that the plan knows what the question being asked is. So, in other words, are you eligible is the wrong question. That’s too vague. Right? The question is for this service from this provider — and there are probably five more things that I’m not smart enough to know what they are that the plan needs to know to answer the question. You know, what is the patient’s financial responsibility, what are you — maybe not specifically what you’re going to get paid, but you’re going to get paid whatever the contract fee schedule says for this. And then who to submit the bill to, if you will. I oversimplified, but somebody here will help me elaborate.
DR. WARREN: Tammy, do you have anything to add to that?
MS. BANKS: Tammy Banks from the AMA. And just in our proposal we went through the use case scenarios, and going through this is like going through the exercise again, because it’s a very complex process. And that’s why our ultimate goal was to give each entity — let’s use then that vague term — one identifier. But then it could be placed in the role that it is serving to reduce the complexity.
And just to add to the rental network, my sympathies to those of you who have just heard about provider networks, because we spent a long time trying to figure it out. And the only way the light bulb came for me was when I understood that a provider network contract with a physician has no connection to the benefit plan whatsoever. I can actually be in-network on a provider network contract, but my patient is subject to out-of-network benefits, believe it or not. And so when you put those two together, it’s two different things. We have two different individuals that are in this relationship. The physician with whatever network they’re with can be with three other networks before it gets to Aetna, Cigna, whomever. And then the patient has a plan either with an employer, a self-funded employer, and the TPA or ASL, or the fully insured product. But that’s there angle in the game. And where it connects is the big missing part that we’re just trying to get clarification. And just by assigning one number to any of the entities who will be using these transactions and providing the information back is something that could be hooked to a registry, and the information could be auto-populated in both of those scenarios. And we were trying to make it more simplistic in the use cases that we provided.
DR. WARREN: So you are suggesting an entity have one number, and that we handle some of this other complexity in a look-up database that has all of this stuff?
MS. BANKS: Partly, partly, because I would see most of the complexity being handled through the transactions where the identifier, the number, whatever it is — the national employer identifier, or the new number — could be coming back on the transactions to denote the role that it’s playing. But, yes, the registry would also be needed, as Karen indicated, in order to do that auto-population of what that number means.
MS. HANSEN: I am Catherine Hansen also from the AMA. And just to add a little more complexity, particularly with respect to some specialties, there will be sometimes the carved out benefit folks who will also be in the role of the information source for a particular transaction. So, for example, —
DR. WARREN: But that for specialty, not primary care?
MS. HANSEN: But specialists also use these transactions, so.
DR. WARREN: No, I was just thinking of our use case when I said primary care.
MS. HANSEN: But actually even for primary care, depending on the particular insurance product or health plan product, you could need to send a particular transaction to the carved out behavioral health carrier, for example, or to a lab, or to a carved out radiology benefit managers. So that’s why we’re saying our suggestion to you all is that all of those entities get a number, so at least there’s a consistent system that when the information comes back, there’s a way for the provider to understand who are we dealing with.
DR. OVERHAGE: Let me ask one clarifying question about that. I think I’m on the same page in terms of understanding the level of the entity that you’re talking about. It sort of places, and things, and people; it’s not plans or benefit designs, and plans, and those kinds of things? So it’s Radiology Services of America or whatever the heck it is, and they may have contracts with 107 different insurers and 5,000 different benefit designs, but one number for them?
MS. HANSEN: Exactly.
DR. OVERHAGE: Okay. So my understanding isn’t too far off.
DR. W. SCANLON: If you are agreeing with Marc, then I’m wondering is that really sufficient information, because —
DR. OVERHAGE: Thank you, Bill.
DR. W. SCANLON: Well, with this idea, sort of, that you were using entity in some respects in the way that one slide showed us we had entity sort of as one category, and we had the hierarchy, and we got down to sort of the product. To me the entity doesn’t tell you enough to know what the relationship is going to be for this particular patient, because that’s a function of the product that that patient sort of has. And so it’s like, I want to be down to that level.
And it can consist of two different things. It can consist of the entity ID, plus this something that sort of modifies that to identify the product. And then I think there’s the potential that, okay, I happen to be a psychiatrist. And for me the combination of those two things tells me that, well, there’s the entity, so to speak, line of business that I need to deal with.
I’m thinking that there are issues of what information is contained within plan ID. And then what information do we gather by interacting that with other things? To go back to the example of the rented network, the function of the location of the patient, zip code tells you that, okay? If I’m in North Dakota it may be a different network than if I’m in Tennessee.
MS. MEISNER: But there can be multiple networks in an area, so the zip codes not going to tell you.
DR. W SCANLON: Well, but will Home Depot use multiple networks in the same area?
MS. MEISNER: Yes.
DR. W. SCANLON: My God, what are they doing?
MS. MEISNER: If I have like a smorgasbord to choose from —
DR. W. SCANLON: I know, but I guess then it comes down to sort of what are we telling beneficiaries? If we’re telling them they’re signing up —
MR. KELLY: That is why it is two different questions. There’s a network for the beneficiary, which is one thing. Then there’s the contracting network that we use. So, within Tennessee, if you’re having your routine care, we might have a standard network, we might be using Multiplan or whatever. But, if you go in for a transplant, there might be a very specialized, high-quality transplant network that we’ve contracted with for a global rate for the procedure. So until the claim comes in, I can’t tell if you’re going in for a sore throat and I’m going to be paying you through one network, which it’s our general fee schedule, or if you’re going in for a transplant where I might be paying a whole separate model of payment.
So, it’s not about trying to confuse anybody, it’s about trying to help you —
DR. W. SCANLON: But if I am the patient and I come to me, and you know you’re the transplant person, and you’re in that network, don’t you know about your relationship?
MR. KELLY: You should.
DR. W. SCANLON: I thinking that what we are talking about here is we’re ending up sort of duplicating information that would be acceptable if we were to combine the information we already had. If we had the plan ID, the location, and the provider, those three bits of information tell us something about the relationship —
MR. KELLY: The benefit. That is why I am saying you should be able to ask me for this service, for this patient, are you going to pay me.
DR. W. SCANLON: If I am a transplant surgeon I’m probably not going to be treating your sore throat. So, I mean, probably, okay?
DR. SUAREZ: I want to make a comment because I think, again, we are looking at different points in time when dealing with these pieces of information. So our eligibility point is one thing. Claim, the generation, is a different thing. And I think going back to the use case, I think that the key elements are for this service, from this provider, in this day, and this location, and for this patient. And then the information is what is the patient eligible for, what is the payment I’m going to get, what is the patient’s responsibility, those kinds of things? That is the information at the eligibility point. But after that, once the patient is seen and now I have received eligibility information back from the payer I have some information that I can add into my claim to route and to complete the claim in the appropriate form so that the claim gets paid appropriately. It’s that connection that makes the case that Justine was talking about at the beginning, which is what is the big issue that we’re trying to address.
DR. W. SCANLON: Right, but I guess what I’m hearing is that what we’re trying to say is at this eligibility determination point, what we want is information to flow that’s going to be very predictive of what’s going to happen later. What’s going to happen in terms of the submission of the claim? And then what’s going to happen in terms of the adjudication of that claim? And we would like all of that to come back and be good predictors from the eligibility query.
DR. SUAREZ: But we know that the plan as has been explained, might do something different in claim, at the network level.
DR. W. SCANLON: And the question is can we minimize the number of time when something unexpected happens by having sort of better information up front. That, I think, is what’s driving some of the discussion.
DR. SUAREZ: The other comment I wanted to make is about the database. Of course we’re hearing a lot about the database and the database to do this as a registry. But I want to test that, because I think one of the values is — yes, the database will have some information. It probably won’t be the most accurate or most up-to-date and all that.
So, in my mind, it’s going to be much more valuable to have the pointer of where I can inside the health plan get that information directly. That’s what happens today, you know, in my clinic they pick up the phone and they call the plan directly to get the details. I mean, if we have that information in a database, that database is going to be as accurate as that day that they fill it in. So it’s important to distinguish what value the database provides versus what significance the ability to go directly to the health plan gives me in terms of being able to access more detailed information about the care. That’s the distinction I wanted to make about that.
MS. BANKS: In our proposal we said that this would probably help automate 80 to 85 percent. There are going to be scenarios — and regardless to the good intentions here, we’re not going to be able to do a hundred percent with this in the short term. And if it would be sent to behavior health, there will be a behavioral health fee schedule that could come back. If it’s sent to the health insurer and you have a direct contract, that information could come back. That’s helpful; then you know a provider network is not involved. Or if you have an umbrella provider network, if that comes back, that’s helpful.
But the way that we had looked at is, number one, you first have to have your code set before you can put ‘em in the transactions to denote what role each of these entities are playing. And with that in mind, just to expand on what you were saying as we looked at the NPI. And the Type I and Type II where you looked at the individual practitioner who actually touched the patient, and then what location that was at. And so we looked at this the same way. Here’s the patient, here’s the benefit plan that they have agreed with, and then here’s the entities and the roles that are serving in the other functions. And that’s where the provider network who has the relationship with the physician — it’s that circle.
So, Type I, the specific benefit plan are the PPO benefit, because we realize people don’t call them PPOs anymore. It could be Classic Blue, and that’s a PPO. So now how do I know which fee schedule I need to use. And, again, it just adds to the complexity.
DR. WARREN: When you use entity, you’re using it like we have on our box?
MS. BANKS: I am using entity like the definition of the health plan and whoever would use —
MS. HANSEN: Any entity that plays the role of a health plan in the transaction. Many things you had in other boxes, in our proposal we have it as a Type II NHPI, because we would put — a rental network is an entity. A company that contracts with doctors is an entity; it’s not a product type. A company that manages mental health benefits is a company, it’s not a product type. So we simply — our distinction was between is it an entity, an organization, or is it a — we called a patient-specific benefit plan. But I think in the typology we had here today, we used product type for PPO gold.
MS. DARST: Just a comment, I don’t think we’re too far off. I think we’re just calling it different things. The need is — you’re saying the same thing we are.
MS. KOCHER: Madame Chair, can I make one comment? I’m a little concerned, because I want to make sure we’re distinguishing, identifying and enumerating a health plan from the need to provide information about the relationship of the patient to the health plan, and the provider to the health plan. And if we try to embed those relationships between payer and provider into the enumeration of the health plan, we are going to create quite an extensive group of numbers, and I don’t believe that was the intent of what I understand we’re trying to achieve.
DR. SUAREZ: We all agree. I think the goal is to find what the lowest level — not too low, but what’s the level that provides the ability to ascertain that information so that it can come back. But not to create an enumeration that drives that information.
MS. KOCHER: We keep talking about all of it together, and that’s why it’s — I just wanted to bring us back that I didn’t believe that was our intent today. Thank you.
DR. WARREN: We have got the beginning of a use case — and I love the top of it. The current one is pretty clear that primary care providers don’t use it. Right, Marc?
DR. OVERHAGE: And just to be clear, in terms that the work involved is greater than the return.
DR. WARREN: Right. And so what you’re doing is — the work is too much for the return. It’s better to just go ahead and fire off a bill and hope that you’re reimbursed. Right.
MS. MEISNER: I would disagree. We have a lot of primary care physicians that are using it. And in Minnesota it’s required. So, respectfully, I think the primary care physicians are starting to see the advantage of it, and it’s being built into their software.
DR. OVERHAGE: I think it just depends on the setting. I agree, in large group settings, people do that; in small groups settings, I think it’s more rare.
DR. WARREN: So I think we have a lot of variability. Everybody knows that the standards aren’t being fully used, as was hoped when they were put into place through HIPAA.
MS. BANKS: I was just going to say that there are products out there now that the primary care physician will be able to use when there’s more consistency and more compliance with this use of the eligibility where the patient will set up an appointment on the website, and the eligibility goes right away, and it comes back to them. So all of this can be automated. We’ve just got to develop the tools in order to make it happen for them on a routine basis.
DR. WARREN: To me I see that as future state, because it’s not there yet.
MS BANKS: Hopefully tomorrow.
DR. WARREN: That would be good. Okay, what I would like to do right now, because we do need to take a break, it’s almost 10:30. And we’re going to leave this up on the screen. I’d like for people to look at it. And what I think you’ve got there Margaret is our current state is what you have up in the parentheses. Our preferred or future state is what you have in the table. Am I reading that right?
MS. AMATAYAKUL: I think I was trying to capture current state.
DR. WARREN: Okay. And so those are the steps then in the information flow? Okay. So people need to look at current state and make sure that really captures it so that when we come back we can at least say we’ve got this one down. What I’d like for people to think about is, in this particular one, if we were to come up with a health plan ID, what would give our primary care provider that’s out there the information he needs. And this guy is a guy that sits in a one or two man physician office.
MS. DOOS: Is there a place for it in the transaction?
DR. WARREN: Well, I think there’s a place for the transaction, and it’s got information source name. Okay. So that’s the slot we’re trying to fill here. We’re still trying to hone in as to what is the thing that we’re enumerating.
So with that let’s take about 15 minutes. So let’s come back at 10:40. Thank you. This has been a very productive conversation.
DR. SUAREZ: I think we are going to go back and start elaborating on this use case. Perhaps the first thing we should do is let Margaret explain a little bit the table and describe what she had in mind and the columns. And then we could go down the flow and see what people see. The ultimate goal really is to understand what’s happening now, and what kind of ID that we use to gather or to ensure that the information that is needed in the information flow is obtained. And in the NHPI situation, what NHPI can help define that — at what level of NHPI. So, Margaret, if you want to take a minute.
MS. AMATAYAKUL: I thought it might be helpful to take a very specific use case, as in this case for a small provider specialist, the 270, 271. So you would do this type of thing for each of the variety of use cases. You identify the information flow — and I was trying to get as specific as I possibly could, and there are alternative flows. So in this case the patient could schedule an appointment in advance or just show up. Not that it’s often that you would show up to a specialist as you would schedule an appointment in advance, but I think it is possible.
So that might need to have some refinement in terms of, well, in this case I would do something different than the other case. I put example; I’m not sure that we really need that at this point. But it’s kind of there to identify, for example, who do I send a 270. If we said, well, I send it to Aetna Health Plan, or I send it to so and so third party administrator or whatever. So we provide an example that might make it more real for them.
The purpose, again, a column that I just though maybe would be helpful to get at why is this important? Is it really necessary? What’s it going to do for me? And then the ID that is now in the transaction, where it’s applicable, because not every one of the pieces of the flow would have an ID. But in some cases the ID might be an EIN; that might be just fine going forward. And in other cases it may be a proprietary health plan number that we would want to see changed to the national health plan ID when it’s appropriate, when it comes.
And then I though, well, is NHPI needed and at what level may it be needed? And so in some respects I think we do need to have some beginning sense of definition. And initially in the use case it might just be at the, you know the health plan level at such and such a level. And then we can kind of agree that there are two levels or three levels, or whatever.
DR. SORACE: Interrupt you — real quickly, just scanning down here, does the provider — maybe I’m just not reading it — do they have to say what their anticipated service might be and some point in this transaction?
MS. AMATAYAKUL: Yes, right here.
MS. WEIKER: They don’t have to, but they can. They can just do a generic request.
MS. AMATAYAKUL: We haven’t gotten that far yet. I was just asked to look at the structure.
DR. SUAREZ: I think as Margaret pointed out, there are two possibilities. One is they use a generic query; and the other one is they specify the kind of service that’s going to be expected to be delivered to the patient. But it’s not required to specify the service.
DR. SORACE: Just to dwell on this for a moment, if they use a generic query, they get a generic answer that says that yes this patient is covered by the service. It doesn’t necessarily give them any information that they could say what they’re about ready to do is covered?
DR. SUAREZ: Well, generally yes, depending of course who is asking the question. In other words, you know, by knowing who the provider is, the payer would see generically what the provider is able to deliver.
DR. SORACE: I will tell you where I am going. Later on in the visit there’s a need for a mammogram, or there’s a need for procedure X. Can I then query and find out from this plan who my allowed referrals are? I mean those queries exist — I’m not familiar with X12, but those queries do exist?
MS. WEIKER: Yes, they exist.
DR. SORACE: So these work flows can presumably be supported?
MR. KELLY: A core certified transaction in the generic response will respond with about 70-odd different service types. So it’s not just you’re covered, but it responds with service types and patient responsibility, and remaining deductible. And that’s by category, and in-network, and out-of-network; so it’s not just a yes/no, they’re covered.
DR. SORACE: Okay. So there is more information there?
MR. KELLY: Yes.
MS. AMATAYAKUL: So the last two columns, again, just kind of getting at what’s the upside and what’s the downside of the national health plan identifiers if you want to go that far.
MS. GREENBERG: And what do you mean by that?
