[This Transcript is Unedited]
National Committee on Vital and Health Statistics
Subcommittee on Standards
Administrative Transaction Standards, Code Sets and
Industry Status of Planning, Transitioning and Implementation
June 17, 2013
National Center for Health Statistics
3311 Toledo Road
Table of Contents
- Welcome and Introductions
- Update from WEDI Executive Steering Committee – Jim Daley,
- DSMO Report
- Annual Report, Change requests, reaction to CMS pilot – Nancy Spector
- X12 – Margaret Weiker
- NCPDP – Lynne Gilbertson, NCPDP
- Status of Implementation of 5010, D.O, 3.0:
- Health Plan Perspective – Jordan Firfer, Florida Blue
- Provider Perspective – Annette Gabel, Express Scripts
- Clearinghouse/Vendors – Debbi Meisner, Emdeon
- Medicaid – Don Oaks, Tennessee
- Cathy Carter, OIS
- CMS Regulatory Update
- OESS – Denise Buenning, OESS
- Public Comment
P R O C E E D I N G S 1:00 P.M.
DR. SUAREZ: My name is Walter Suarez, I am one of the co-chairs of the
National Committee on Vital and Health Statistics Subcommittee on Standards and
we want to welcome you all to this hearing on various administration and
verification topics. We have a full agenda for the remaining of the afternoon,
and then tomorrow all day, and we want to go ahead and start. Just to mention a
couple of introductory notes.
Usually our Subcommittee holds a hearing around this time of the year, every
year, to assess the stage of implementation of various administrative
simplification standards and requirements and to discuss the status of planning
of upcoming adoption and compliance of standards.
The purpose of this hearing is primarily to do that and to have an
opportunity to listen from the industry and hear perspective from the industry
about how things are going with various implementations of standards on both
HIPAA and the Affordable Care Act and then talk about some of the planning of
some of the next round of standards.
We wanted to take some time during these hearings, particularly tomorrow and
focus specifically on two very important topics. One is operating rules and
discuss the state of implementation and the state of operating rules in terms
of those that are already in place and being implemented and hear about how
things are going with those. Then talk about and listen to the state of
development of the next round of operating rules.
The other main topic is on ICD-10, but we wanted to focus the attention on
both the preparation and the progress that is being made in getting the
industry ready for that. Talk about some of the possible initiatives that are
going to be important to put in place in the industry to raise awareness or
increase the level of awareness and begin to consider a one-year countdown
campaign or something like that to raise attention to the preparation needed
for ICD-10. The second part of this topic will be on some opportunities to use
ICD-10 beyond administrative transactions and beyond the billing and coding,
but to use it in some other ways and connect to some other standards that are
now being adopted in the industry for other purposes. For example, SNOMED and
meaningful use and talk about some of the opportunity there.
That is our agenda for the next day and a half. I think what we want to do
first is go around the table and have our members of the subcommittee introduce
themselves and state any possible conflicts and then we will proceed with the
agenda. I will state with my co-chair, Walt here on the left.
DR. SOONTHORNSIMA: No major remarks, I am Ob Soonthornsima, co-chair of the
Standards Committee. As I look at the agenda for the next few days, I just
reflect back on how we are constantly implementing or in the middle of
implementing something all the time for years and years. Often times we will
not stop and look back, take the pulse and say are we actually achieving the
goals that we set out to do? That is why a subcommittee meeting like this helps
us to reflect on some of the past experiences that we can learn from and from
time to time to pause and feel the pulse and see are we actually receiving
these benefits. That is my only comment for the day. I do welcome everybody who
are scheduled to speak today and I am looking forward to interaction, feedback,
and inputs. Thank you.
MS. KLOSS: Good afternoon. I am Linda Kloss and I am a member of the full
committee and a member of the subcommittee, a co-chair of the Privacy,
Confidentiality, and Security subcommittee and I have no conflicts.
MS. GOSS: Good afternoon. I am Alex Goss, I am State HIT Coordinator for the
Commonwealth of Pennsylvania. I am a member of the full committee, a member of
the subcommittee, and I have no conflicts. Thank you for having me.
MR. SORACE: Hello I am Jim Sorace, I am staff and committee, a subcommittee
MS. FERRAR: Hello everyone my name is Kamahanahokulai Farrar and I am
filling in today for Loraine Doo. I am with CMS in the office of EHealth
Standards and Service.
MS. WILLIAMSON: Michele Williamson, CDC’s National Center for Health
Statistics and staff to the subcommittee.
MS. GREENBERG: Good afternoon, I am Marjorie Greenberg, the National Center
for Health Statistics. Welcome to NVCHS and I am the Executive Secretary of the
DR. SUAREZ: Thank you. We are going to quickly go around and have people
DR. SUAREZ: Marietta, do we have people on the line? Do you know if there is
anybody? No one right now, okay. We probably have people on the Web listening
in I suppose. We also welcome everyone that is on the Web listening in and we
will try to make sure to mention the name of those that are speaking so the
people on the Web listening in can follow the testimony.