MS. AMATAYAKUL: Well, so if you determine, if you kind of keep saying level I, level II, and all of the sudden you have a level III and you wonder if level III is really needed. What would be the value or what would be the problem associated with that?
MS. GREENBERG: If the answer to the fourth column is yes, that an NHPI is needed, you’re saying what level is needed? I don’t quite understand.
MS. AMATAYAKUL: It may not be necessary, those two columns.
MS. GREENBERG: No, I think that’s a good question. I just don’t get the upside down.
MS. AMATAYAKUL: Should we take those off for now?
MS. CARR: I think what’s the benefit? What’s the burden? Is a bit of what I was thinking of.
MS. GREENBERG: That relates to the granularity.
MS. AMATAYAKUL: Well, I think it could relate to even if you want to have the national health plan identifier versus what we have today. So, if you have an EIN, for example, you want to keep it, then it would be maybe less burden or more burden depending on what you’re doing to get that number. So that’s kind of what were trying to identify.
DR. SUAREZ: So column number 4 answers two questions: is the NHPI needed, and then at what level? And then there would be benefits or burdens associated with either of the two answers.
DR. W. SCANLON: The burden may be more global than this, though, right? After one has looked at column 4 and decided that you need the identifier and then a level, and you’ve examined the benefits from it, there’s this question of, okay, if this is the level we’re going to go to, what’s going to be the burden in terms of changing systems or using a number with that kind of level. So it’s not tied to these info flows.
MS. AMATAYAKUL: You may identify a burden there and then see that it’s consistent across, so then it would be — I would say it’s a global issue.
DR. SUAREZ: So we can now go through and see what all of this relates to in terms of the information flow. So the first two rows, a patient schedules an appointment, or the patient presents to the specialist.
MS. MEISNER: There is no identifier.
DR. SUAREZ: There’s not identifier on this one. It’s just whether the patient has or doesn’t have the information with them.
MS. GREENBERG: Wait, a patient schedules an appointment, you don’t ask them what their plan is?
(off mic discussion)
MS. DARST: We do that very often. We have two processes I can just share with you. We have patients that make their appointments. They want to be proactive. Their appointments at three weeks out, we send them an insurance authorization, and we do the eligibility before they get there. The other case would be when they show up at the office and we do it then.
DR. W. SCANLON: Do you need a row for sort of eligibility? I would think when you get down to where do I send the 270, that’s what we’re talking about here.
DR. SUAREZ: Exactly. So then you do, of course, want to get that information when a patient schedules the appointment or shows up.
MS. AMATAYAKUL: So in either case you still have to make the determination where do you send the 270?
DR. W SCANLON: Right and you need information to go with the 270.
MS. AMATAYAKUL: Yes, which is done — do I make a generic query, or do I try to get more information?
DR. SUAREZ: The generic inquiry, of course, will include the same things as the specific inquiry, except for the service part, right? The generic inquiry will still show the point in time, the provider, the location. So the only difference between making the generic inquiry and the next row is information on services, but everything else would be the same.
DR. W. SCANLON: I am wondering about the two yeses and the identifier. Those two steps are between the patient and the provider. And I guess I’m wondering if it’s only starting in the line where do I send the 270, that there’s the issue of is the current ID sufficient to know where to send the 270, or do you need the new health plan identifier to do it? And so the question is — and I don’t know the answer to whether the current ID is sufficient, but is that yes or a no, and then do you have a yes in this column?
MS. MEISNER: Yes it is needed, but no it’s not sufficient right now.
DR. W. SCANLON: It’s not sufficient? Then I think —
MS. MEISNER: Well, if you just stuck with the question of where do I send it, the problem is it’s not standardized. So the benefit would be that it would be standardized so that if I know an entity by this number whether I’m sending the eligibility transaction, or the claim, or request for authorization, I would use the same number to identify that entity. And if it was a COB situation, the next crossover would use the same number to identify that entity. So standardizing it at this level would be very good.
MS. AMATAYAKUL: Is there a specific type of ID that’s used now, or it just proprietary?
MS. MEISNER: The NAIC number has been adopted, the National Association on Insurance Commissioners, has been adopted by a lot, but not completely. And mostly in the government worlds it’s not the NAIC number; it’s proprietary numbers.
MS. WEIKER: Right, Margaret, in my testimony in doing the evaluation of what numbers used in the 270, 271, the NAIC number, proprietary number, the Blue Cross Blue Shield plan code is another number that you see quite frequently, as well.
DR. W. SCANLON: In reading the materials, I understood that as not mapping to an address. So to me it doesn’t answer the question where do I send it?
MS. WEIKER: Are you talking an electronic address or a physical address?
DR. W. SCANLON: Either one; does it map into an address?
MS. WEIKER: It will map electronically.
DR. SUAREZ: Okay, so —
(off mic discussion)
MS. WEIKER: Where you send the 270 is in the envelope of the transaction. It’s not in the transaction. Where you send it differs from how you identify who the source is in the actual transaction.
DR. DARST: An example would be, if we’re sending this through a clearinghouse, we’re going to do all of our inquiries using a clearinghouse versus going to every website, every different process. The envelope is going to say it’s the clearinghouse, not the payer.
MS. WEIKER: Right, then in the transaction at the source level they’re going to say Minnesota Medicaid, Blue Cross Blue Shield of Minnesota, whatever, but in the envelope of where to send it, you’re going to put Embion, or whoever is the Medicaid processor for Minnesota. They may do their own, or it may be a fiscal intermediary, or whatever.
MS. MEISNER: You would think I would know that, but we did have the conversation last night that submitter and receiver are not in this conversation around health plan identifier, and so that’s why I — sorry, I should know that. So we took receiver and submitter out of the envelope for this whole conversation when we were doing it last night.
DR. SUAREZ: That is one important point. I think in the testimony that we heard that the envelope itself, the identifier doesn’t require to be the plan identifier. It could be if the entity that receives the transaction itself is the plan and they choose to decide that that’s the number. But in the current guides it’s not defined as an XB option.
MS. WEIKER: Right. In the enveloping, the XB value is not even in those data elements. So if you were going to use the national health plan ID to do the routing, we would have to add the qualifier. But you could use what we call a ZZ qualifier, which is mutually defined. So in your companion guide you would say I’m going to require the national health plan ID to be used in the enveloping to do the routing, and you would use ZZ as your qualifier and this number. And that’s an example of what you would put in a companion guide.
DR. SUAREZ: It’s just as an option.
MS. KUPPE: Hi guys, this is Patrice. I was thinking that the number on the card is a key to the NPES, which would then maybe inform me where I route transactions. So, I see tons of Blue Cross of Minnesota people. I’m going to build that in and say every time I see number 123456 I know the connection that routing envelope information is XYZ. So the number on the card, the plan ID, is the key to more info you can find in the registry.
DR. SUAREZ: Are you saying that the number on the card should be or could be the number where the transaction gets sent?
MS. KUPPE: The number is there, the entity who does the insurance. I can use that number — this is our challenge in Minnesota, trying to do a hundred percent EDI; there are no EDI yellow pages. So whatever number that plan is seen on the card, can I then use that number to go look up in the registry about connectivity information?
DR. SUAREZ: Exactly because you are trying to address two different subjects. One is the eligibility query itself, and the other one is where to send the transaction. In other words, the query really is more about is this patient enrolled in this plan and this product, and eligible for this service, and all of those questions. And that’s one number.
And the other number that is potentially is different, and in many cases is different, is where do I route my transaction? Both pieces could be on the card distinguishing — it could be the same number in both instances, or it could be one number is an actual plan product, and the other one is a place where to send the transaction.
DR. WARREN: Are we talking about routing numbers being the same thing as the plan ID? And I know this is where pharmacy comes in, because for routing number you want the bin, right?
DR. SUAREZ: I think that Margaret in her testimony pointed that out, that currently the envelope section of the transactions, in general, they use a number to route specifically the transaction, but it doesn’t have to be the plan ID. It could be, but it doesn’t have to be.
DR. WARREN: Right. That helps, thank you.
DR. SUAREZ: Is that sufficient for the first part of route and send?
MS. AMATAYAKUL: Do I have that right?
DR. SUAREZ: You might want to put “optional” in that for envelope. You know, suggest optional, because it’s really an option to use the NHPI as the identifier of who is the routing recipient.
MS. GILBERTSON: This is Lynne Gilbertson at CPDP. Part of our testimony was also that, from our experience, by putting the routing identifier information and plan identifier information on the card, you start providing those keys that people need. So, by only putting one versus the other, you’re missing half the puzzle. So, if we can start doing that and making those required that that information be present on a standard card, it goes a long way to starting the key structure off.
DR. SUAREZ: Excellent point. Absolutely.
MR. KELLY: At the risk of creating more misunderstanding, routing in today’s world, on the Internet world, things could be coming in through secure file transfers. They could be coming in through the Internet with web services connections. They could be coming in through bulletin boards. And that will change. And the routing information will be different based on which channel the provider decides to submit transactions. And it might change for batch versus real time. So the idea that I would send out new ID cards every time we change how you’re going to get to me is in my world insane.
DR. SORACE: Just listening to these work flows, a lot of these are actually requests for transactional data, and I’d also say referral data and referral transactions would be very frequent in these visits, that essentially you can’t really hardwire because the business relationships would change very rapidly. I think that’s what you’re saying.
MR. KELLY: Yes.
DR. SORACE: But it still seems to me that the NHPI should be able to point to the source of that knowledge and get the message back, correct?
MR. KELLY: Absolutely.
DR. SORACE: And it also seems that a lot of this is stuff that should really be resolved up front with practices, not every time, with every message, with every encounter. There is sort of a limited amount of communication going on between providers and payers perhaps on some of this information. Would that also be accurate?
MR. KELLY: That’s true, and that’s why I think the registry is important in terms of — I’m not sure exactly what should or shouldn’t be in the registry, but would should be in the registry, the nature of the information should be to support the currency of the information that’s needed to actually conduct business back and forth. And the volatile information that can change either with the patient, or the network, or the provider on a frequent basis, should be in a transaction that happens in more real-time.
The other thing, I think what Greg said was very important when he talked about the plan administrator. Whatever you want to call it, I think it is very reasonable, and good for everybody that on a card there is an identifier that says who’s responsible for managing this. And that entity, in most cases it’s the plan that sold the product. They should take responsibility for removing the complexity and being able to route based on that point of contact.
As a use case example, United and Harvard Pilgrim have some joint venture products, which originally when the patients came in, if they were on the one side of the product, they’re ID card had one set of numbers and the providers had to send them there. It still had a Harvard Pilgrim brand on it. Another set of cards, they had to send them to Harvard Pilgrim’s address. And the providers went nuts. So we invested a lot of time and energy in saying, we’re going to put one number on the card, you send everything to Harvard Pilgrim, and we will take care of all that back end mess. And I would thing that’s where we’re trying to get to with the national ID, that there’s one number on the card that the provider can take to the bank, that whatever I have to do I’ll deal with this entity and they will hide all of that ridiculous complexity that we’ve created on the back end.
MS. MEISNER: Walter, I think we could make a high-level statement as we’re going through the use cases, where the enveloping that we’re talking about, the submitter and the receiver, those are trading partner agreements. When you hook up with a payer, or you hook up with a clearinghouse, or you hook up with another intermediary, you’ve got a trading partner agreement and you discuss what form of communication are you going to use to get this stuff to us, here’s how you need to do it, and here are the numbers you need to put there. That’s all trading partner.
DR. SUAREZ: And if things change they get handled in that trading partner agreement.
MS. MEISNER: That needs to be a blanket statement that we’re not taking — we’re talking from information source down.
DR. SUAREZ: Good point. I think it was important to distinguish.
Going down the example, there are the two elements of, you know, the two inquiries, the more generic and the more specific. And so in today’s world basically the IDs that are used based on the guide on the 270, 271 are the ones that have been described: the employer identification number, the NAIC, and then payer proprietary identification numbers. And in the note it says if the use of the national payer ID is required, then that’s the one that’s mandated.
So right now proprietary ones, and then I think this is one of the places were it just comes clear and critical. The question is, in the NHPI, the question is what level? So, if the first question whether the NHPI is needed is a yes, the second question is what is the level that is needed in order to reply or to respond with the more generic inquiry? So does anyone have any thoughts about that?
MS. DARST: I just want to make a clarifying point. At the point of the inquiry, we don’t necessarily know what the product is. It may be just Aetna. That’s what we’re querying. Our hope would be that we would get it’s Aetna PPO Silver. But just so we clarify, we don’t always know that. We don’t know the product line.
MS. DOO: So you request won’t include the product line; you’re will request will just be somebody that has some information, benefits.
DR. SUAREZ: Well, today you don’t know the product line or the product in which the patient is enrolled.
MS. DARST: The patient just tells me they have Aetna.
DR. SUAREZ: Part of the question is if they have a card and the card says some group ID —
MS. DARST: That is a group ID. That’s not necessarily the product line.
DR. SUAREZ: The idea is, would it be at this point beneficial that that number on that card be the generic ID for Aetna at a high level, or the product line ID?
MS. DARST: So are you saying that the payer would already have on their card the product line for us?
DR. SUAREZ: Well, that’s a question. If the patient enrolls and they are going to be issued a card that identifies them enrolled in the plan, what number would that card show?
MS. DARST: And I think it varies by payer right now.
DR. SUAREZ: Right now it does.
MS. DARST: Right. What would be ideal is if it had the product line on it.
MS. HANSEN: The issue certainly from the provider side it would be perfect if there was product line on the card, and that would be ideal. The question is — and this is the difference between having a group number and having a product line number — there are employees certainly who move every year, but a lot of employees stay with the same employer, but they may move product lines every year. So, if you require a new card every time, basically you’d require a new card every year, or potentially every year, as employees moved from product line to product line. Whereas, if you let the cards stay the same while the employee moves from product line to product line, that might be easier from the card issuer perspective. On the other hand, it is critical that the product line information come back in response to the 270 request so that the physician does know what product are we talking about, what benefits are covered, what’s the deductible, and all of those questions.
MS. DARST: I would concur with that.
DR. SUAREZ: Great, excellent. That’s very helpful. So in the outbound of a 270 you can have just a generic group number, and then in the inbound you bring in the —
DR. W. SCANLON: I guess I’m trying to think about sort of when people are making these changes in a given year — let’s say that they’re in Blue Cross, and they go from — I’ve forgotten the names in FEHBP, standard and my option or something like that. Okay. They go from gold, silver to bronze. Is it the issue that we wouldn’t want that there, because I guess I’m thinking about for subsequent transactions what do we want to code. And go further down the road, you know, it’s more burdensome it seems to me that if we don’t have it at this level, if the information about the product line comes back to the provider, does then the provider have to start to use that as opposed to using what they got?
MS. MEISNER: My personal opinion, and with working with the providers, I think what I’m hearing the providers wanting to do, and it makes sense for me, is let me do that high-level number on my inquiry, you give me back the information to talk to the patient, but I still want to give you that high-level number when I send it back to you. I don’t want to get granular and get back 3,000 checks because you got 3,000 numbers, or 3,000 ESPs because you were registered with 3,000 numbers.
So I think the subsequent transactions, the payer doesn’t need the provider to tell them; the payer already knows that. The provider doesn’t need to tell the payer that Debbie Meisner’s in this particular network. The payer already knows that. The person that didn’t know that was the provider. So it should only come back on the response transactions, and not force the provider to get it right on the claim or the request for referral. Just get it back on the ERA, get it back on the 271.
DR. W. SCANLON: I guess what I am talking about is not thousands of numbers, but for Blue Cross and FEHBP it’s standard versus high option or whatever the two terms are. There are only two levels.
MS. TRUDEL: No.
DR. W. SCANLON: When I get my FEHBP guide, there are only two choices for me to make. The question is, am I working at that level, or am I just going to put down Blue Cross? And to me that’s a significant distinction.
MS. DARST: I think the difference is when we’re trying to describe between product line and benefit plans, I know a lot of that discussion happened yesterday and we were listening to someone from the pharmacy talk about, you know, they had thousands of benefit plans. Benefit plans I think are one thing, you know, where you’ve got an 80 percent plan with this deductible, and it has this coverage. That to me would be benefit plans. When we’re talking about product lines, I would agree with you that hopeful — I would certainly expect my Blue Cross Blue Shield to have — in fact I know they don’t have thousands of product lines; they may have ten. So I think there’s just trying to derive that distinction between benefit plans and that product line, and what we contract with.
MS. POWELL: Actually I think the question about FEHBP is a really good example of the dynamic that we’re trying to figure out, because you’re right, there are basically two levels of benefits, and clearly the provider needs to know that. But they also need to know which of the thousands of plans are actually handling that benefit, because I need to know where to send the claim. The claim has to go to — if it’s Blue Cross Blue Shield of North Carolina who is one of the options for FEHBP in North Carolina, then they need to know then if it’s Blue Cross versus another option that’s available to federal employees in North Carolina for the standard high or low.