With that, let’s just go into the agenda. The first testimony or the first
participant is representing WEDI. We wanted to hear about the state of the work
that is being done by WEDI and the new 2013 WEDI Report, which basically comes
into the 20th Anniversary of the 1993 WEDI Report that set the stage
for a lot of the administration publication, is happening in the country. I am
going to turn it to Jim for that report.
MR. DALEY: Thank you. I thank the committee for inviting WEDI to testify
today. First of all, I think everybody knows who WEDI is. We were founded in
1991 by Secretary Sullivan and the goal is to make things more automated, use
electronic transactions, and do things electronically as opposed to paperwork
and phone calls. We are an advisor to the Secretary of HHS under the HIPAA
legislation and regulations, and we have an extensive organization of industry
volunteers who help support what we are trying to do with whatever it is in
Health IT, whether it is transactions, code sets, or any initiative like that.
It is all a volunteer organization. I am sure most of you know that.
Today I would like to talk about three different things. One is the 2013
WEDI Report. Then go over what we did in our February 2013 IC-10 Readiness
Survey, couple of slides on some other activities going on at WEDI, and then
some time for questions if you have them. Let’s start with the WEDI Report.
We were formed in 1991 as I mentioned, 1992 produced a large report,
distributed about 5,000 copies of that with suggestions of how you can make the
industry more efficient. That was followed a year later with some more discreet
recommendations and activities that needed to be performed on that one. In
1996, the HIPAA Law came out which was based on that report, and as I mentioned
we were named as an advisor. Since that point, you have had the HITECH Bill,
Stimulus Bill, the Affordable Care Act, a whole bunch of different pieces of
legislation out there, which is extending some of those original administrative
items that went on in here. With all of this stuff going on we thought it would
be a good time to go through and see where we are and where do we need to be
heading at this point.
This is some of the background in here and I do not think I need to go into
great detail here but it was formed again by public and private coming
together. The industry, payers, providers, vendors, coming together to say how
do we make things work better? The original report, we had 11 technical
advisory groups. Different subject areas we looked through. You can see
standards implementation, data content, identifiers, all the kinds of things
that you saw coming out in the HIPAA regulations. Of course, fraud detection,
COB, financial implications, a laundry list of things. There was not any
particular constraint on what to look at. It was more, what is the whole circle
of things that would make this industry work better.
With that they focused on some items. The same time to do the transactions
you needed some kind of standardized transaction so that were ASC X12 was
working on and began to work on some additional transactions to form all of
those that we are using today under HIPAA. Some people may not aware that they
really were not all in place when this first report came out.
Setting the stage as a result of all of that you see where we are today. We
had the TCS Rule, NPI, the employer identifying, security and privacy. All of
those rules came out and set the baseline for it and of course, there have been
some updates since that point with the new 5010 version of transactions.
On top of that I mentioned the other ones, the HITECH Act, as part of the
Stimulus Bill and Affordable Care Act, which brought along the operating rules.
Use of VFT, that was not part of the original HIPAA, Health Plan Identifier,
and Claims Attachments. Section 1104, that bill actually set the required
delivery dates for these items. Before under HIPAA they wanted to do it and in
fact the original WEDI Report said, let’s do all this stuff in five years. It
took them about five years just to get the HIPAA Law in place. S it has taken
quite a bit longer but Section 1104 of the Affordable Care Act actually defines
some dates that we are living with right now, trying to get certain things done
according to those requirements.
This is an interesting little chart. This is from the original report and if
you look at it, it is the same chart we have today. That is the health care
industry. Nothing has really changed in terms of the players and their need to
communicate with each other. It is just that we are slowing moving forward to
make this all happen.
So why are we doing another WEDI Report at this point? Despite everything,
we have tried to do and we have had some successes, there is still a lot of
inefficiencies in the system, so we need to look at where we are and try to
remove additional inefficiencies. I would love to say get rid of every last one
of them, but as many as we can we would like to remove.
We have new opportunities out there certainly there is a lot more
technology. A lot of things you can do, the industry has changed a bit since
that point and of course it is a great time, 20th anniversary, to do
a review of where we are and refresh that report. It looked like a good time to
be doing that. And as I mentioned the Internet now used pervasively, mobile
devices. They did not have Smartphones way back then. Cloud technology and a
lot of need for security obviously that is a big issue reading the newspapers
and the newsletters every single day, so all of those need to be taken into
account. But the workforce is changing, our technology is changing so there may
be different things we can do to drive some of those inefficiencies out of the
Last year September actually, we had a WEDI Executive Advisory Council
meeting. We got a few key players from the industry together and said, how can
we make a difference? Certainly, WEDI has been known for helping get these
transactions and identifies and things in place, doing the education, holding
meetings, Webinars, writing White Papers, and all that good stuff, but that is
implementing what is on the table in front of you. We are looking at how do we
get back to some of those other drivers of what should we be doing beyond the
mandates? What can we do as an industry on our own initiative to make things
Part of that meeting came up with the suggestion of we really should revisit
what we said in 1992 and 1993, and look at that in the context of today’s
environment and refresh that report and come up with a new report. Not to say
that what we did was wrong, much of it may still be applicable, but there may
be additional things we need to do or we may have to tweak a few things that we
originally recommended that 20 years later do not make as much since with a new
environment. That was the impetus to starting this report up.
In early 2013, we sent out a request for quotations, we had several
responses to that and a selected Cornichon. Ed Jones who was former WEDI chair,
and his proposal looked very good, and from that, we formed a WEDI Executive
Steering Committee. I have a quick slide and I can show you the names of who’s
who on that committee. I had a first meeting April 2nd and they gave
us some guidance. We went in there saying here is what we are thinking of
doing, what do you think? They said that is pretty good but we have some other
thoughts on that. Their guidance was very instrumental in helping to focus us
down to several target areas, which I will cover in the next couple of slides.
Our Go Forward Objectives. We went around the room and said what do we need
to be doing here? This is pretty much a high level summary of what they said;
better care and quality, cost, everybody mentioned cost, cost, cost. Said, okay
but you need to do something to better cost. It does not just happen by saying
I want less money to spend on this stuff and it happens. The cost is there
because of some other action going on or some inaction. We had to get down to
what were those factors driving up the costs.
We talked about population health, preventing the disease, with an ounce of
prevention is worth a pound of cure, expanded coverage, decreasing waste,
increased efficiencies, patience safety, and patient empowerment. Getting the
individuals involved in their care, trying to stay healthy instead of doing
whatever they want to do, ignoring certain things and then going to the doctor
or the Emergency Room. Take care of me, I am sick now. If you can keep them
from being sick, that drives cost out of the system as well, and creates a
better lifestyle for the individual.
Removing silos. Everybody has got their own thing they are doing and they
are doing their best to get it accomplished but there is a real need in this
industry to talk to each other, get some synergy, so acting together, sharing
our thoughts. One of our goals was to really get a good cross section working
together and not independently on these matters and overall excellence.
The other quotation we used quite a bit is got to stop saying no, you cannot
do it because of all of these reasons that you cannot do it. Start saying, we
could do it if only these things occurred. Take that positive approach. If we
did that, we could accomplish something better. We are trying to push towards
Building a roadmap forward. Getting the right data to the right places at
the right time, and of course it must be usable when it gets there, speaking to
the data hominization aspect of it. We have got the tools. I have seen some
great things recently that people can do with all this technology, but you have
to apply it in the right ways to make it useful. We do have the business and
government decision makers at the table, which is great. They are collaborating
on this one. We want to work together on that. We need to identify those
barriers, what is keeping us from being more successful, eliminate them, and
Of course, it needs to be win-win. If one sector wins like crazy and the
other sector is a big loser in a proposition that is not going to make it work.
They both have to have some skin the game and some end goal that benefits them
or they will not be accepting of the recommendations. It has to work for all
the stakeholders and the patient, after all the goal of health care is the
Here is just a sample of some of the barriers you have got out there. You
have got to know the problem you are working with. There is so much
fragmentation that makes it difficult. Resources are always an issue. The
infrastructure may not be there. You need to prioritize and keep it to a sculpt
that is achievable.
On the accelerators if you can clarify the problem what you are trying to
do, get the purpose solid there and the roles that each organization or
individual plays in that, that will help you work towards getting that problem
Aligning your goals, instead of fragmenting and work together towards shared
objectives. The resources, there can be economic accelerators so it is like
meaning for use incentives help push those electronic records out.
Infrastructure, it is a barrier if it not there. If you have the infrastructure
in place, it can help accelerate your goals. The impact. Look at something that
really has a key impact. People are going to jump on board with something that
is meaningful to them as opposed to something that really does not play into
their world all that much. Commitment. You have got to have committed
individuals to make this work.
With that in mind, after we talked to the Executive Steering Committee, we
boiled it down to four key areas of research. Patient enablement. How do you
get those individuals involved in their health care, paying more attention to
it, abiding by the things they should be doing, eating properly, visiting the
doctor when they need to instead of waiting until till they are sick? How do
you deliver information to a patient so they understand what it is? Somebody
gave a great example when they announced to a lady that here cholesterol levels
were way above normal. She said, oh great I am way above normal, that is good.
Said no, that is not good. You have the education aspect of it as well.
Payment models. I am sure we all have heard of the ACOs and everything else
that is going on out there, but recognize that fee for service will still be
there. You cut your finger. You are not going to wait for ACO kind of
deliveries. You are going to run down to some place to have it stitched up, so
you will still have that model. Data harmonization exchange. Yes, we need to
get the data back and forth between places but if it is not usable when it gets
to the receiver’s shop, then why bother to exchange it. This is looking at what
needs to be exchanged, how do you make it usable on both ends so point A and
point B can really communicate with each other.