MS. KOCHER: I will defer to Marc.
DR. OVERHAGE: I think anybody who thinks in annual cycles is forgetting about out vulnerable populations. You have Medicaid and uninsured where it’s monthly they’re changing their eligibility and benefits, if not more often. And that’s 40 percent of the world.
MS. KOCHER: And we’re talking here about putting information on a card that while I agree is important, but would greatly increase the number of cards and the number of times that would need reissued. But yet we’re really being asked as payers to really look at the administrative portion of the MLR. And this approach by going to that level of detail could drastically impact that, and I think that’s counterintuitive to what we’ve been asked to do out of health care reform.
MS. AMATAYAKUL: I know there are a lot of interrelationships between the different transactions, but I think it would also be helpful to make sure that if we’re looking at 270, 271 we sort of stick to that, get that down, get some of the others done, and then look at how do they interrelated. I’m hearing claims, I’m hearing prior auth, all sorts of different things. And yet we’re focused on —
DR. SUAREZ: Great point. And we’re also combining or bring up a lot of the health ID card. And realistically nothing in the regulations require or mandate the health ID card. Indeed it’s very valuable to consider what are the implications of a plan ID with respect to health ID cards. And probably to describe how it relates, because in the regulations there is also a message about December it’s expected to be able to be using readable machine cards.
MS. TRUDEL: Maybe.
DR. SUAREZ: May be available for that. So let’s go back to this, because what I’m hearing is really on the outbound of the 270, 271, the inquiry part, the provider would probably only need to send the identifier of the overall plan entity or the plan that the person is enrolled in. And then the payer would know based on the information about this is the person, this is the date, this is the provider, this is the location, which product they belong — and even which network and all of those things.
And that would probably be the same for whether the inquiry is generic or specific, correct? Or is there anything unique about when the provider sends the specific inquiry?
MS. MEISER: That’s correct. The difference would be the response.
DR. SUAREZ: So now let’s get back. So you get information on what money you need to collect from the patient, so this is the co-pays and all the information. So would there be anything special about the NHPI itself that is needed? Right now, basically, what kind of practice — the same identifier that is sent, or?
MS. DARST: Well, I think there are two distinctions. For the most part when we get back the eligibility transaction, we get back the co-pays, we get the deductible, we get that information fairly well from most of our payers. So, there’s no problem there.
It’s those situations where it’s that out-of-network piece that we don’t know, that we should probably collect everything or tell the patient that there is going to be a higher percentage. That’s the issue. So we get back really good information sometimes, and then we don’t get back enough in other situations. It’s the other situations —
DR. SUAREZ: Is the main factor the in or out of network situation?
MS. DARST: For the most part.
DR. SUAREZ: For the most part? Is that the biggest issue, or are there other issues, too?
MS. MEISNER: I think this is where you want to get the product. When you get the information back, this is where you want to get the identification of the product.
DR. SUAREZ: Okay. So in the NHPI the information coming back should provide the in network, out-of-network? That’s almost a requirement expected to be able to be fulfilled with the 271?
MS. MEISNER: It is my understanding the problem is the payers can’t tell you that you’re out of network because they’re not pinging the provider file. But the provider knows whether they’re in the network if you just tell me what network it is.
DR. SUAREZ: Is product level enough level, or do you need network level?
MS. DARST: Then you have the network also. So it could be either/or.
MS. AMATAYAKUL: Are you talking about the network as in rental network or as in the benefit network?
MS. WEIKER: Both, depending on what the patient has?
DR. WARREN: Can we start using benefit network and rental network when we talk about networks? Otherwise we’re going to get confused again.
MS. WEIKER: Can I just say I don’t know that it matters to the provider whether that’s a network that you’re contracting with as a payer or you own. And that’s the only differentiation between the two. The only reason we called it out is a rental network could be affiliated with more than one payer. Where if you own it — unless you’re renting your network out, which some people do — if you own it, then it’s probably yours and you would be responsible for enumerating it. That was the reason we called it out differently. But I think from a provider’s perspective, I don’t think you care whether I own the network or rent it —
MS. DARST: I just want to know do I have a contractual relationship with who’s going to process this.
MS. BANKS: You would care because if it was the actual — let’s use Aetna because it starts with an A — if you had a contract with them and that NHPI for Aetna came back that they’re responsible for the contract, you know that’s what’s going to happen at the end. But if the provider network comes back, then you know it’s subject to a different contract, because even though you have a contract with Aetna, there still may be surprises at the end that you and your patient have to deal with.
MS. DARST: That is exactly the point. We don’t like surprises at the end. And the patients don’t either.
DR. SUAREZ: Here is where the information will be critical to come back, the detailed information. Would that be applicable also to the — let me go to the next two boxes. That’s where the benefit and burden are. Of course, benefit we just mentioned, you know, the ability to know the patient or the provider is in or out of network, and the conditions of the network. But is there a burden element if the payer is now going to be expected to provide that level of detail? There is a burden. So let me ask then how big of a burden.
MR. FISHER: This is Greg Fisher, United Healthcare. I can answer part of that for you. In the majority of the cases — I don’t know if it’s 80 percent or 90 percent, or whatever, yes, you can return network information. But there are some situations where you don’t know what you’re going to adjudicate until the procedure comes in, which is only coming in on a claim.
At the time of claim adjudication you look at all the actions and say all the networks that are in play, all the relationships that are in play, what’s the one I’m going to adjudicate with, which every once in a while is not the same as the one that you expected in the beginning, because you have networks repricing things and all that sort of stuff.
So the issue is do you know the rental network? Yes, most of the time. Are you going to use it? No, not 100 percent of the time. On the 835 you’ll need to return back the actual network used and the actual relationship used. So on the 271 payers cannot 100 percent of the time return exactly the network that’s going to be used.
MS. DARST: I think if we look at the 8020 this would get us leaps and bounds ahead. I just wanted to make two other points about the positive aspects of this. One is that we know there are certain payer products out there that based on product line have different prior authorization and precertification requirements. Again, we can hit those if we know them. So, we will eliminate some of those issues. And one of the other things, too, is it would cut down on phone calls — I talked about that a little bit — between us and the patient, the patient and the health plan, us and the health plan. So, I mean it’s hopefully an opportunity to cut down on all of those phone calls and frustrations.
DR. SUAREZ: Excellent point. Thank you, yes. Those are the exciting things that we’re hoping to see.
All right. So then the next role is get information of what payment the providers going to be able to receive. And in that case does the same level of information in terms of pro level and even network level is necessary? I mean, it flows with the previous one too, right? It’s the product level; it’s not the network level to get to that, how much payment I’m going to receive.
MS. WEIKER: Walter, keep in mind that this is an eligibility response, and in most instances you’re not going to get a true how much am I going to pay you. You’re not going to get how much am I going to pay you for an office visit, or how much I’m going to pay you for an office visit and a lab draw. You’re not going to get that on a response of a 270 inquiry. That’s more of a — if you want to know it before you actually submit the claim, that’s a predetermination of benefits transaction.
MS. DARST: It won’t be specific, but what we’ll know is are we completely out of network and there’s no money, or out of network and it’s going to be at a reduced rate, and we need to talk to our patient and let them know that, and whether they want to proceed or not.
DR. SORACE: Is there a difference in turnaround time and general business rules between those two requests? In other words, if you really wanted to know the full details, can that still be done? Or from the providers point-of-view, is it just a question of studying the second message and waiting another 30 seconds, or does this actually require some machinations on the part of the payer to get back to them?
MS. DARST: To know exactly how much money?
DR. SORACE: Yes, I mean, just to ask.
MS. DARST: We talk about this in real-time adjudication. The difficulty is, as a provider I may be able to know the patient’s going to come in for an office visit, but I don’t necessarily know what level of office visit, or if they’re going to have lab tests, or if I’m going to send them for an x-ray. It’s not a for sure, so for me to try to do some sort of predetermination of benefits, it’s going to be iffy at best.
DR. SORACE: I understand because of the clinical workflow that’s true. But I’m saying when the event arises and now you do know with certainty what you want, how long does it take to get back the definitive payment?
MS. DARST: I would call that the bill. And I mean as soon as we can turn the bill in, it varies by payer. Sometimes some payers, the turnaround can be within the next couple of days. Now our actual reimbursement isn’t usually for a couple of weeks. But it varies by payer how quickly we know.
DR. SORACE: I guess the difference in concept here is, one would be what you anticipate to get at a given point in time. But you want that number to be as close as you can to what you’re finally going to get, versus what comes through a formal billing process.
MS. DARST: Right.
DR. SORACE: But we’re trying to narrow that window, right?
MS. DARST: What we are really trying to do is not necessarily tell the patient how much they’re going to be paid. That’s kind of a predetermination of benefits. We want to just tell them if there are no benefits or that they would have greater benefits going to a facility that reimbursement would be higher. That way it’s their choice, and it’s not a surprise at the end.
MS. BANK: If we get into pricing rules and code edits, we need another weeks. I mean the complexity is just as great. And so in our proposal, again, this is just how we were trying to make it as cost effective as possible, because we don’t want to add cost either, is if there’s any way with this national health plan identifier there could be a standard format so that whoever contracted with a physician, they could identify a number to the specific fee schedule that applied to the patient. So, in this case, if I was contracting with classic new contract, that would have a number 123456, if you determined six digits would be the format. And then that would be passed back with a national health plan identifier for the provider network.
That identifier would be generated by the person that you do the contract with and negotiate the fee schedule with. So you would have a key so you could go to that provider network and get your contracted rate. If you know your contracted rate and you can actually put the fee schedule with this, then you can give an estimate, especially in the primary care office where you’re usually dealing with two to three procedures or services.
DR. SUAREZ: Okay, so I think we have this one —
MS. BANK: Fee schedule ID, maybe.
DR. SUAREZ: Fee schedule identifier. Anything else on this one?
DR. FITZMAURICE: Walter, what I’m thinking of in this talking about a national registry, if you’re the health plan and you know the patient’s ID, the provider identifier, and the health plan identifier — that’s how it got to you — and somebody tells you then the type of service, that let’s you link down to the patient’s network, whether it’s a service covered by direct benefits or not, you can get to the network, the contract, the fee schedule, and the benefits from those four bits of information, can’t you? And so a lot of these we looked at you may not need to have a fee schedule identifier because you can track it down through this registry that each health plan would have to maintain, because they need to know what business the provider and the patient are doing, and what is covered by the fee schedule.
MS. HANSEN: I think this gets back to the point that it’s so complicated. The fee schedule relationship is between the provider and whatever entity they have contracted with, which could be a health insurer, or it could be a self-insured employer, or it could be the TPA, or it could be the rental network entity. So it’s the entity that did the contracting with the doctor that has the information about the fee schedule. Okay? So that means — and I would just say that the way that this is written here, the fee schedule would not be in the database, if we’re talking about having a database for the national health plan identifier registry. This would not be in the registry. This would be in the relationship between the entity that has contracted with the provider, and the provider. So what you need is an identifier, just a standard identifier, a standard format of identifier that could be used so that every time people contract they get a unique, standard format identifier that they will now be able to match with the company that they have contracted with, and understand — both of them — which fee schedule is going to apply to this circumstance.
DR. WARREN: At the relationship level?
MS HANSEN: The fee schedule identifier would not be in NHPI. In our system the fee schedule identifier would need to be returned in the standard transaction along with the entity that has the direct contract with the provider, because that’s the only entity that’s going to have the information about what is the contract.
DR. SUAREZ: Where would that fit in the standard?
MS. HANSEN: it fits in the standard transaction.
SUAREZ: You mean in the actual 271 there is a place to send back such a number?
MS. HANSEN: We laid out a way that made sense to us, but we would need X12 —
MS. WEIKER: There is a contract number qualifier; is that what you all used?
MS. HANSEN: I believe so.
MS. WEIKER: I can double-check it, but there is a contract number qualifier. But my question is who would enumerate that? I as a health plan would decide and give all of my contracts a number, and then I would hand that to you and say here’s all that you contracted, here’s the number. So then when I gave that back to you on a 271 and it was ABC123, you would know then that’s how much?
DR. WARREN: So let me just kind of restate. If I’m looking at a system that’s going to manage all of this, I need a health plan ID. So if I’m in the back office of a physician practice, and I’m sending out query, I need to have the health plan identifier. And then when I do my contract with that health plan, they’re going to give me back a contract number. Okay. So I can put that in. So with those two numbers I can get my fee schedule, and I can get everything else.
Now the only thing that’s missing still for me is this product information. So that what I’m still thinking of is that maybe this health plan identifier be at the product level. But then I get nervous about that.
DR. SUAREZ: No. When you send the inquiries, you don’t need the product level.
DR. WARREN: So then they’re going to come back?
DR. SUAREZ: They will send it back.
DR. WARREN: Got it. Okay. That’s why I wanted to restate it again and make sure I got it right. Thank you.
DR. SUAREZ: I don’t if you would as a provider would need to send a fee schedule number on the outbound, on the 270.
MR. DARST: But they’re going to send it back. We don’t necessarily know it at that point in time.
DR. WARREN: You are going to be sending the health plan ID and also the patient’s ID that comes off his card? Okay. And then in return what the physician gets is going to be the product information and anything else like fee schedule, et cetera.
DR. SUAREZ: Eligibility.
MS. TRUDEL: So a fee schedule identifier doesn’t actually do any good unless the plans then post all of their fee schedules using the number?
MS. BANKS: There are two different ways. Right now in the physician contracts, they are supposed to get the fee schedule at that time. And that’s when an identifier should be passed the first time. And yes there are health insurers that you can use the fee schedule key to download a fee schedule directly from them into your practice management system. Others do not, so down the road, the phase III, that would be really nice. But right now that’s where the identifier would pass originally.
MS. TRUDEL: I don’t get this. If you’ve already got the fee schedule attached to your contract, then what is this doing for you?
MS. BANKS: We have multiple fee schedules with each contract, so we don’t know which one. So when I negotiate for a fee schedule for provider select, and then that provider network with provider select goes to Aetna, and I also have a PPO, and I also have another contract. I don’t know which one of those three was the agreement that my discount would be — which one of those fee schedules was in the agreement. The biggest reason for mismatch with auto-posting is that part.
DR. WARREN: So the help plan is going to respond to the provider, and in that they’re going to tell them the product ID and the fee schedule ID in that return. Is there any need, other than for the health plan themselves, to enumerate those numbers?
MS. HANSEN: I think the issue is the term “health plan”.
DR. WARREN: I know that. But what I’m saying, once we figure out what health plan is, can they enumerate their own product and their own fee schedule?
DR. SUAREZ: Their own product would be NHPI; the fee schedule would not be in NHPI.
MS. DOO: Is the plans number for it?
DR. SUAREZ: It’s the plan, and what is being recommended is that you create, using the HL7, you recommend a defined way of numbering the fee schedule so that everybody uses the same number schema, but each one chooses which number they assign. Of course, there could be collisions.
DR. WARREN: I think that is what I am saying is if each — we tell the plans here is the number format you have to use when you give a number to your product. But I don’t think we need any external body to assign that number. We are looking at enumerating the health plan. We’re still getting closer to what that is. Within the health plan they have different products. We tell them that they can enumerate their product, that they have to follow this format, and they also have these fee schedules.
DR. SUAREZ: You are confusing products with fee schedules. Products and networks are in NHPI. We’re talking about plans, products, and networks; those are NHPIs. Fee schedule is a different thing. It’s not in NHPI. This is an additional recommendation, additional idea of helping —
DR. WARREN: I am confused. I thought that when the provider sends the query to the plan, the plan then comes back with here is the product line that I’m paying for, and here’s the fee schedule. If that’s what they’re doing, then why do I need to have a health plan ID for that product?
DR. SUAREZ: You need to confirm –- the provider needs to know if they’re in the network or not, and if they can service the patient.
DR. WARREN: When I reply to them, I tell them that.
DR. SUAREZ: When the health plan replies to them, you’re saying why would an NHPI at the product level help clarify that?
DR. WARREN: No. What I am saying is do I need a third party entity to assign a health plan ID to a product that a health plan issues?
DR. W. SCANLON: The question, one is the third party entity or do you need to have that number assigned, and whether that number’s assigned according to certain rules. I think there is an issue that number needs to be assigned. And I think it needs to be, then sort of involved in future transactions so that we can be tracking service utilization.
And the only reason for having an external entity is to make sure there is some kind of consistency with the rules so that we’re defining these things appropriately. You can say that we can specify the rules well enough that they will be adhered to, then we don’t need the external entity. I don’t know whether I’m confused and not understand your question.