Innovative encounter models. TeleHealth, using the mobile devices. I
actually was a witness to that many years ago when I was having dinner with
someone who pulled out their Smartphone and pulled up a picture of a poisonous
mushroom. I said, somebody just ate one of these and he just did some quick
typing and texted back saying that is what this thing is, here is how you treat
it, and he actually treated the patient from 1,000 to 2,000 miles away. Very
impressive and that was years ago that could be done.
Within the framework, we are going to be looking at again those four
workgroups. We will be looking at what are those barriers. What has happened
since the first WEDI Report? What do we still need to do? Look at the business
cases. There has to be a good business case or people are not going to
accomplish these things.
Obviously, privacy and security is throughout this. We talked about a
separate workgroup but privacy is not necessarily the function itself. It is
something that goes along with all these other functions. You need to do them
in a private and secure fashion. And ROI, obviously.
Actions needed for success. Looking at what can the industry do on its own,
what might need to the regulatory action to accomplish, and take a balance
there. Avoid the barriers, look at the accelerators, which I have mentioned in
the previous slides, and look at how do you measure it? How do you know you
have got to where you want be? Maybe it is a continual journey but you have got
to have some goal that is in mind or you do not know if you have accomplished
what you set out to do.
Look at innovative things that are going on right now. I am sure you guys
get lots of newsletters in your email and all sorts of great things here every
day, somebody did this, somebody did something else. We are looking at that and
trying to leverage what is already going on in the industry. We are not trying
to reinvent the wheel but take a look at what is out there and bring it
together and synergize and again, make things move forward.
We are looking at some short term wins, a few things we could do in the next
couple of years to make an immediate difference but also set the stage for
longer-term gains as well.
In this report, I should mention we are not actually going to write the
report and design everything and implement it by the end of the year, but we
are going to come up with what needs to be done. Then from that point forward,
the plans will come out for actually how to actually accomplish this.
Here is the scope for it and the schedule and you will see we had our first
call in April. We had a call just a week or so ago on June 5th with
the Executive Steering. We are doing a survey of the industry stakeholders on
some of these matters to collect information in each of those four research
areas. Face-to-face meeting in August 6th, probably back in DC with our
Executive Steering and then start drafting the report. Have it ready in the
fall timeframes, and we hope to have a big press announcement in December
releasing the report to the world.
Here is just an example of the Executive Steering Committee, on there is a
lot of impressive names in the industry. I will not bother reading them to you
but they should be in your slides. Our Advisors, and we have a couple of
individuals from NCVHS right here today who are on our advisory, and we thank
them for their participation. Here is our workgroup co-chairs. We tried to get
balanced co-chairs of three or four for each one of those workgroups, payer,
provider, vendor, government, whatever we could do to try and balance it off.
Of course, it is open, the participation is open to everyone. We sent out
announcements looking for participation on this. With that in mind, the report
is underway, we will have more updates as time goes on and I am sure Walter or
Marjorie can provide update as well from their participation in this.
That is the first part. Now I would like to switch gears and go over into
the ICD-10 results. In February 2013, we finished our latest survey or the
seventh in a series of surveys. About a year after our last survey and a year
after the extension was announced. We wanted to see where we are obviously but
how did the delay impact the schedules, the resources on there, and did people
use that time to catch-up and get back on track? There is one caveat, the
survey was totally voluntary so it was somewhat random as to who responded but
with our stakeholder group within WEDI and others who responded, as well. We
did have support from CMS to push it out and some other industry organizations.
We still had a decent amount of responses so it is a fair cross section of the
industry. However, the people who would think enough to get the survey and
respond to it, very likely are more aware. This might be skewed slightly
towards the more ready end of the spectrum.
Three respondent groups, the vendors who had 87 of them, 109 health plans,
778 on the provider side. Half are physicians so that was pretty good mix
there. You can see the numbers in there, all different sizes from the very
small up to over 1,000 clinical FTEs. This was less than the previous survey, a
little more than a third. We had 2600 in previous one we did, but it is a
decent amount to get some idea of where we stand.
The vendor results. This was one of those first questions of how did the
delay impact what you did? You will see about two-fifths said it did not change
anything, it did not delay anything. They just kept working, but a quarter said
they slowed down three to six months. Another quarter said more than six
months, so they pretty much slowed down or stopped for a bit as a result of the
delay. Interestingly enough, most of them said they did not change the
resources assigned. The general conclusion and each slide has a conclusion on
it, there has been some slowdown in the vendor service deliveries in their
How complete is your solution development for your IC-10 products and
services? About 40 percent, two-fifths say they have not started or less than
one-quarter complete. Interesting, that is the same it said in 2012, so a year
later they are about the same state. One-fifth of them said they were complete
so that is a little bit more than we had in 2012, so there has been a little
bit of movement in there but it is quite alarming that by and large there has
not been a large amount of progress in there.
When do you plan to start customer review and testing? Half said they would
do it in 2013, but in 2012, half of them said they were going to start in 2012.
When you compare it against the compliance date, there really has not been a
lot of progress. A fifth said 2014, which is about the same as they would be
testing in 2013. Again, when you compare it to the compliance date has not been
a lot of progress. The conclusion is yes, there has not been a lot movement
forward in this regard.
Vendor results. When do you plan to have your services or software available
to customers? About the same portion, about a fifth of them said they had their
products ready already. About one-third will be ready this year which is one
year prior to compliance which is a little bit more than the quarter who are
going to have them a year prior to compliance in the 2012 survey. About a third
will be ready next year. Same as last time and the unknown dropped a little bit
so at least they are starting to have some idea of when they want to have these
things ready for usage. Again the conclusion not a lot of improvement in their
Top three issues. Customer readiness, our competing priorities are the
regulatory mandates. On 2012, it is essentially the same three things. Does
everyone have copies of the slides in front of them?
MS. KLOSS: I was just wondering if in the survey there had been any more
detail about what customer readiness means? Was it your impression that because
the customers are not ready, they are not feeling compelled to speed this up?
Or are those two separate issues?
MR. DALEY: That question was not really asked. Now I could make a couple of
assumptions that they customers have not done an assessment and know where they
want to be. Some of the customers of course have had influences saying maybe we
can push this thing off and not do it at all. Some of the customers were busy
with E-HR requirements. There is a whole bunch of reasons why they may not have
been ready but we did not get down to tell me why your customers were not
ready. Of course, I have also heard in the past the vendor community is saying
we cannot build it because we do not know what the customers want. The
customers are saying we cannot get it because the vendors have not built it, so
chicken and egg.
MS. KLOSS: I am wondering if it is more of miscommunication than it is.
MR. DALEY: It just reinforces the need for dialogue but again we did not get
down to that level of detail. We tried to keep this very simple, short and
sweet, easy for the respondent to enter their responses, and easy for us to
summarize results. We could go into great detail on these surveys but we
probably have 42 respondents instead of almost 1,000.
Moving on with Health Plan results. Did the compliance date shift the
timeline of any of your major projects or change resources? For half the health
plans said it shifted them greater than six months. They have other things to
do, they said good we have a breather, let’s just take some time to do the
other things, and get back to ICD-10. Some, about a fifth said a three to six
month delay. A fifth of them said no delay, they just kept moving along
forward. A third said they lost resources. A quarter stayed the same and there
was actually a group that said they gained resources as a result of the delay,
which is very interesting. You have more time, you need more resources so they
might have been under resourced at the start. So the conclusion is that many
health plan did slow down a bit, but they are still moving forward.
How to complete your formal impact assessment or Gap Analysis. In 2013, we
had about a half of them said they had completed their impact assessment.
Another quarter were nearing completion so we are getting close to having a
health plan that at least know what they have got to remediate. In 2012, the
figures are about a third and a fifth, so there has been some pretty good
progress in getting the impact assessments done.
How to complete your internal business process design development? In 2013,
slightly more than a third were complete or nearly complete which is good news.
In 2012, it was about half of that number, about a sixth. In 2013, less than a
tenth had not started. It was around a sixth in 2012, so in 2012, most of them
had started and some of the stragglers even more of them have started at this
point. Again, there has been some progress in the health plan. Certainly not as
much as we want but they are moving forward a bit.
Next slide is what is your estimated date to start internal testing or fully
functional IC-10 processing? About three-quarters said they would start
sometime in 2013, which is the year prior to compliance. So that is good sign.
In 2012, around half said they would start this step via prior to compliance.
Everybody still says, sure, we are going to be doing it ahead of time. Whatever
that year is we will do it ahead of time. It looks like they made some progress
in there but it would be great if they had said we had already started.
A couple more. Estimated date for health plans to begin external testing.
They are about split 50/50 between those that would begin external testing
before the end of 2013 and those that would start after January 2014.
In 2012, seven-eighths, a vast majority said they would not start until a
year compliance. So that has been a good shift. There is more that are going to
start the year ahead of compliance than previously. But still with a 50/50
split half of them are not going to start until there is only nine months left.
The top health plan obstacles? In 2012, 2013, same thing you might have
heard that before, internal priorities, regulatory mandates, staffing, resource
issues. It is a common theme no matter what type of organization. We did ask
the health plans what their strategy was for ICD-10 processing. Two-thirds
indicated direct processing of the I-10 codes, a slight increase from 2012.
About a quarter say they will combine some cross walking with direct processing
and just a very few said that they are cross walking as their main way of going
Now if we could switch to the provider results. First question, did the
compliance delay shift the timeline of any of their projects or change
resources? About two-fifths said no change. A third said more than six months
but most indicated no change in resources. That is good that they are keeping
their resources on the project but the timeframe still slipped a little bit.
When did they expect the providers expected to complete IC-10 impact
assessments? Over two-fifths said they did not know and that is about the same
numbers we got in 2012. That has not changed. They just do not know when they
are going to figure out what ICD-10 means to them. For those who completed or
plan to complete it in the next three to six months there was a slight increase
so those that are moving forward have made a little bit of progress but there
is still a large segment out there that have not done anything yet.