DR. FITZMAURICE: Judy, I think the way to handle it would be this product ID, the first X digits are the health plan’s ID, and the health plan is responsible for —
MS. WARREN: No, no, no.
MS. TRUDEL: I am just not seeing where the issue of the fee schedule is relevant at the time of eligibility. I think knowing what the fee schedule is is an 835 issue. And so I would suggest that we move on to the next step in the process to see if it’s relevant there.
DR. SUAREZ: Okay. Thank you.
DR. CARR: Can I just say one thing? There’s the physician’s fee schedule, and there’s the service plan fee schedule. So there are two different ones. So, if I want to know what I’m going to get for an EKG, that’s one thing. If I want to know what I’m going to get paid as a provider, then that’s another thing.
DR. SUAREZ: Good point. Thank you.
MR. FISHER: As a payer, let me make one comment about your question about the enumeration level. The difference between enumerating at just a company level and a product level should be left to the organization doing the administration. I’ll give you and example, United Healthcare. We have 45 payer IDs. And you may ask why do we have 45 payer IDs? It’s because we’ve acquired probably 30 companies, each one having separate products. However, the old United Healthcare Group has one number. So in one instance we have a payer number that covers all products. But in other cases we have separate companies that perform product-specified numbers. So we need to be able to do both.
DR. WARREN: Can you just give me an example. Tell me three of the products that you have in your plan. If you’re a health plan, tell me three of the products that you just mentioned.
MR. FISHER: That are separately enumerated, or that are included? I mean, United Healthcare, PPO, HMO, whatever, is all under one number. But for Medicare Advantage, and Pacificare, and for Americhoice, Americhoice has eleven numbers because they’re operating in eleven different states, and each one is considered separate issues.
DR. WARREN: That’s what I needed. Thank you.
MS. HANSEN: I just want to go back to why you need the fee schedule in the 271. Another reason that you need it at the beginning is to the extent that you have co-insurance, it’s really — if you don’t know what this fee schedule is, you basically are not going to be able to give the patient even an estimate of what their responsibility is going to be. So, we really would strongly encourage you to keep this as something that gets returned. There is a place for it to be returned in the transaction, and we would strongly — but right now, if there’s not a standard mechanism identifier for it, then there’s just no way that it can be programmed by practice management systems. And that’s what we’re trying to do at this point.
DR. SUAREZ: Thank you. We have about 20 minutes before we break for lunch. By the way, after lunch we will be focusing on operating rules until around 3:00.
DR. WARREN: So we have 15, and then before we break for lunch I want to tell you how we’re going to work after lunch. But that will be a real quickie.
MS. WEIKER: And don’t forget pharmacy; we have a use case.
DR. WARREN: We’re not done doing use cases. They may be done offline. They may be done through email or phone call.
DR. SUAREZ: To finish up, there is another sort of money collection or the coordination of benefit part of it. So here we’re looking at currently basically is there any information in the 271 coming back, or in the 270 going out, that helps that. Is there anything?
DR. WARREN: FSA, HAS, information if there are other sources of money — or your secondary payer.
MS. WEIKER: So here’s where we get into COB.
DR. SUAREZ: This is all COB. There is nothing on the 270, 271 that points to that.
MS. WEIKER: Yes there is on the 271.
DR. WARREN: When it comes back.
DR. SUAREZ: When it comes back.
MS. WEIKER: There’s not on a 270.
DR. SUAREZ: Exactly. So on the 271 there would be information. What kind of plan ID would there be indentified.
MS. WEIKER: That is part of the problem. There’s a list, and it goes back to — I know a lot of the Medicaid assign numbers themselves. So, Aetna HMO in Missouri may be 123, and Aetna HMO — same entity — in Iowa may be ABC123976547. And that’s part of the problem. So the provider, they didn’t have to keep track of all of these proprietary numbers that entities are identities are identifying for other insurance.
So, Laurie at Mayo, which people all over the country, she’s got this mammoth database built will all of this stuff in it. And anytime somebody adds something and it bounces back, she’s got to go in and update that. So I think one of the things the national health plan ID needs to do is to have these numbers assigned to where coordination of benefits is consistent across all health plans.
DR. SUAREZ: The question is, Margaret, is then so the health plan that received the incoming 270 looks at it, finds that this person has another insurance. They use whatever number they have on their record. And what an NHPI would do is say to that health plan — and every health plan — use this specific number. Now, what level of identification is needed there? Is it a entity level? Is it a product level? Would the health plan that received the 270 know whether the coordination of benefit with the other insurance is this particular product? Would they know that?
MS. WEIKER: Being a health plan or a vendor of health plan systems, et cetera, provided the national health plan identifier repository database is available, what I would do is we would bring that system and have a frequency update to it and bring that into our systems. So when I go and I say they have other insurance, I pull that number.
DR. SUAREZ: So there are clear benefits on this particular part.
MS. TRUDEL: So that adds another requirement that we haven’t thought of before, because that secondary information comes from the enrollment transaction, which we haven’t been talking about yet.
MS. DARST: To add to that, Medicaid a great example. If we do have a Medicaid patient that comes to our facility, when we check eligibility and say that there’s primary insurance, means we have to bill them first before the Medicaid. If we don’t have enough information, let’s say we don’t have a contract with the Blue Plus plan, but we do with regular Blue Cross Blue Shield. Now I would be seeing this Medicaid patient out of network for that primary insurance. I’m going to get no payment. It is important to have that granularity on the COB.
MS. MEISNER: Just because I might not be here for some of the other discussions that you have, there’s a step if we could go up, that I think we overlooked. And it says — right after you say where do I send the 270. There’s another question, and this one we have to understand the impact of this one. Am I enrolled with that payer or entity? As a provider have I been approved by that entity to submit transactions electronically? And the reason this is important for me is if you remember the whole nightmare of NPI enrollment process.
If, for example, United goes and gets 14 plan IDs, would the assumption then be that if I had enrolled to do EDI with United, I am blanketly enrolled with all of these other ones? Or would there be an expectation that if the payer decided that they needed to have my Medicare, my Tricare, my Tricare for Life has a different plan ID, would I then need to enroll with each of those plan IDs? Would it be cross-locked to those plan IDs? As a national clearinghouse we keep all of that stuff and we’ll bounce it back to the provider saying you’re not enrolled with that payer, and here’s how you get the forms. Go enroll with the payer and then send the transaction back through if you want.
DR. SUAREZ: You are not enrolled with that payer. Now the question is whether you point to you are not enrolled in that product.
MS. MEISNER: Well, I don’t know that. That is what I am asking. You have to think about the impact all of the enrollment, that takes a lot of paperwork for the government, for the Medicares and the Medicaids. It’s a lot of paperwork going back. We do a lot of work trying to get the providers enrolled with the payers to be able to do electronic transactions. And you have to enroll for each transaction. And there are different tables maintained for each transaction.
DR. WARREN: If you are not enrolled, you don’t have an information to —
MS. MEISNER: It is just are you allowed to — and especially on the claim side, if you have a rejection rate that’s greater than two percent, Medicare says don’t send them to me electronically until you get your act together. And they’ll shut you off. So we have to keep them on and off, and we have to keep the table that tells us can we send this on behalf of this provider. And the only reason I’m bringing it up is I don’t know when it starts going to a level of granularity, will we be forced to re-enroll everybody, and that’s a huge effort — unless there’s going to be a blanket enrollment process across all the organizations when this happens. And I think the committee needs to take that under consideration.
DR. SUAREZ: Thank you for that.
MS. KOCHER: Can I just ask that we not use the term “enrolled” here, because enrolled — we’ve used that term all day long to talk about provider enrollment with the health plan in terms of product and network. What we’re talking about here is do I have a trading partner relationship established. I think if we can not mix the terms at the beginning, it will serve us better in the end.
DR. SUAREZ: Can we call it a trading partner relationship with the plan, and at the plan and product level? Is that the level, or just generically?
MS. KOCHER: For the transaction type.
DR. SUAREZ: For the transaction.
MS. WEIKER: It is not really a trading partner agreement, because I may have as a clearing house a trading partner agreement with Medicare, but this provider has not been approved.
MS. KOCHER: It is still that that provider is establishing a trading partner agreement with Medicare in which they’re using a clearinghouse to communicate for them. It’s still ultimately a trading partner agreement in the context of how we’re talking about it.
DR. SUAREZ: It is sort of an approved trading partner agreement. Great. Thanks for bringing that up. I think that’s an excellent point. I hope we captured also the comment that Karen made about the enrollment transaction. Margaret, did we get that?
MS. AMATAYAKUL: We did.
MS. MEISNER: And on the response side, there’s just one more thing that we mentioned that I want to make sure gets captured somewhere along here. We talked about Medicare aggregates the eligibility. We call it sometimes hosted eligibility, so you get a feed. And Embion does that on behalf of a lot of payers who don’t want to get involved with opening their gateway and doing real-time transactions. So they’ll give us a feed, and I’m assuming that’s similar to what Medicare’s major system does. They get the feed for eligibility. So there are processes in there that you need to consider in the whole deliberation that you do that feed to those hosted eligibility systems. We’ll have to change if the number goes from five to eleven, and et cetera. So that’s just another impact of this change.
DR. SUAREZ: Okay.
MS. WEIKER: Margret, did you capture the Karen enrollment, that when a member enrolls within a health plan and they have other benefits, more than one type of insurance, that he enrollment must indicate that national health plan identifier, so then that becomes part of the system. So when you do that 270, on that 271 I can tell you that because when I go and enroll, that’s where you’re going to gather that information.
MR. FISHER: From the perspective of the payer, remember the 834 is not a required transaction on the HIPAA for employers. So we don’t get 834s for everybody, and we’d have to revamp the request for information from every type of enrollment.
MS. SUAREZ: Okay. I don’t know if we captured necessarily very well the last point that you just made.
MS. MEISNER: It is just that if there’s a file transfer that’s being done from a payer to a hosted eligibility system somewhere, and it has to carry some of this information, it may need to be added to that. Those files may need to be altered to carry that information, that’s all. It’s just another impact to consider. Not that it’s a bad one or whatever; it’s just more work.
DR. SUAREZ: Alright. Well, we have only six more minutes, so I think we are probably going to — I think the last two elements we had were later in this additional services are identified, so sending a request for preauthorization is what you would need, right, or for other services, if the provider wants it. And then who to send the bill to, this goes back to — there’s the two questions of who to route the bill to, and then who to submit the payment request; is that-? Are we talking about those two, still, in this case, right? The routing as well as —
MS. HANSEN: Can I just say again, if you go back and look at the AMA proposal, the entity that is administering the 270 is not necessarily going to be the entity that is administering the claim. And so you need to make sure that all of these entities get a number so that the number can go in the right box.
DR. SUAREZ: Good point. So there’s a difference between, in many cases, the entity that receives the 270, or that the provider sends the 270 to, and then the entity that’s the plan. It may be a different number, so it will be in the last column. The key element is the difference between the entities that receive a 270, that receive a claim, that issue the 835.
So let me just say thanks for all of this. But we need to finish up. I think we had a terrific — this has been probably one of the most productive sessions I think. Besides listening to all of the testimony, I think putting all of this into a real example like this one was very, very helpful. What we want to do, I think, is we’re going to have to schedule a number of conference calls and do a lot of exchanging of emails on different scenarios.
Usually our conference calls are open, right?
MS. GREENBERG: We can arrange for them to be open. They aren’t standardly open in the sense that they’re just working calls. And, you know, there will be some that will probably just be preliminary discussions among the subcommittee. But Debbie and I were talking about — I mean this is obviously we’re in real-time here. So I think the subcommittee will need to have some conference calls. Then if you have questions, you try to get those answered. But if you have some preliminary recommendations that you’re working on, we can make those open calls so people can have input or feedback to them. And then we’re probably going to have to have a call with the full committee as well, I think, because if you really want to get whatever you’re proposing approved through September meeting, as simple as this is you can’t expect people to get it on the first try.
DR. SUAREZ: I hope that we captured the names and contact information of the people that came in today, and yesterday, and Monday, right?
MS. GREENBERG: Absolutely. And we’re really grateful to them.
DR. WARREN: I have two more things. One, I want to thank the group that put the slides together that kind of kick started our whole discussion, because I think that was very beneficial.
The second thing I want to do, it’s really obvious we only got through one use case, so if anybody wants to go with this and send us other use cases, please do that and send them to Lorraine so that we can work with those. We will be doing more, and I promise we will do pharmacy, in taking a look at this. But I think working through this was incredibly helpful to me to understand —
DR. SUAREZ: I thought pharmacy was out of the question here.
DR. WARREN: You are living dangerously, Walter. So we’re going to come back at 1:00 o’clock. And at 1:00 o’clock we’re going to be looking at the operating rules. So, Justine and I met a little bit yesterday, and then I’ve met with the two organizations that have put their hats in the ring to be this entity, and those are CORE and MCPDP. What I’ve asked them to do is to come back and to do a presentation to walk us through what they have published as an operating rule to tell us what problems it fixes, in other words why they need that and not just the standard. So, you know, fix the problem, who’s using it, and then other information that they think will be very important.
At that point, then, I want to quickly go into — there are criteria for this entity that are in the law. I just want to run through those. NCVHS has some principles that we work with when we develop standards. We’re going to run through those and see if there are any that apply to this situation or any that don’t. And then there were quite a few people in testimony that had some other ideas for principles that may apply in this area, and so we want to uncover those.
And then I’ve asked Linxus to make some comments based on their work that they’ve done in New York, and I think we also want to open this up because Washington and Minnesota also have similar state organizations that do some of this. We would like for them to make some comments, and then again we’ll got to open mic to see if there’s anything we haven’t covered yet.
Now, what I have to tell you is we have a hard stop at 3:00 p.m. — actually, not 3:00 p.m., but probably about 2:55 because Justine has a required meeting for all of the co-chairs in NCVHS that we have to meet some other requirements on our plate. So, as you’re taking lunch, really try to get anything else that you want to have us consider as criteria pretty crisp in your head so that you can be specific on that.
MS. GREENBERG: This might just come up in what you’ve described, and thank you it sounds very comprehensive. One thing that we’ve heard quite a bit was the problem with the timing on some of this, particularly the operating rules deadline being after the implementation of the 5010, et cetera. So, I think we just need to reflect on that. I mean, there may be nothing that can be done other than to be sympathetic. But I do think we need to reflect on whether the committee wants to make any comments about that.
DR. WARREN: At this point, Marjorie, I think we do need to make at least a comment in the letter. So, if people can give us examples of what the real maybe barriers or challenges of having the timeline that way, that would be very helpful. We’ve found it’s always helpful to give one or two examples in our letters, instead of saying something as a global phrase. So is that what you’re after, Marjorie?
MS. GREENBERG: Yes, just so that we capture some discussion on that.
DR. WARREN: All right. Ladies and gentleman, thank you for a very participative day so far.
(Whereupon, a luncheon recess was taken at 12:03 p.m.)
A F T E R N O O N S E S S I O N
DR. WARREN: Let’s get started. For the committee members we have given you a worksheet — and places for you to make notes, too, to better elaborate on the presentations that they gave us yesterday. And so that’s what these presentations are about. They are also for the committee and the staffs of the committee to clarify any comments that they have.
At the end of their presentations I’m going to go over what the legislative criteria has in the law. And then we’ve also established a set of criteria for looking at HIPAA standards that we’re going to look at to see if those apply for us to consider as we look at this. And then I’m going to have Linxus, Washington, and Minnesota make any comments after that criteria. And them I’m going to try very hard to make sure we have an open mic in case anybody else has some comments. And the reason I chose Linxus, Washington and Minnesota, is they are state consortia that have been trying to do the same thing, and so bringing in that perspective to help us with this deliberation.
And then just if you’re not able to provide any verbal comments or anything during open mic, please send Lorraine an email with any more comments that you want to make on operating rules, etc. Again, we’re on a very fast timeline. We have to have a letter completed to take to NCVHS’s full committee meeting in September, and this needs to get to the Secretary within like a week or so after that in order to make all the things happen that the law specifies.
And then Marjorie’s comment, if you really are concerned about any of the timing of this, whether it’s timing of the law, timing of release of operating rules, please also send us your concerns in that. I don’t have the ability to change those dates, but we do have the ability to express our concern about those dates. And so if you give us examples of problems and stuff we can use those in the letter.
So, not to take up too much more time, what I have asked them to do is go over an operating rule that they have currently in place, to talk about what problems it fixes for them, who’s using it, and whether or not they have any data on ROI for using the operating rule, knowing that ROI is very difficult and they may not have that data yet. And I don’t mean that to be a negative thing for them. It’s just trying to get out more information for us to consider. So with that, who is going first?