When do the providers expect to complete the business changes? Again,
two-fifths said we do not know, which is similar to what we had in 2012 survey.
A third indicated they would not be complete until 2014. So the conclusion
again the providers, many of them have not taken significant strides forward.
What is their expected date to begin external testing with health plans and
trading partners? Same as 2012, about half of them answered, we do not know.
There is a common thread in there we do not know. They are just not sure when
they are going to be doing these various steps. A third expected to begin
sometime in 2014 so it is not encouraging there. It looks like many providers
will not have a lot time less the nine months for external testing.
The obstacles for the providers? They are a fairly even split. They had a
little bit more variety in their answers. Staffing, budget, priorities, vendor
readiness, IT impacts, and those were the same mix of answers they gave us in
2012. So conclusion is the providers have whole bunch of issues they are facing
out there and they are just not moving forward quickly enough. We did ask them
the same question of how do you plan to produce ICD-10 codes. Over half said
they would use a mix of cross walking and direct code selection. About an
eighth of the responders said they would only use cross walking, which is very
interesting. This is similar to what it was in 2012, so we have not seen a
slight shift where the providers are relying on cross walks less. They pretty
much stayed the same percentages in our last survey.
General conclusion across both vendors, health plans, and providers. The
one-year delay caused at least some organizations to delay their IC-10 efforts.
Health plans appeared to have made some progress from early 2012 to early 2013.
Not quite as sure on the vendors and providers side, they seem to have made a
little bit less progress. Provider readiness is still a major concern in
meeting the 2014 compliance date and of course, the industry may not have the
time necessary to do enough testing to prevent major disruptions when this
compliant date occurs.
We do plan to conduct additional surveys in 2013 and 2014 to see where they
stand, see what the issues are, and see what we need to do to help move the
institute forward. WEDI does recommend working with CMS, partnering together
both with CMS and others in the industry to engage the stakeholders, get their
concerns, coordinate their efforts, and just get the message out and keep
people moving forward. Some of those actions you will see in a subsequent slide
are already in motion.
Moving down to the last few slides, here are some of the other WEDI
activities. This is still IC-10 related. We have a new affiliate sub workgroup
under the IC-10 workgroups formed in May of this year to coordinate IC-10
implementation efforts. You may be aware of our WEDI regional affiliates where
we had different groups around the country who are regional affiliates as the
name implies of WEDI and they helped bring a more local presence or regional
presence to the initiatives that were going on and bring the WEDI message out
there. Gather those issues, bring them forward to WEDI so we could address them
and share them amongst the different regions. We felt that, that affiliate
program although it is effective many of the states are forming something
specific to ICD-10 so we said why don’t we get all of those state groups
together, which are specific IC-10 initiatives and get them together to talk
amongst themselves about some of the issues they are facing?
So we have got them in place now. We had a first meeting coming up in July.
We actually have had them together at WEDI meetings and at HIMSS they got
together and talked about what they were doing so they are already started to
collaborate on that one. There is about five involved so far. We have
California, Massachusetts, Minnesota, and NCHICA from North Carolina, and
Wisconsin. There is rumors of a couple more that might be forming IC-10
collaborates. We want to get a collaborative of collaborative to share their
The goal. Facilitate interstate communication around implementation, bring
them together, and work successfully. Again, share their best practices, share
their issues, things of that nature, and overall hopefully reduce the risk and
effort required to implement ICD-10.
Some other things, non ICD-10 that WEDI is working on. We have over 40
workgroups looking at various things. Transactions, we still look at those
transactions. Identifiers, privacy, security, I-10, health ID cards, HIEs,
health insurance exchanges, Accountable Care organizations, you name it. If it
is an industry related and deals with moving information, WEDI has a workgroup
trying to help address it. We write White Papers and things of that nature,
trying to help everybody move this stuff along.
Some of the things we do that I am sure you are well aware we do industry
education, we identify issues, we prepare recommendations, best practices if
you will, give implementation guidance. Again, we cannot give mandates as to
how to implement but we can say this is a way that looks like it will work.
Many people are doing it successfully and this might be a good approach to take
but then it is up to the organizations as to whether they use that approach or
not. Obviously, we give testimony, we write comment letters to the Secretary,
White Papers, issue briefs, lots of presentations, and we also have a
legislative and regulatory tracking service many people are not aware of. To
click on the WEDI website you will actually be able to look at any legislation
or regulations both at the federal level and in every single state and see what
is going on out there, click on them, and actually read the text of some of
these items. It is a great service out there. It is free to our members and I
do encourage use of that.
We also have a workgroup on Cloud computing. A little technology workgroup
as well. Some of the other activities we are involved in, we have health plan
ID listing assessment with CMS. We had over 1,000 virtual attendees for that
one. It was a very success event. We are working with CMS to develop an
industry coalition, IC-10 support to help smooth that transition. So we are in
dialogue right now forming up how that will work. We have a new partner with
the Office for Civil Rights, a new partnership with them. We are going to be
producing five Webinars on that targeting the provider community about the new
Omnibus regulation and that should be rolling out as we speak.