MS. AMATAYAKUL: Were you going to review these?
DR. WARREN: After they are done with their presentations. I want them to have the ability to give the presentation they want, and then we’re going to be taking a look at these criteria at looking at what they’ve talked to us about. Both of these organizations already know what those criteria are — it was published in the law — that we have to deal with. And then they have plenty of opportunity to contribute any other criteria that they would like for us to consider.
And I know that both of them also have been working with NCVHS over the years and have been fairly familiar with our principles guiding standard development, so it’s not like I’m asking do your stuff and then we’re going to test you afterwards. That’s not the situation that I want to put here.
MS. LOHSE: I think you already explained well what we’re doing here. And we’d just like to note in our written testimony we have several examples of the overall scope of the cooperating rules. And there are individual examples of how rules work with standards, calling out a few standards, because as we enter this new realm — and I think NCVHS did a fantastic job with your concept paper to say how much —
Within our written testimony we provided four examples that really speak to the different standards that are coming out as the health care industry becomes more automated and interoperable. And they speak to non-mandated aspects of the HIPAA standards, and then non-HIPAA health care standards, industry-agnostic standards, and non-HIPAA, non-FCO developed implementation guides. So those are all in our written testimony if you want to take a look at it.
And we are going to focus today on just two of those examples. I had spoken with Judy about focusing on two aspects, based on the questions yesterday, and tried to highlight the pieces that she asked for.
Here’s a quick overview of the overall rule. And this is just stuff so you can see we’re reiterating the point that this isn’t going to happen overnight. There are milestones that are going to need to be reached. And I think Judy’s point about tracking ROI is essential, and tracking that ROI across the milestones.
And so we’ve added in with each of the phases more content and more infrastructure that builds on the earlier phases. And just so you know, Phase I of CORE came out in 2006, Phase II came out in 2007, and both Phase I and II, the content took 5010 in mind as we tried to build upon what we thought would come. And as we stated yesterday, we’re extremely supportive of standards, including those that are in HIPAA. So how do we continue to adopt more of the standards in a meaningful way?
This is the first example. We really looked at pockets of experience that have driven value in the industry, and how they were getting to that value in the medical world. And I think it’s important to not medical and pharmacy are very different. We’ve been working very closely with NCPDP to make sure we’re aligning as we move forward.
And other industries have been exchanging data and benefiting from this value proposition. So how do we make sure as we move forward that we are supporting the pieces of the standard that are going to add the most value, and do it at a time that allows for critical mass movement forward, but not so much that no one else can do it.
So this first standard that we’re looking at is the eligibility data content. Providers really were driving this. I think Tammy Banks who’s in the room from the AMA can speak to that. They really wanted the financials that were driving the phone calls. So we collected a number of data from the providers that were driving up their phone calls, and also some individual vendors that worked with the small providers, and they gave us some data that were driving the phone calls. And how do we find where that interwoven place is where we can add enough value, but not too much that we can’t move forward. So, that’s that 80/20, pushing with the 80 percent change and moving on to the next stage.
And the financials are co-pay, co-insurance, deductible, year-to-date deductible. And then additionally we looked at what was coming out of the clinical side and thought to ourselves, how can we make sure with what’s coming out on the clinical side, like labs, x-rays, radiology, that we’re also delivering the financials for those. And I think pharmacy has done a very good job in doing that. There are a lot of lessons learned there, as well.
We looked at service type codes, and all of this is supporting the standard that exists. We’re not re-writing the standard; we’re taking out places that bring the value. X12 was involved in the discussions, and they also helped with the voting on the rules, and they sat on the steering committee. So we’re really trying to work in collaboration. Obviously our goal here is how can we continue to improve that.
DR. SUAREZ: Can I ask you two questions. The first one is, with respect to the data, you’re not adding in the operating rule the data — you’re not adding data that is not already part of the standard?
MS. LOHSE: We are not. In this instance it’s raising the bar. So there are pieces of the standard, and they’ve done well. And how do we grab the business value so we can drive adoption and reduce the cost?
DR. SUAREZ: But the second question is, you are making some of the data in the standard, and more specifically on the implementation side, that is situational, required?
MS. LOHSE: Yes.
DR. SUAREZ: So you are turning the key on all the data elements in the standard and in the implementation. There are three positions: not used, situational, or required. Many the key is in the situational stage, and the situational description of the rule itself in that the guide says this is required if the following is met. You in the operating rule are making that situational element required.
MS. LOHSE: I think that nuance, hopefully other folks are catching it, because it’s a fantastic nuance. There are the elements that are situation: if this, then that — a logic tree for lack of a better word. And then there are also things that are situational, I think because there’s not necessarily — if you’re at the hospital and you get an inpatient procedure, and if you get a laboratory, and if you get a medical, those aren’t situation in a long logic tree; they’re situation in activity. So, yes we did, in the situation of an activity that was happening, to meet the 8020, those high-volume services. If a patient went into a provider’s office and one of those 8020 happens, we were saying embrace the standard and deliver the financials.
DR. SUAREZ: And the last point I want to make is that is exactly what most of the companion guides that exist in the market today ultimately do. They define in the situational element, they define when that situation is met and they —
MS. LOHSE: I think there are two layers, if I may. There are situations where there’s a high volume and it’s the instance that it does happen. Then there are situations where it could be — and this is a great example, I think — where sensitive data. You all have done a great job with the committee to identify some things that were sensitive: maternity services, HIV, a few things like that. Companion guides do speak to those in different ways. And there is a lot of policy that contributes to that and legal aspects.
Then there are situation pieces that are on instance. And so we try to focus on the instance, not on the situation as the next nuance. Does that make sense? I think there are a few different ways we could divide this.
DR. SUAREZ: Okay. Thank you.
MS. LOHSE: And I guess, Walter, also, with a companion guide, we did collect across the board for the 50-plus services where there are financials, who was using those financials. And in many instances they weren’t required for use. And an x-ray or lab, providers were saying we really want those happening on a day-to-day basis; that’s going to add some significant value.
And we did get quite a lot of pushback from different health plans that were not comfortable with delivering it. It was a huge investment for them. But it’s that constant balance between what the providers were asking for, what the health plans were asking for, and what the vendor data showed as well.
DR. OVERHAGE: Can I follow up? You had commented about the companion guides in particular addressing some of the more sensitive information. How has the CORE group approach overall, how do you incorporate the privacy, and security guidance, and — so on this emerging out of the broader discussions into the operating guides or rules.
MS. LOHSE: Very conservatively. I think it’s evolving very slowly, and as meaningful use comes out, we’re going to see quite a lot of challenges in that area. If there is a law or there is a policy, or even you all put out a concept on sensitive benefits, it wasn’t necessarily a requirement, but it was a very strong thinking, we’ve tried to follow those in all instances.
It was a real struggle with the financials for maternity services, HIV, mental health — especially mental health. The providers loud and clear were saying we need that data. There are very high cost purposes. And because of the privacy issues, the agreement was made not to deliver year-to-date, because it meant you used the service. All of the other financial could come, because they were static, and use would not be able to be detected electronically.
So, there are a number of instances also with digital certificates. People have different policies on digital certificates, so across the board conservative, across the line conservative, because I think it’s going to be evolvement. And that’s one reason why as we look at the operating rules, your committee is going to play a critical role in helping weave in the policy, and also the need for the data, and the policy effectiveness, and the cost reduction.
DR. SCORCE: I was just curious, do any of the operating rules fall under what you might call quality of service? So things like response time, or numbers of incomplete messages, or messages that require follow-up in some manner?
MS. LOHSE: Absolutely. We wanted to really respond to the question at hand, so we only gave one example. We actually have two examples for the discussion we had earlier today. There are other rules that speak to things like response time and error tracking. And making sure, for instance, batch — we had a big discussion yesterday about batch. And there was not doubt we heard loud and clear again from the providers, many of them rely on batch. However, the batch turnaround times are all over the board. So we had to come to an agreement about what was a respectable operating rule for batch that spoke to the business needs of the provider, and also spoke to the realities of the market.
So the answer to you question is yes. I just didn’t want to go in — we have limited time. I didn’t want to go into all of the details. But we can give that to you if that would be helpful.
DR. SCORCE: I actually think it would be.
DR. WARREN: Can I just go back? I asked them — I gave them very limited time to do a presentation with time for us to ask questions after, so can we hold question to the end? And let me manage the time, because we really are time-crunched.
MS. LOHSE: You were very clear that we had specified time, so I’m trying to be respectful of that. But we’re happy with any of this, if you want to see the data analysis or the detailed work, we can share it with you.
Connectivity has been an ongoing challenge in the industry. So even if you’re having all of the data available, if you’re not able to connect, it’s very difficult. And we’ve really taken this to a place where we’re trying to embrace the Internet that’s evolving quickly. It’s used in a lot of low-cost methodologies that are available. But just like with the data content standards, some of the clinical standards, there are many different ways entities have implemented the standards in this area.
So there was a significant best practice approach, quite a lot of work done with what is clinical doing, and how can we get to a place where CORE could offer a connectivity rule that was a safe harbor. So, if you became CORE certified, you needed to offer this out. If you had other things that worked, and the providers wanted to use that, they could continue to use that. But if you became CORE certified, one way to connect.
And this is the CORE Phase II connectivity rule. Pharmacy obviously as we think about Surescripts and the work that they’ve done with having Surescripts, which connects up to all of the e-prescribing systems, Surecripts is CORE certified also. So it’s that ongoing connection with pharmacy and medical. Pharmacy is not our focus, but alignment with pharmacy and the other segments of the industry is our focus. Medical is the big focus, but making sure we’re aligned.
So as we looked at connectivity, it was the CORE participants that helped develop this rule. And they supported standards that are listed on the slide. Most of these are international and national standards, and they were not applied systematically in health care. So we looked across how entities were using them to date, and how we could come to agreement within CORE on a connectivity rule, and then make sure it aligns with the bigger picture of health IT that was evolving.
And this would be available for both batch and real-time, again, understanding some providers want batch and not real time. Other providers want real-time and not batch. So really being able to complement both.
As you’ll see, there are some guiding principles for the CORE connectivity rule: facilitating interoperability, enhancing efficiency and lowering cost, building upon existing standards. Those are standards like web services, digital certificates. They’re standards that are industry neutral, but we need to adopt into health care and really work towards our policy goals to see how they fit into the bigger picture.
And then creating a base and not a ceiling. We’ve talked a lot today about we’ve really worked to support the standards, and we’re not constraining what you can do with them. If you want to go further and above, that’s all encouraged, because we need to have people that move forward and do more.
And then providing a safe harbor, I already talked about this, what the connectivity rule is not doing. And these are policies that there is a policy workgroup that looks over all of the rules and figures out, as it rolls out in the marketplace, will it impact certain policies, and do we need to get additional input? So, for instance, there are connectivities that are proprietary right now, and some people do not want to use the Internet. And that’s fantastic; if the trading partners agree to that, have them move forward with it. Or, for instance, require all entities to use this connectivity for all of our connections. That’s now what this rule is about. It’s to provide a safe harbor to start connecting some of the entities and do it so it’s in collaboration with the other segments of the industry.
And NCPDP has spent a lot of time with us on this. And I think we’ve done some great work collaborating in this area. If we think about he vision of interoperability, we’re all going to need to connect and be aligned.
So this is in our written testimony, and I don’t want to go into too much detail here. But it shows where these two examples, which transaction they apply to, if it was a federal requirement, what some critical decisions were made while we were writing the rule, and then the benefits in the market, many of which I’ve already talked about. But it’s in our written testimony if you want to look into any of the detail.
And we also are happy to have to talk to any of the users, which we’ll go into right now. Judy had asked for who is using this today. For Phase I certified entities, for the first level of this — and this again for the financials and the connectivity — there is a range of providers: Mayo is in the room; I know Laura did a great job earlier speaking, the U.S. Department of Veteran’s Affairs, who we heard from yesterday, and Wake Forest.
There are health plans. ASMED, they’re in Florida, they have a very heavy Medicaid and Medicare population. Healthnet and Humana have applied it to their Medicare Advantage population. And then clearinghouses, and we heard from GE yesterday, VisionShare, and they work a lot with Medicare, CSB. And then there are a number of entities that are using the Phase II rules, and those are listed as well. And I know Janet Jackson presented yesterday, and she’s in the audience if you want to ask her more questions.
And the benefits, we’ve spent considerable time trying to track the benefits, and did retain IBM to do that. They went out to several provider locations and did the whole process, collected detailed data. And we looked at the impact from non-Phase I to Phase I use across health plan vendors and providers that covered about 33 million lives. And it’s hard to break up by rule what the impact is. But the concept of studying the impact of any of these health IT adoptions is going to become more and more critical. The challenge in doing it is tremendous. The cost to do it is significant, and the commitment from the entities, whether it’s the health plans, the providers, or the vendors, plus those that are funding it and helping it to coordinate it; it’s horrendous, but very important.
And we do have a detailed study on this. And if you’d like to talk to IBM, we’d be happy to do that, or any of the people that participated in this study. It really drove down claims. We started to see all of the participants that were using the CORE rules for Phase I and II were starting to see more transactions across the board. And then there was a 24 percent increase in eligibility verification at the providers’ locations, because they had the ability to receive more eligibility, either in batch or real-time, and more data. So they were able to have the resources and the time to ask more patients that came in the door before at the time of service, were they eligible and at what level.
So as we think about moving forward, how the standards and operating rules work together, we’ve thought a lot about this, especially in regard to X12. Obviously they’ve been very involved in CORE. We’ve been working to promote the use of their standards, both the ones that are health care specific, and non-health care specific, such as some of the acknowledgements. And then additionally we have to consider the other standards that are not yet part of the current DSMO, those international and national standards that we’re using on the Internet, as well as some of the policies and procedures. So, as you consider about how this is going to play out, we hope that you think about the role NCVHS can play given you’ve got a wide range of skill sets at the committee. We’re going to need to combine all of the skill sets to really get to where we need to be.
And I wanted to just provide some points of clarification. CAQH, as it was developing the concept of CORE, CAQH is an independent nonprofit organization with an independent board and bylaws. We are focused on administrative simplification. That’s been our mission from day one. And CORE is supported by CAQH staff, but it’s the CAQH participants that make the decisions through the subgroups, the workgroups, the steering committee, and quorum-based voting. So all of those rules that you just saw were developed through that process.
CAQH is the facilitator, but CORE makes its own decisions. And as I testified yesterday, we did make a change in the bylaws. The CAQH board did have a right to veto the CORE rule, and we removed that. And they never exercised the right, but we removed it because it made sense. It was never exercised, and also in the mission and vision of CAQH, the administrative simplification, having providers, health plans, vendors, FCOs, all of those critical making this change at the table, that we weren’t sending any other message.
And then for a few other points of clarification, in case there was any confusion about this yesterday. Operating rules are delivering the real world business value. So, a lot of the analysis is about how to reduce the claim denials, how to reduce the cost, how to increase the connections and reduce the time on all of the proprietary connections that are happening how. There are operating rules that address standards, as well as those that do not.
And there are a number of policies, so we need to think about the role of the DSMO, because there are some standards involved there, and there are other standards that are not. It’s technical and there are policy pieces to this. It’s a base and not a ceiling. And then the rules are interdependent. So they are addressing both the roles within the organizations as well as between the organizations. And we’re only going to get so far if we don’t think about the whole chain.
I liked the gentleman that presented from GE yesterday, I know there have been several academic medical centers that have contacted us to say, I see that your to-date deductible information is out there. Why isn’t it coming to me? And GE’s system is not yet changed. And this is not going to work if we don’t all recognize that it’s going to take more than just one aspect for the big picture. And we’re happy to put you in touch with those hospitals, as well. And I don’t mean to call out GE so if you’re here, my apologies. But there are many other examples like that.
With the data content, I think as we move forward the business deeds are going to vary, and we do see some of the pieces that are in the CORE rules that are supporting the pieces that are in the standard. We absolutely see, as we saw in that visual with the cycles, that some of that will just go into the standard. We are not a standard-setting body. Margaret and all of her colleagues at X12, they have that level of expertise and have experience over the years that we do not have. We have to work collaboratively and cooperatively. And we do have staff that attend those meetings — we usually send two to three people — to keep that continued discussion moving forward. And if you look at the Phase I and II rules, there are pieces of the 5010 just for coverage, yes/no, on certain services that are in the CORE rules before 5010, and now they’re required by 5010. And so we will remove them, because we are not repeating what HIPAA does. There’s no time or room for duplication.
And then the last thing is just really focusing on the medical components of the industry. We need to collaborate with other sectors, because whether it’s the health ID card, whether it’s the EMR, the HER, this is all going to need to work together. And wherever anyone has made some significant progress, we need to really work with that, because there has to be that clinical admin cooperation.
Those were our examples, if you all have any questions.
DR. WARREN: I have two points of clarification. One, is CORE ANSI accredited yet?
MS. LOHSE: We are not. We have not sought ANSI accreditation because we have really felt like we’re not an SDO. And I think moving forward, there are other industries that have operating rules, and they’re not ANSI accredited either, so how do we continue to send the message?
DR. WARREN: Okay. And ANSI also has accreditation for ways decisions are made, so even if you’re not an SDO, there are some other avenues. So that’s what I was asking about.
The second one, and maybe this is just really obvious, but I want to make sure that we’ve got it on tape. So is there one and only one operating rule for each standard? Like there’s one for a 270, one for a 271, or do you have multiple operating rules?
MS. LOHSE: There is one for the content. And there are infrastructure rules that apply across standards. So batch turnaround is —
DR. WARREN: So you would have one operating rule for content, one for batch standards. You wouldn’t put those all in one operating rule.
MS. LOHSE: They are all in one phase. So the CORE rules are in phases, so they’re all in one phase of the CORE rule.
DR. WARREN: Okay. So let me ask it a different way. Do you publish them together, so if I were looking at a piece of paper they would all be together?
MS. LOHSE: Yes. They all three are on the website, and they’re in one package. And maybe Margaret can speak to this better, or Lorraine, because I think we sent them to both of you. And we believe they should be free and they should be all consolidated and together.
DR. WARREN: As I say I just wanted it stated very explicitly on the tape.
DR. SUAREZ: Right. But just to follow up on that, there are 14 operating rules that apply to eligibility, or 12, or 11, right? So there are a number of operating rules. So when we say — we’re not talking operating rule, we’re talking operating rules —
MS. LOHSE: Rules, yes.
DR. SUAREZ: — for eligibility.
MS. LOHSE: Yes.
DR. SUAREZ: And there are eleven of them. Some of those operating rules that apply to eligibility apply to every other transaction. That’s what you call infrastructure operating rules. For example, system availability could be — maybe not. But there are some — connectivity, security, and authentication, that could be something that applies to every rule, every transaction.
MS. LOHSE: Absolutely. And specifically with connectivity, because it’s payload-agnostic, so it could be used —
DR. SUAREZ: And then there are one or two specifically — two that are specific to the eligibility transaction in terms of the content?
MS. LOHSE: Yes.
DR. SUAREZ: I just want to be very clear that that is the distinction. When we are talking about this is the set of operating rules for eligibility, we’re talking about eleven in your particular case, right, in the CORE case?
MS. LOHSE: Yes, and what we will do after this that will be most useful for you, is we will send you by phase the list of operating rules, and they address both data content and infrastructure, and the infrastructure rules can be applied to more than one transaction type.
DR. SUAREZ: The other question I had was the phases and the fact that some are in one phase, some are in the second phase, some in the third — or are being developed for the third phase. So, there is no versioning implication in the phase; is that a true statement?
MS. LOHSE: I don’t know if you are asking about versioning with — the phases build off of one another. So, for instance, year-to-date with deductibles were not required in phase I; they are required in phase II.
DR. SUAREZ: Okay, so the next phase of a rule is an expanded version of the first phase? It cleans up, adds, expands?
MS. LOHSE: Yes. There is an entity right now, a large health plan, that’s going through CORE certification for both I and II. You can do them simultaneously, or you can do them separately. Every phase is more aggressive than the first, and it builds upon the other. It is not editing the other one; it is building upon it.
DR. SUAREZ: But by saying building upon it, it’s not like 4010 and 5010 where 5010 replaces 4010, and 4010 is nobody would be —
MS. LOHSE: No. Absolutely not.
DR. SUAREZ: So would the recommendation be that a particular rule that has three phases already — it’s in three different phases — be considered the three different phases be part of the rule?
MS. LOHSE: I think that as we look at the legislative intent of what we’re discussing, there are milestones the industry has developed to this point, and there’s then phase I, phase II, and we’re developing phase III. One of the questions we’ll need to ask ourselves is we could wrap, because the phases build upon each other, we could wrap them all into one set of requirements. It makes it much more aggressive than what the market has done to date. They’ve done it sequentially because they build on each other. Each of them support standards, and that will continue at each of the phases, but each phase builds on the other, so you could for the legislative intent wrap I and II together. You could just require phase I. You could require phase I and parts of phase II. Or you could require I, II, and III.
DR. WARREN: I want to clarify with versioning. To me versioning is not phases. But I understand you’re building on capability. But versioning to me is, on this date this rule is in play. So when you’re looking at certifying, it’s certifying to the rule that’s published on that day. Is that how you handle how these evolve? I would imagine that these rules evolve over time as you still go about this. You don’t just here’s the rule for 5010; it stays that way. You may have more business needs come up in your process, right? Am I in the right domain for this?
MS. LOHSE: You are certified by phase. And within that certification process, which is all online and cannot be done for free, you will sign a HIPAA attestation that you are meeting the HIPAA requirements. And the rule, if a new version of HIPAA comes out and there is anything in the rule that is required under 5010, it is removed from the rule. And the upgrades are made accordingly.
DR. WARREN: That’s not what I am asking. So, I come in and I get certified at phase I today for 5010. Through your process that you have for creating your rules, you have the ability to keep changing those rules to meet needs. But I’m only certified on the dates that I took certification; I’m not held accountable for meeting things that happen after that. I have to be recertified? That would be the versioning control of your operating rules. No, not at the phase. She’s got one rule; there are three phases to it, so three levels that I can meet at.
DR. SUAREZ: But it sounds like you get certified not by 5010 version, you get certified by phase. So you get certified for phase I. If CAQH develops phase II, you have to get certified for phase II, whether it’s 5010, 4010, or 6010.
DR. WARREN: I know that. But if they’ve got a CORE rule dated January 2010, and in that process they update that, so they have some slightly different things in their phases on January 2011. So when you get certified, this would be for 2011 if I’m coming in on ’11. Or do you just write this rule and it stays that way forever until we go to 6020?
DR. SUAREZ: No, until they go to the next phase.
DR. WARREN: No, no, that’s not what I’m saying. To get these phases you have people sitting in rooms like this that say oh, this should be in this phase, and this should be in this phases, and might want to change different things in the phases. Otherwise, you’ve got one job, you create the rule, it is done, all three phases of it are done until we get ready for 6020.
MS. LOHSE: Forgive me if this is not clear, but Walter you are both correct.
I may asked people that are certified to explain this much better than I am, because I’m obviously not doing a good job. With the phases you are certified by the phases. And some entities, it’s voluntary, they may stop at one because they can’t deliver the other service types, they can’t deliver the year-to-date deductibles. Maybe they don’t want to do the connectivity piece yet. So they may stop.
You’re not committing — in certification you’re only committing to that phase. So it stops by phases in a voluntary environment. Within those phases, it supports different standards. We talked about the standard 4010, and 5010, and the X12 standard. So it could be 1.1, 1.2. So as those standards, the new versions come out, we do go back to make sure each of the phases appropriately support the mandated standard.
Now right now the mandated standards under HIPAA are the X12 standards, and also the NCPDP standards. Within the phase I and II rule, they support the 4010 right now, because the 5010 is not required until January 2012. The analysis was done, if there are small changes — primarily removing requirements that will not be required by 5010 from the CORE phase I rule. And so we do go back to the phases as federal mandates come out with the standards. And as the NHIN moves to 1.2, we will go into the CORE phase II rule and make sure the connectivity is aligning with that standard.
DR. SUAREZ: To simplify you could build a table, let’s say this type of table, phases in columns, and in the top instead of title CORE rule, if you just say eligilibity transaction, phase I, II, III. And the in the rows it’s really the X12 versions, so 4010, 5010, 6010, et cetera. And you can say phase I for 4010 you’re checked. So you have phase I done for 4010. Phase II, I don’t know if it’s built for 4010 or 5010 already, but you can build a tracking mechanism that shows the phases and the rules.
DR. WARREN: We are running out of time. I’m sorry, I’m going to need to cut us off. I really am out of time. So we need to move on to NCPDP, because we need to give them equal time to talk about their stuff. And you can also send Lorraine other stuff on that. Sorry, I just looked down and realized that we were a quarter to, and we need to have NCPDP do their thing.
MS. GILBERTSON: This will be much shorter, sweeter, not taking anything away from what Gwen was saying; it’s just we’re coming from a totally different perspective. And as noted yesterday, operating rules were huh in pharmacy.
Once again, just to pull my thoughts together, I went back to the definition when asked by the subcommittee to look into what we had for operating rules. I had to dig pretty hard, because part of the point of the regulation is there can’t already be in the standard or implementation guide. Well, that’s where all of our stuff is, or in the reference material that’s already in the package of information that you implement.
So if I was going to find something that wasn’t in somewhere already stipulated, I had a little difficulty getting to that level. So we have to recognize that what an operating rule is supposed to be is something that’s not already in the IMP guides, it can’t cover — or they may cover exchanges not already defined in the IMP guides. I don’t really have good examples of that in the pharmacy world of things that are not used in the implementation specifications, unless I go to other layers, which are outside of NCPDP environment. So then we cannot add, modify, or remove requirements, which we’ve already stated.
So the operating rules, basically in our implementation guides already, we discussed the real-time or batch requirements, what the sender and receiver’s expectations are all about, the business examples, and the scenarios and examples of using the guide, as well as the business examples.
I kind of feel sometimes, yes, there is a lot of information in the IMP guides that are technical, but it really isn’t. These are business people who are sitting around the table saying I’ve got a problem and I need the guide to explain the problem and show how the standard can exchange that information. But we start with business stuff; we don’t talk about lets shove bytes around like I think sometimes — we’re not propeller-heads just sitting around in a room. These are business people who are asking the questions.
We have reference documents, dictionaries, values, explanation documents, and the other day we mentioned the payer template. These are all part of the standards package that the industry uses. So when I was digging, I really had to dig hard to find things that were not already in the guides that really addressed factors within the concept of what an operating rule is.
I happened to find this one. It’s not a terribly great example. But the long-term care pharmacy industry came together and said we’ve got some guidance we have got to give on the processing of long-term care claims, and this is actually in one of our reference documents. But it’s not really as standard transaction-related type rule.
So, this is one example of what the industry pulled together and said, okay, here’s a guidance for best practices. And we have other best practices documents, but once again, I don’t know that best practices necessarily become operating rules because there is a concern that we have to look at those with the idea of now they’re being regulated, versus what’s best practice as just good guidance for the industry. And we don’t have that many best practices documents, because the expectation is using the standards correctly you don’t need a lot of best practices extra documents; you put it all in there.
We also have guidance information that I mentioned a little bit yesterday, the day before, about consistent use of the X12 standards in the pharmacy industry with using the pharmacy ID card, or electronic prescribing functions in the doctors office. And we also have a mapping document that shows here are the pharmacy claims that have taken place, and here is where the appropriate information should be on the 835, and the remittance advice so that things are lined up nicely for the real-time claim versus the remittance advice processing.
And unfortunately I didn’t have the ability to grab an ROI. I’m sorry, but it’s just not — NCPDP doesn’t usually go into why do you need this for business. If we bring enough people together, and they agree, even the dark side of competition, all agree, that’s enough ROI for us to put it forward.
So I think we’ve seen consistent use of what we would consider operating guidance that’s already in the guide. One of our biggest examples is the entire Medicare Part D world. That is such a collaborative environment in pharmacy, it is amazing if anybody wants to see something in action of getting the plans together, CMS, the Medicare divisions, the pharmacies, the vendors, and the switches all together and really say Medicare wants this, how are we going to make it happen? They may grumble a bit, but guess what? What comes out is the operating guidance, and many of the things that they have done have actually been used in CMS guidance that they actually issue saying this is what you will do come January 1st, 2012 or whatever it is. So those are our operating type guidance as it comes forward.
I’m not saying the industry is perfect. We have our set of warts, as well. But that’s some of the functions I could see that would fit within the operating rules environment as defined in the regulation. So, short, sweet, sorry.
DR. WARREN: So what I’m hearing from you is the way your process has evolved is that the SDO has also become kind of owner of the operating rules, although you’re really calling them companion guides, implementation guides?
MS. GILBERTSON: Implementation guides and reference materials, yes. The term companion guides is not in our vernacular.
DR. WARREN: Okay.
MS. GILBERTSON: For whatever reason it has emerged as not only the technical lining the bytes up on the wires, but also the business practices that you use for the different functions.
DR. WARREN: And so — and the two of you can answer this — what you’re having in your implementation guides and reference documents are some of the same things that you’re having in the CORE operating rules.
MS. LOHSE: I can’t comment on the details of the NCPDP guide.
DR. WARREN: Just what you’re hearing Lynn say.
MS. LOHSE: Sure, there are absolutely some similarities. I think one of the challenges with medical and pharmacy — you connected up to pharmacies. The PBMs and the pharmacies came together to form Surescript, which is now connecting out to all of the vendors. The medical world and the pharmacy world have a lot of variation. And so the challenges in the medical world and the challenges in the pharmacy world and the different standards that are used, and the different stage that medical is than pharmacy, they’re at very different place, they have different challenges, and they have different players. It’s not a complete comparison.
DR. SUAREZ: Just to get clarification, from your perspective you’re saying you want to be an authoring organization, but you are putting forth some documents that could be referred to as operating rules that support the pharmacy transactions. Is that what I’m hearing? There are two parts of this, the authoring organization, but then also the operating rules for eligibility and for claim status. And what I’m hearing is that there is no need for operating rules for claim status for pharmacy. And the operating rules for eligibility are already covered within the current specification and supporting documents.
MS. GILBERTSON: To the first part, what we would anticipate, or what I’d expect to happen, is to take the definition of the operating rules from the regulation back to the industry and say is there anything that hasn’t been addressed. If there is, we’ll get it written up, get it approved, and get it before the DSMO and then the NCVHS as the operating rules.
If the industry comes back and says we don’t want something built, I’m not going to make it up. I mean, we will keep trying on an interim basis to say, okay, is there anything that’s coming forward, any pain or pressure points? I’m not saying we would ignore that; we would take that very seriously. But we can’t make the industry come up with rules just because. So it would be continuing to ask.
DR. SUAREZ: But when you’re referring to the industry, you’re referring to the pharmacy industry?
MS. GILBERTSON: At this point.
UNIDENTIFIED PARTICIPANT: Do you think also there’s some value to be learned and lessons learned from the formation of Surescript in the pharamacy world, in the sense that it has helped your segment of the industry connect? It plays a role with the operating rules.
MS. GILBERTSON: We would look into it from all aspects. You know, we tend to focus all on claims, because the rule is more HIPAA based. But we also have the e-prescribing transactions. Is there a need for any kind of operating rules there? Now, they don’t have to really come forward, because they’re not HIPAA transactions. But is there a need for operating rules in e-prescribing of any type? Are there needs for operating rules in manufacturer rebates? Things like that where we can formally address is there anything. Now, we have a utility, and environment where if it hasn’t had a voice, it now can have a voice.
DR. SUAREZ: Then with respect to the CAQH, the operating rules related to eligibility, are they being used in the pharmacy industry transaction? You might have addressed this already.
MS. LOHSE: Where there are crossovers, and Surescripts is a good example. Surescripts was formed by the PBMs and they did become CORE certified because it benefited them to connect under the health plans that are working with CORE, and some of the vendors as well. So you’re going to see a little more crossover as that continues. I know, for instance, there’s a woman — Johnson and Johnson that has a subgroup that NCPDP has started where there is more crossover between biopharm pieces, that’s medical and pharmacy. And they asked us to try to work together. So I think we are going to see more of that as we’re looking at — whether it’s EMRs, or if it’s practice management systems that are doing both clinical and admin.
So we are starting to see that. We obviously work in collaboration. I think that is going to be more and more important as we move forward. And there are aspect to — Lynn mentioned non-HIPAA standards. There are obviously — I wanted to show both the example of the HIPAA standards, our support for version 4010 now going above it, as well as 5010 before it was required, and going above it, even parts of it that are not going to be required. So if there are other standards that are not part of HIPAA, and that’s one thing that’s happening in connectivity. So as Lynn mentioned, it’s non-HIPAA standards that are going to be critical to the operating rule initiative. It’s not just the HIPAA standard if this is all going to work.
MS. GREENBERG: I am trying to understand what role so far CORE has had with operating rules related to pharmacy. Did you mention there had been some collaboration or there’s obviously been some communication. In your process of developing the operating rules under CORE, did you identify needs in the pharmacy transactions that you then took to NCPDP, or?