Recently completed our annual conference in May. We had the largest
attendance in WEDI history. A very successful event. We are planning IC-10
health plan ID implementation excellent forums in July in Fairfax, and we will
have CMS health plan ID listing session at that event as well. Another chance
to collaborate with the federal government, hear what the industry is saying,
hear what the concerns are at CMS, and have a great dialogue there.
We are involved in implementing the HIMSS/WEDI National Pilot Project. The
first round of testing is underway. I do not have a lot of slides on that one
but this is using a synchronous approach of test cases.
Theoretically, if a clinical situation occurs in some provider setting,
eventually that documentation should be very similar no matter what setting you
are in. The resulting recording and electronic health records or claims that
result should all come out looking somewhat the same. Maybe the dollar amounts
may differ but the codes and things on there should be about the same. Of
course, when that claim shows up the payer should be able to process it with
those codes on it as well. We are looking at using that a synchronous approach
that will allow a lot of independent testing and then we hope to link all of
them up and run a few end-to-ends to see how it all hooks together. This will
allow people to be ready.
For example, if your vendor products are not ready you can start coding the
scenarios and see what your codes would be. If they are ready then great, you
can then enter them into the next level of your product. A whole bunch of ways
to go at it. We have pretty much sliced and diced the things that occur along
the trail from patient encounter to paying it. At any point along there, we
know what the results should be so you can jump in at any point and compare
what your segment is from that to the next one like a clearinghouse. Assuming
this came from the provider here is some I am going to send to the payer, you
compare what you receive in, what you send out.
Looks like a great initiative is out there is underway. We do not have all
of the results yet. There will be subsequent phases after that.
MS. KLOSS: Jim, is that exclusively HIPAA transaction related or is that
also for are you getting into the CCDs at all?
MR. DALEY: It is ICD-10 related. As you are doing IC-10 where is it going to
appear in the various entities? With that, yes transactions will be a part of
it because it is going to show up on a transaction. We can compare what did you
get out of your provider shop to what the quote, approved transaction is, and
see if the codes are the same. If not, why are you different from what the
standard industry answer should have been? Maybe there is something wrong
somewhere or other. That is what we are hoping to do and find and in those test
cases we had some of the finest experts in the industry come along and say we
all agree after a little backroom fighting, to say that is the way it should be
coded. That is what should end up on that transaction. It is a good panel of
experts at HIMA, AAPC, and people of that nature who said that is the answer.
There will be subsequent phases to this but after the pilot concludes, which
it is concluding shortly the proof of concept will be done. We will put out a
report on the results and from that point forward we are not going to be
actually running the entire industry testing but we have put that forth for the
industry to use. Results will be out there on the HIMSS website their IC-10
website, so people can use those test cases and test and there is a vendor who
is offering services in that regard as well.
With that in mind, just one other brief detail we have got out here. We did
have a slight change of a very positive change in our membership. We have
announced free membership to governments, organizations, and to students. We
now have over 70 federal and state agencies which have joined WEDI and we are
working with state universities to expand to reach to future health IT leaders.
When the students are going into some kind of health care or medicine, health
informatics, whatever it might be, public health. Get them involved, see what
the industry is doing out here, read our papers, get involved with WEDI, and
see what contacts they can make, et cetera. Getting them early to know what is
going on and to be able to start to network with peers we think would be very
beneficial as time goes on.
With that in mind, I do thank you for the opportunity to speak today and I
will entertain any other questions.
DR. SUAREZ: Thanks so much. Jim let’s start with some question from original
question from the committee.
DR. SOONTHORNSIMA: Thank you, Jim very much. I noted a couple of key points
you made with ICD-10 and that is on the recommendation page. You talked about
looks like the industry may need more time and that CMS needs to be engaged in
helping people. Are you at any point right now to say whether we are going to
make it or not? Are you saying that we need more time to assess? That is the
first question and I do have a second question not related to ICD-10 but you
have these 40 workgroups and I would like to learn from your perspective
because it looks you touched on a lot of things. What are some of the biggest
areas of threats and opportunities outside ICD-10? I know you spoke a lot on
ICD-10. Thank you.
MR. DALEY: The first thing, more time. I am sure in your role and people
here if you expand the time the work expands to fill the time that it is
allowed. More time is not necessarily the answer. I think what needs to be done
right now is to just push forward and get the information out there. I still
run into people who say I have heard something about IC-10, I am not sure what
it is. Get that message out there.
Again, I do not have the authorizations to speak on behalf of WEDI and all
their recommendations but certainly saying the date is not changing. I think is
good, that is Jim speaking. That is a good thing to say but we have to be a
little firmer and if we keep letting it slide that could pose some issues.