MS. LOHSE: Where there has been the most crossover was really through the connectivity piece. And that really came up as a result of the Office of National Health Care Coordinator developed, and they sponsored HITSP. And HITSP was looking for a way to promote connectivity. And both CORE and NCPDP were participating in that group, and we said we would absolutely work closely together. So it’s really been in the realm of connectivity, as my example showed, and as Lynn did a great job the other day showing.
And then we did also, when we looked at the ID card, we also collaborated there, because there was a big push with health plan ID cards to have it pharmacy and medical coming together. And, again, going through milestones, the industry was not at a place where we could do a combined card, a requirement for a combined card.
So there has absolutely been collaboration and coordination. We are not looking into the details of pharmacy and working closely with NCPDP on that coordination where there is crossover. Would you say that accurately describes?
MS. GREENBERG: These operating rules are obviously supposed to fill gaps that are keeping people from using whatever the transactions are, as efficiently and as effectively as possible. So, if gaps are identified by X12 in those HIPAA transactions, I assume they either attempt to fill them within the X12 standard, or they’re outside of really the X12 standard, so they go into these operating rules. Is that correct? I mean, obviously you’re working closely with X12 as well, so you’re not competing with them, and you don’t want any duplication. So I guess I’m — if there were only one group, as several people asked for, named to develop operating rules —
DR. SUAREZ: For?
MS. GREENBERG: — for —
DR. SUAREZ: Eligibility?
MS. GREENBERG: — all of the HIPAA transactions.
DR. SUAREZ: No, no. There is one entity for all transactions.
MS. GREENBERG: Okay. So nobody was saying they wanted one entity for all of the transactions?
DR. SUAREZ: No, no.
MS. GREENBERG: Well, then I don’t understand what the issue is here.
MS. LOHSE: I think this hearing is only on eligibility and claim status, and obviously the long-term vision we all want to consider. But I thought today we were just talking eligibility and claim status.
MS. GREENBERG: Okay, we are talking eligibility and claim status, but I felt that people who were testifying on operating rules were looking more globally down the road, given that we don’t want to start over from scratch when we have the next requirement, and start as if we haven’t had these hearing in the past.
So, if people were only saying they wanted one group per transaction, then I don’t see any conflict here. You’ve got the people responsible for the pharmacy transaction saying, you know, we’ll meet whatever is needed. We’re trying to meet it now, and if you can tell us there are things that aren’t being done, we’ll continue to do that. And then you’ve got the X12 transactions, you’ve got four doing this, right?
MS. LOHSE: I think, Marjorie, I think there are absolutely interdependencies among the transactions, between the transactions, and that’s why there is a number and entity that have said they want one entity to look at this.
MS. GREENBERG: Okay, but you are not looking to take over the operating rules? CORE is not looking to take over the operating rules for the NCPDP transactions?
MS. LOHSE: We are looking to meet the needs of the legislation, which does call for a nonprofit focused on administrative simplification to write operating rules. And we have been working on operating rules. The concept of operating rules needs to support many standards among those that are already named under HIPAA, which is X12 and NCPDP. The operating rules need to support the existing standard and fill in the gap. And that means everyone’s going to have to collaborate, and there is a need for an overarching umbrella. So that is the description in legislation that we’ve been working towards to present our testimony today.
MS. GREENBERG: Well, is NCPDP looking to have a role with operating rules beyond the NCPDP transactions?
MS. GILBERTSON: I guess my answer has to be yes because of the X12 testimony yesterday. We will collaborate. We would like to have strong control of our destiny. But we will collaborate. But if it becomes recommendation that there should only be one, we will take on the role of more than just the NCPDP standards; whatever is appropriate.
MS. GREENBERG: Thank you.
DR. WARREN: Okay. So if you remember, the organization here was to let them present their proposals, have the committee and staff ask questions, and then we were going to review real quick the criteria that are in the law, and the NCVH’s criteria, and then what we were going to do is ask the three state groups to do a response. I know they have some concerns of pieces that are missing, some suggestions for how to fill those out.
So with that, Margaret has put together in all of her brilliance a table. And so probably at this point it would help me, Margaret, if you would just briefly go through the criteria that are in the law. And then let’s stop there, and then we’ll go on to our guiding principles.
MS. AMATAYAKUL: So the criteria in the legislation identified the need for an entity, and it had five criteria: that it be focused on administrative simplification, it’d be multi-stakeholder and consensus based, it has a public set of guiding principles, open, transparent, build on transaction standards under HIPAA, and allows for public review and updates. And that’s a slight shortening of some of the statements, but essentially the essence of those five elements.
Then there were also three requirements for NCVHS to review operating rules. And these included that the operating rules represent a consensus view, were consistent with and do not conflict with other existing standards, and were consistent with the electronic standards for health information technology.
DR. WARREN: Okay, those are the requirements that we have for considering the two proposals. Now what we’ve done with the advent of HIPAA is we’ve accrued a set of guiding principles that NCVHS has used to try to untangle everything and help us do good work. So if you’ll go over those.
MS. AMATAYAKUL: So, as early as 2000, when NCVHS was tasked under HIPAA to look at recommending standards for what was called patient medical record information a long time ago obviously. These guiding principles were developed, and I think they have been used or slightly modified and used subsequently. They include improve efficiency and effectiveness with health system. That’s the first one. I’ve continued the numbering so it’s easier for us to reference. But number one would be to improve efficiency. That they meet the data needs of all in the health community, that the standards would be consistent with other HIPAA standards. I put HIPAA in parentheses only because I’m assuming there may be some other standards. Also, low additional standards development and implementation costs relatives to benefits of using the standards, that the standards be supported by ANSI accredited, SDO, or other private or public organizations that will ensure continuity and efficient update of standards over time, that the standards have timely development, testing, implementation, and updating procedures to achieve benefits faster, that they be gender neutral and technology independent of computer platforms and transmission protocols, that they have additional data collection burdens on users as low as feasible, the standards incorporate flexibility to adapt to changes, standards be consistent with characteristics and attributes for clinical specific terminologies, and that they be consistent with features and characteristics of what was called data quality — I think we’ve come to use the term data integrity.
DR. WARREN: Okay. So from committee and staff, are there any of those principles that we have probably we should ask that you feel are inappropriate for this deliberation?
DR. WARREN: Okay. So with that before we open it up to other and get to an open mic situation, we’ve asked Linxus, and Minnesota and Washington — and if you don’t have any comments, you don’t have to. If you have comments, come on up. Patrice, are you still on the phone?
MS. KUPPE: Yes I am.
DR. WARREN: Okay. So, Eric is getting set up to show us some comments. While he’s doing that, do you have any off-the-cuff about concerns that you have about the criteria from the two proposals for the operating rules entity that we’ve heard today and yesterday from your state perspective of doing this?
MS. KUPPE: I wasn’t able to hear all discussion, so I’ll start with that. But I appreciate that you might consider looking at the timing of these. Otherwise, from my perspective the question around should there be just one, I think — and Eric will probably be saying this — I think it’s okay to separate pharmacy from the X12 transactions and the two different operating rule developers. And that the business owners need to be on the operating rule side, and then standards are just to figure out how to format the data.
DR. WARREN: Any questions or clarifications from the committee for Patrice?
DR. SUAREZ: Yes. One question. Patrice, Walter here, just with respect to the experience and specifically eligibility transaction, the experience of the State with the companion guides, and the extent to which the content of those companion guides could or would or need to be reflected in the operating rules. What can you tell us about the experience in the State about that, and the perspective perhaps about the need to incorporate or consider those statewide uniform companion guide requirements into the operating rules for the eligibility transaction?
MS. KUPPE: Two points, Walter. I think if we do it right, the operating rule eliminates the need for a companion guide, which is around data requirements. The companion guide can talk about a trading partner ID, or their hours of operation. But Minnesota basically eliminated all payer companion guides by making the data and the grouping of the code sets clear enough.
The only other point is if whoever is appointed, I’m not sure that the phase I, II, III approach will work for the nation because it’s sort of confusing if I’m going out to see what requirements are for transaction XYZ, to find them buried into a phase. So I would just suggest that whoever we pick, when you write operating rules, there are rules around connectivity, which are more generic. But if you’re writing about eligibility or claim acknowledgement, the 277 or whatever, that you’d want to break that out into its own rule book. Does that answer your question?
DR. SUAREZ: Yes, absolutely. And perhaps just to amplify the significance of — in the end health care is done at the local level, and that’s why a lot of states have organized within their markets these initiatives to create common companion guides in their region. We heard, you know, Minnesota, we heard Washington state, we heard New York. And so I wanted to bring up the significance, the importance of thinking and considering those kind of experiences that states already have and have in place and are using today in the development of these companion guides.
MS. KUPPE: And our experience is one national health plan who was at our table — we didn’t have just one, but I know for sure one — eliminated their companion guide for the whole nation because it was specific enough.
MS. LOHSE: I just have a comment, Patrice. I know Minnesota has a guide, obviously Washington, New York, through Linxus, which has not been a state effort, but a private effort, Colorado, Texas, Oregon; I could name a few others. I think as we look at this, if we’re going to take that approach, some of them have just identified data content, and a lot of that data content is some of those additional requirements that the CORE participants identified that would add the business value, many of which are participating in the state. Some states also decided to pair that with the infrastructure rules. So whether it’s phases, or if you wrap the rules together, many people feel the infrastructure and the data content are both necessary to have the intent of the legislation.
DR. WARREN: Okay. Do you have any more comments, Patrice? And if not, then we’ll turn it over to Eric.
MS. KUPPE: None. Thank you very much.
MR. WALLACE: Okay, thanks. So I wanted to — actually I think I’m appropriately situated here, because I feel like really the proposal that we have is a bridge between I think the strengths of what the proposal is of the SDO’s and the strengths the CAQH CORE has presented, but both have inherent weaknesses. And I really think we have to consider the long-term when we design this and when we start to select an entity and we take into consideration the process that’s going to unfold here. And this is really a repeating of what we said yesterday, but I know a lot of what we heard yesterday really fits with what we just heard and a lot of the testimony that was stated yesterday.
And I think before we can start talking about operating rules and standards, and getting into the confusing terminology, let’s go back to what we originally said at the beginning of this, which is, what’s the problem we’re trying to solve? And CORE is correct is stating that we need to get to the business value of the transactions. And the SDOs are correct in saying that the standards have the potential to incorporate the business value. There’s data content incorporated in the implementation guides, and if it’s constrained and if those situational rules become required, if data content becomes required, we can handle that through the SDOs. And both of those are correct.
So that essentially is this process that we laid out in the long-term, which is you have to have a group that represents the business imperative, that’s equally directed by the plans and providers, ultimately those that are accountable for driving the savings.
And we’re calling it a steering committee, but really what this is it’s a group. This has to be a group that meets regularly that’s going to drive the business imperative and work closely with the organizations responsible for developing the technical specifications.
And our view in the middle of that is the DSMO, but the DSMO is not constituted this way today. So this really means a reconstitution of the DSMO as it exists today, because it’s a little troubling to hear, again, the weakness I think what we heard from the SDOs is we’re not hearing anything, so we just have to promote a website. It’s really more complicated than that. In order to translate the business imperative into specifications in a standard, you have to have a group that’s going to bring those parties together.
The reason you have these thousand flowers blooming in all the different states is we’re trying to move the ball within each of our states, and frankly New York has been able to reach out to Connecticut, and we’ve got the national plans that were at the table in developing these specs for this, because we’ve recognized this has to be at a national level, and the national process has moved very slowly. And we have to be able to have transparency in those requests that we put into the standards organizations, so when the business imperative is identified and we have to constrain standards, that there’s a two-way feedback loop in terms of prioritization of those efforts, so they get incorporated.
I want to give some specific examples, because I want to get to what the problem is that we’re trying to solve. And, again, this is really the first recommendation we had yesterday is let’s have another hearing and deal with these critical questions because the long-term is critical. We have to be able to answer the problem that we’re trying to solve so we’re not repeating the same mistakes and expecting different outcomes. That’s absolutely critical; that’s the opportunity we have. And I think we can’t just rush to pick an entity that’s going to ultimately be responsible for this without taking into consideration the ideas of governance, funding of all of this, because as we’ve heard it takes a lot of effort and staff time and so forth to make this all work, and we absolutely have to be able to deal with those critical questions in an open and a transparent way.
So let me just try to give you — I did this last night, so I apologize if it’s a little rudimentary. If you kind of take those little bubbles, each of those things are kind of recommendations or change requests that we’ve heard, right? So each of those are things that people come up with. Minnesota has a bunch of them. Linxus has a bunch of them. Gwen just listed a couple of them that were examples of operating rules that were prioritized by their group. We just heard that NCPDP had some examples.
But somebody has to prioritize those things and say what is the list of things that we’re trying to accomplish, and then what are the most important things. Somebody has to take on that function. And that’s the industry, that’s a business imperative.
Then it has to go into a work queue and someone actually has to start developing specifications around that business requirement, and then there has to be prioritization, because there may be a hundred things in that hopper, but we’re not going to be able to deal with all of them. So there has to be a prioritization process, and that has to be transparent back to the industry.
So if somebody says, well, I want system response times at 20 seconds, and that’s in the hopper, well, is that more important than having specificity in the remittance transaction? I don’t know. I mean, there needs to be some transparency around that process so we’re dealing with them. And at the end of the day we’re getting technical documents that incorporate how to implement those specifications, because those ultimately are what the regulations are going to require the industry to adopt.
And this overall cycle has been what’s going so slowly. So the regulations are where — if you look at the cycle that’s happened with 4010, it’s 12 years. And this has to be made much faster. So transparency is going to help do that, and governance is going to help do that, and we absolutely need funding.
DR. WARREN: When you say regulation, you’re talking federal regulation?
MR. WALLACE: I am talking about the HIPAA regs that named 4010, yes. Thank you. And now the regs that are going to name operating goals, correct.
So, as we’ve been hearing, there’s sort of this different view, right? So you can have the hopper that deals with standards, and the hopper that deals with operating rules. And you can have two different entities dealing with this. I think that is mistake. As we’ve been dealing with this, many of these issues as I’ve been hearing there is overlapping understanding of what’s in an implementation guide, versus an operating rule that constrains it. I don’t think that’s the role of this committee, nor do I think that’s what this committee wants to do is look at what’s going on and try to figure out if something in a standard or an operating rule is corresponding, or whether it’s conflicting. I think that gets too confusing.
So, again, what we think has to happen is we have to reconstitute the DSMO. We have to make clear what the operating rules are so that the standards organizations can develop them to meet the business need. And I want to give some examples. And I just actually copied down, Walter, what you wrote yesterday to try to distinguish between the two. You know, what operating rules are and what standards are. And I think you did a really nice job laying it out, and I think this provides some differentiation.
And, again, if we call something operating rule, we call it standard, let’s kind of hold off on that and first talk about the business product, okay? I have a question: is what we’re talking about an update to the standards, meaning it’s going to have to go from 5010 to 6020 to get this? Or do I need an operating rule to get it? And that’s the open question I think that’s here before us.
So here’s something that Linxus came up with in the eligibility transaction — very specific, okay? So in the implementation guide it’s situational that the health plans can respond back with an eligibility response with first and last name, date of birth. We heard it many times during the course of the last two days a patient doesn’t present with an ID card, or the wrong ID card. I’m using outdated information in my patient registry from the last time they were there. They went from Aetna to Cigna since the last time they came here. So the last thing I want is to be able to check the Cigna benefits, but all I’ve got is the first name, last name, date of birth.
In New York, even though that’s a situational rule, half of our plans are supporting it and half of them aren’t. That’s a problem. So we think and we agreed as a group that everybody should support that situational rule, and we made it required. And we know that is going to help providers be able to do more eligibility transactions. It’s going to simplify how they do eligibility because it’s going to be one way of doing it going forward.
And then I guess the question then before us is, if we know this has business value, and we heard it multiple times yesterday. In fact, I saw a gentleman present the Medicaid charts and the variability across Medicaid plans. Let’s make this required, and the question is, does that fix a standards update, or an operating rule? I’m not going to pretend to know the answer to that.
DR. SUAREZ: I can tell you — and Patrice can confirm or clarify this — but I can tell you that in Minnesota, this is exactly the kind of content that the universal, or the Minnesota statewide uniform companion guide defines. And so everybody now does this the exact same way in the state. Is that correct?
MS. KUPPE: Yes.
MR. WALLACE: So, in other words, we’ve got consensus. So Minnesota agrees, New York agrees, and our brethren in Connecticut agree. We have consensus on this. This needs to go into the implementation guide, moving from situational to required. And that’s our belief. We want to put that out there for broad industry consensus through the SDOs to say, as you said, Walter, let’s turn the switch from situational to required, and are we ready to do that as an industry. And is that an operating rule or a standard? I don’t know. But I personally think it should go in the implementation guides and it should be in a single document.
I’ll give you another example on the eligibility. I talked about this one yesterday. Here’s a requirement of 5010 to return primary care physician information. And I have an example I’ll show to you, but in 5010 it says you have to send the primary care information for the physician, but it lacks specificity in the implementation guide. So this isn’t a situational role. This is a requirement in the guide that says you must send PCP.
Okay. So let me actually show you what we did. I keep hearing this is business, but there are practical specifications behind this. So here are all the fields in an X12 transaction that you can send related to PCP. We actually went through these fields and said, okay, well what do we really need as providers, and as payers what do we have and what do we think we can reasonably send if we require it? And require where to send that information. So the question then becomes again, is this an operating rule or is this a part of the standards, update the standards? This is getting into data content around the intent of the legislation again. If it’s contained in the standard, it should be part of the standard, but this is a further refinement of it. Personally I think this should go into standards and should be part of the next standards cycle.
So, you have many other examples where we’ve gone into specificity. I don’t know whether you want to call this a standards update or an operating goal, but this is a key question we have to be asking ourselves, because we’re mixing terms. And let’s not talk about operating rules, let’s not talk about standards, let’s talk about the problem we’re trying to solve.
These all represent problems. We’ve heard them repeated, so I’m not going to go through them all. But we heard a lot of these problems that Linxus identified, other states have identified, that we have to build into standards and we’ve got to move quickly on this, or build them into operating rules, however we want to do it. But we have to move through this process quickly.
And I don’t think anything we’ve done through Linxus is inconsistent with what we’ve heard other states say they’ve had issues with. So why don’t we submit it through the DSMO? Why don’t we have an eligibility and claim status process to have these incorporated either as operating rule documents? Have everything go into the hopper through the SDOs, and then have the SDOs come back with their recommendation in terms of whether we need operating rules or whether we needs standards.
I think we need that single hopper. I’m not clear yet with NCPDP is the right one. But my recommendation is we leave that to the DSMO to assign the correct entity, and CORE and Linxus can each put in their balls and we can go through the DSMO to put them in the hopper and come out with our right technical specifications.
I think we’re thinking and we’re talking about short-term and long-term, and I think we have to keep both in mind. This is not just claim status and eligibility; this is how we want to move forward to solve the problem. And ultimately we’ve got to pull all of these different state initiatives together. We agree with that. We agree that the prioritization that has to happen of the issues that we work on has to be national, it can’t be state based. And we are fully supportive of that. In fact, we’ve been embracing that for several years since we started. So, I’ll leave it at that. Thank you.
DR. WARREN: Can the three of you be sure that Marietta gets a copy of your slides.
MS. GREENBERG: Earlier on you said that the DSMOs have to be reconstituted. So when you’re saying that all of this should go to the DSMO, then are you talking about the DSMO as it’s currently constituted?
MR. WALLACE: Yes, the entities of the DSMO are predominantly technical standard writing —
MS. GREENBERG: I know who’s in the DSMO.
MR. WALLACE: Right. So, what we are missing are the folks like Rick Donahue who is with me but couldn’t be here today. The folks who are ultimately responsible for signing contracts with vendors, to have certified systems to be able to manage their personnel to have a reduction in staff who are going to ultimately be responsible for cutting costs, who are going to have to prioritize and say there’s a bigger priority for me to have specificity in the transactions, such as specific PCP information where I’ve got two staff people on the phone calling the payer to get the PCP information, which now I can get electronically, so instead of two I need zero staff people? Or is it more important for me to have a 20-second response time? We need to have those discussions as the business level requirement.
MS. GREENBERG: So you’re recommending that the DSMO be expanded to include —
MR. WALLACE: Yes.
MS. GREENBERG: — either certain organizations or certain —
MR. WALLACE: Voices.
MS. GREENBERG: — voices?
DR. SUAREZ: I thought I heard a different recommendation, which was the box before the DSMO is the one that needs to be established, that doesn’t exist.
MR. WALLACE: It doesn’t exist and it needs to be part of the reconstituted DSMO.
DR. SUAREZ: But that box is the one that describes this thing called operating rules. And then those come to the DSMO. The DSMO is really the six entities and they get —
MR. WALLACE: Something has to determine what’s going to be thrown into that hopper, right? So Gwen presented a bunch of recommendations. I mean, I don’t know that those are a high priority for providers. I mean, it’s what CORE thinks are high priority. NCPDP may have a different perspective of what’s a high priority set of items, Linxus has a different perspective, and Minnesota has a different perspective. So something before it goes into the hopper when we assign the work to the standards development organizations to begin writing technical documents, because that’s an involved process. It has to be able to first meet in advance and say, okay, if there are a hundred things on our list, we’re not going to be able to get to all 100. Where are the 20 that are going to solve 80 percent of our problems, and are we putting the right 20 things in the hopper to begin with? Then from that process, those 20, you may not get all 20 in the next version of a standard or in an operating rule; that’s going to have to be further refined. But the first thing that has to happen is something has to prioritize what goes in, and that’s what I’m suggesting as part of the DSMO.
DR. WARREN: Can you go back to that last diagram that has the two boxes with DSMO in the middle and NCVHS at the top. So, what’s confusing me is the box on the right has SDO’s rules, but the organizations are all SDO’s and are ANSI accredited. So right now the only ANSI accreditation that an entity that those rules can get is they can be accredited on how they make decisions, that they follow a specific decision-making process. It doesn’t give them the right to do standards development.
So, to me, operating rules over here is kind of an misnomer. What you’re saying over here about business imperative, maybe I’m not — it seems to me that this is where operating rules really kind of better reside is in working with industry to find out what you need to push the adoption of the standards. And then those would come together and representatives from each would go into the DSMO and then do that.
MR. WALLACE: Right. But, again, go back to this question. I like to use specific examples. So, is this an operating rule, or is this an update to the standards? It’s currently situational in the guide. Right?
DR. WARREN: I have a feeling we’re going to find out that things go into operating rules and eventually wind up as a standard.
MR. WALLACE: Remember both are going to be regulated and required, right? So, the interplay of the two — I mean, what NCPDP was just stating is that we had a hard time finding operating rules because we’ve got it all in the standards. Well, they’ve been able to progress to a level of specificity and lack of variability and having real tight standards through a consensus process that we haven’t gotten to on the medical side yet. We’re behind the eight ball here. So we have to move that process faster. And the question is, does it move faster by doing this? I think that slows it down, not speeds it up.
DR. SUAREZ: If you go back to the list that suggested yesterday, which has six items — five? Anyway, there are a number of items, number 1, number 2, number 3 there — probably those three primarily — that are things that usually or would probably not be appropriate to include in an implementation guide. And then there’s that middle thing that I’m calling the refinement of the implementation guide, which are all the examples that you’ve provided, which is the one that expands the content of a response, because now you are requiring, instead of situational.
That middle ground is where the two aspects of this, the operating rule development, and the standards development, become more difficult to separate. Some things are clearly in most cases probably going to be really — well then that should really become required rather than stay situational. Some things could be, yes, for health care it’s a required thing, but for the standard it should be situational still.
But, again, that’s where the interface becomes more difficult. But that’s why if you go now back to the slide I have, that particular slide, I think that the real sequence is really you start with a national strategy, get into the operating rule aspect, the standard development process, and then goes to the DSMO. That kind of a system — and then the DSMO goes to NCVHS. It’s not coming from two directions, but it’s really more —
MR. WALLACE: Honestly my colleague said why don’t you make it yellow and blue, which is green so when they get together. I mean, that was the concept here is they do have to be hand-in-hand. And the notion that the operating rules deal with separate things as you said, before we talk about whether it’s an operating rule or a standard, because I think the one thing we have established it’s clear there’s a difference between the two. What’s the prioritization of the business problem we’re trying to solve? And if the business priorities that we’re trying to solve are mainly in updating standards versus operating rules, then let’s have our technical development organizations focus on things that are going to solve business problems.
Maybe NCPDP is right. Maybe we’ll come back and not determine there were any operating rules that are necessary to solve the business problems in the short-term because there are too many problems we have to solve for standards updates, as you define what they are under standards updates. And we need to have that open and transparent discussion.
And I understand that there’s a timeline to go through for having operating rules, which is why I said in the short-term let’s test the SDOs through the DSMO to say let’s come back to the table with us, with the industry as your partner, to define what potential operating rules are to help solve a business problem. And let’s have a second hearing and actually present those. And let’s move forward on whether we’re actually going to implement something that’s going to solve a problem, as opposed to something that we all think an operating rule might be.
MS. TRUDEL: Just looking back at the statute, I think it’s pretty clear that Congress was looking at two different issues and two different time tracks. Section 1104 is looking at the short-term, 10109 is looking at the longer term. And so we’re here today looking at section 1104, which is — it isn’t working right now. How do we fix it right now? So let’s get operating rules for the standards that exist, let’s put them into place really fast, and try to get some of the return on investment that hasn’t been showing up as of now.
Section 10109 then talks about setting up a longer term process for reviewing and amending standards and operating rules. And it talks about having a hearing no later than April 1st of 2014. So it’s clearly saying, all right, you guys fix this problem and buy yourself a little time to figure out how to do this on an ongoing basis. And then it talks about interim final rule making, it talks about a review committee, it talks about coordinating a standard, and it talks about operating rules for other standards. But it continues to talk about operating rules and standards.
So clearly in Congress’ mind those were two different things, no matter how you define them. So I guess I’m saying that the long-term issue is definitely one that we have to look at, but it doesn’t preclude us from making short-term decisions about what we need to do right now.
DR. WARREN: I am looking at our time and we have ten minutes. I haven’t been able to do an open mic. So is anybody desperate for a comment in the audience that can’t send Lorraine an email? I’ve already had one wonderful card that says you will expect to hear from me.
MR. BECHTEL: I am Don Bechtel. I am with Siemens Medical Solutions. I presented yesterday representing WEDI, and I just want to refer back to my WEDI comments. I got a little concerned when I heard one person say we just want one entity, and another person’s saying, no we could have one for every transaction standard. That really alarmed me.
DR. SUAREZ: Which of the two?
MR. BECHTEL: I know you drilled me yesterday on is it just one. And I said, well, it could be. So I wanted to clarify. I think we could certainly see one per standards organization perhaps. I would really not like to see — and I say “I” — I think we would not like to see one for every transaction standard. And I go to the point I made that the cost of participation would just go through the roof. And it would be very difficult to keep up with all of the different entities and what I’m supposed to be doing in one transaction versus another. You need coordination between them all. So I just wanted to make that distinction.
MS. WEIKER: Margaret Weiker, representing X12, and I’ll just do a couple of things. One, we have to keep remembering what the definition of operating rule in section 1104, which is it’s exchanging of information that’s not defined by a standard or its implementation specification.
So if there are things that need to be fixed — I’m going to say it again: if there are things that need to be fixed, people are writing a companion guide, people are writing an operating rule and changing situations to mandatory, where are these changes being brought to the standards organizations? They’re not. I can’t fix what somebody doesn’t tell me needs to be fixed. I’m not a mind reader. So I implore people: submit theses DSMO change requests. We can fix these things that I keep hearing about. Some of them are minor; some may be a little bit major. But we can fix things, but I can’t fix it if I don’t know it’s broken. And I can hear other states say, oh, we did this and there’s too much variability, and there’s too much of this, and this, and this. Okay. Tell me what you want to fix. Don’t just say fix the problem. You need to be very specific with what you need to do.
I think your five points that you brought up yesterday, and one of them were the scenario queries and response, and Eric’s example in regard to the PCP. Okay. It says return PCP information, so an example of that would be here’s the information. Does the standard support all of this? Yes. Off we go, and say now it’s returned, we’ll update the guide. But it’s a collaboration; it’s not we need to test the SDOs as I just heard a few minutes ago. The SDOs are tested, battle tested in many entities and many times.
And, Marjorie, I don’t know — yesterday I just want to make sure you understand X12 did not endorse CAQH CORE.
MS. GREENBERG: I did not say that you did.
MS. WEIKER: Okay, okay. I just wanted to make sure.
MS. GREENBERG: No, I only said it was my understanding they had worked together.
MS. WEIKER: Okay. Yes.
MS. GREENBERG: Did you endorse NCPDP?
MS. WEIKER: Yes, we endorsed NCPDP.
MS. GREENBERG: To be the single entity?
MS. WEIKER: Yes.
MR. KAYA: Tim Kaya(?) and I work for United Healthcare. I’m responsible for all provider and provider service operations on behalf of the United Health Group. And I also have a side job of implementing 5010 and ICD-10 across all of United Health Group’s platforms.
I’ve got to tell you, I don’t necessarily see here a competition. I see a NCPDP standard that’s working well, and operating rules — if that’s what you want to call them — that are working well, and the fact that they are working well for that industry. And on the medical side I also see operating rules under development in that side of the house there. So I don’t know that we see a competition. From the audience perspective, I don’t know that I see a competition here at all.
But what I did want to comment on here, and I think this is really very important, particularly around the fact that we are all charged here with removing administrative costs from the industry. And let me give you a bit of a sense here.
This goes to the separation, at least on the medical side of operating rules and standards. At United Health Group we are spending over $100 million dollars to put 5010 into all of our platforms. This is a huge, huge number. When you go back and you look at the business benefit of 5010 going into our platforms, that business benefit is almost zero.
Now we have consulted all across the provider community. We have 700,000 physicians and hospitals inside of our network, and the business benefit of 5010 inside of our network is also coming back at almost zero. Now, imagine going into any business discussion and talking about the fact that we should implement this in an organization.
Conversely, you look at CORE. We’re investing $8 million dollars in CORE to become phase I and Phase II certified by the end of this year. That business payback benefit is in less than a year. And the IBM study I think Gwen went through, demonstrates the business benefit associated with the provider side of the house.
The reason why I bring this up is because you take this up a level into the world of administrative cost, any of us sitting around the table here has to admit that 5010, implementation of 5010 is a fairly big failure. We have increased the cost for the consumer because it all gets passed on to the consumer at the end of the day.
This isn’t X12’s fault; this is the management of the people who sit around this table, the people who manage health plans, the people who manage these committees in order to make this happen. So I would ask this committee, as you think through the business problem that we have in front of us, that our biggest, most important thing that we have to worry about is how do we remove administrative cost from the system?
And through the things that we’re going to put in place here in this committee, whether it be CORE, NCPDP, any of those items, as we think about those items, the ultimate question at the end of the day we have to ask ourselves is are we setting this industry up to take costs out, or are we setting this industry up to add costs in? And I would argue with you right now that we’ve set the industry up to add costs in.
I guess the only other couple of things that I’d like to comment on here is the cycle time component of this. A cycle time anywhere between 24 and 36 months feels right. It feels right from a technology cycle time perspective, and in fact when you start to think about operating rules, the off-cycle nature of implementing operating rules like we’re doing with CORE phase I and phase II, almost becomes a mute point if in fact you have an enhanced cycle time for technology development.
We would ask the NCVHS to task the operating rules organization to develop a use case that gets to adoption in the industry. In other words, how do you know that in fact what we put in place is going to get adopted in the industry? We will all spend a ton of money on implementing what gets adopted here or what gets promoted here through the NCVHS and the Secretary.
But we have to, I think, be smart about the fact that when you look at a curve and you look at the adoption nature of whether or not physicians are going to use the transactions, whether or not hospitals are going to use the transactions, what’s the criteria necessary in order for a physician or a hospital in their practice to actually use an eligibility transaction? I don’t think we know that today, and I think as we think through what the operating rules should be, we have to answer that question.
The other thing I’d ask the NCVHS —
DR. WARREN: I’m going to have to ask you to hurry up, because you’ve got about a minute.
MR. KAYA: One minute? Okay. All right. Then I’ll just conclude here. I think the last thing we asked the NCVHS to consider, is there was some comments made about the content of the X12 rules, at least in the interim here, to be flexible around the fact that content can be clarified through operating rules, but generally then adopted by the operating rules organization. I think Margaret here mentioned the fact that she implores the organization to bring things on. The operating rules organization can be that organization to bring that on, to bring the next set of business criteria into the X12 transactions. So, that’s it from this end. Thank you.
DR. WARREN: Thank you. We are right at about 2:55. Justine is looking at me eagle-eyed. I want to thank everybody, especially for staying with us to the bitter end, for being so open and so magnanimous with your contributions. Send us letters, calls; you can send them to Lorraine.
Walter and I will respond through Lorraine. And thank you very much. We really appreciate you coming here.
(Whereupon, the meeting adjourned at 2:55 p.m.)