By the same token we do not want the industry to fall apart. We have got to
look at how can we accelerate, get that critical mass forward so when that date
stays the same assuming it does we will not be leaving a whole bunch of people
in a dust trail. What are those measures right now to move forward, push people
into that, and encourage them whatever it is. We are looking at our measures
again collaborating with CMS on this one. The cooperative exchange is looking
at the clearinghouses, which have a presence throughout all the different
provider areas to get the message out there. These states collaborative and
sharing their information to say look you did not start on time but you can
ride the coat tails of those that did. Here is some information. This worked
quickly for them and this did not so maybe you want to follow this path. We are
actually in the midst of producing something that said okay here is a cheat
sheet of you did not do your assessment. Here is a paper that will tell you how
to do it and here is some quick stuff over there. Try and point people to all
those little things.
CMS has some great information on their website. WEDI has some great
information. A lot of good stuff but people may not even know where it is.
Anything that we do to get that message out I think would be helpful. Will we
make it? I certainly hope so. I often use the analogy of if anyone who has ever
ridden a school bus there is some kid that always missed the bus someday or
other. But the more people you have on it, the more people that are ready, I
think the less disruptive it will be. We will continue to do surveys to see
where we are so we can make informed decisions as time goes on.
Second part of the question. Threats and opportunities outside of ICD-10.
Certainly, everybody is working right now in insurance exchanges to get them up
and running. There is a lot of activity in that regard and that is an issue, we
will see how that works out. The regulations are coming out. There is still a
couple more to do so as we are trying to build towards an October
1st date and January 1st implementation date not having
all the requirements on the table certainly does cause a little bit of stress
for some people.
Health Plan ID. That is coming up soon. I am not sure that a real stressful
point right now but it is something we need to consider is to how that is going
to work and make sure we go in and understand how the industries are going to
work together through use of those identifiers. I am sure you have seen things
on both sides of the table of why we are even doing this. We already route
stuff correctly. What else is this going to be used for? How will people
enumerate? Will they just get one? Will they get a hundred? We need to start
getting that under control so it becomes a smooth item.
Couple of things out there. The new payment models. That is underway. What
is going to be needed for those? I cannot say it is a stress point right now.
It certainly is an opportunity to get a jump on the game. Some of these things
are going to require changes to standards. What information has got to be
exchanged? Is it there on the existing standards? Do we need a new standard? Do
we need to just modify a current standard? I cannot answer that but those are
things that need to be looked at as well.
Threats, obviously security is always a threat to everything and one of the
things that is a concern. I actually had a businessperson tell me one time do
not tell me I cannot do this because of security. You figure out how I can do
it safely at which point I was scratching my head saying that is a tough one to
figure out but they want this technology and it helps them do their job. We are
all mobile workers now and we have got to be able to work on the road and how
do you do that safely. That certainly is a threat and an opportunity at the
same time. That is just a few things off the top of my head.
DR. SUAREZ: We have time for one more question. Linda.
MS. KLOSS: Thank you so much. Excellent report and I know your coverage of
ICD-10 will help us a great deal in tomorrow’s discussion. I will not ask all
the questions I have on that. Back to your report, the 2013 report, because it
is broader in scope. Do you envision that it is going to give us a sense of how
far we have come in this journey? It seems to me, sometimes some sense of
metric of what percent of these transactions are now the way we had envisioned
them. There are so many aspects of this that are measurable and I am just
wondering to what extent you are going to come up with any of those kinds of
numerical answers through your research?
MR. DALEY: We will have some of that in there. Part of it, okay, here is
what we said we wanted to do, what have we accomplished? From there what still
remains to be accomplished but also should it be accomplished 20 years later or
is that something we do need because we really need to do something else? But
will definitely be reflective but we did not want to dwell on that was HIPAA.
Here is what is gone and in the report. We really want to be forward looking to
say okay that is important but starting today forward where do we want to go
and then add those on top of that. We will be a little above.
MS. KLOSS: The idea that it has taken 20 years to get a quarter of the way
there, a third of the way there, and what are the accelerants that will?
MR. DALEY: Right, it should all be in there somewhere or the other and we
certainly would love additional volunteers on that report.
DR. SUAREZ: Thank you very much for the report. A couple of quick notes.
Most of you know HIMSS is hosting today and tomorrow the ICD-10 sort of a
summit, I guess here in DC, in another part of the region. The keynote address
was actually delivered this morning by Farzad Mostashari, the National
Coordinator and he noted very pointedly apparently, that there was not going to
be any delays on ICD-10. From the Administration perspective, that is position
from position and that is an important point.
The other things I think we need to mention, we have a full session tomorrow
on ICD-10. So we will be taking a lot of these findings. So thank you for
bringing those up and bringing them tomorrow into the discussion. I have seen
in the last two days national coverage of reports made of surveys actually
completed by different organizations. We will hear tomorrow from one of them.
There is a lot of still concern about the speed at which organizations are
getting ready. Clearly at the end of this we are going to need some major push
to get people really to focus their attention on this. The challenge of course,
is by the first of this year we have the Insurance Exchange Program is started
and a lot of attention is going to be of course, focusing on that and having
the ability to concentrate on different priority topics as big as this one is
going to be challenging. We will talk more about it tomorrow. Thank you again
We are going to move to our next agenda item is the DSMO Report. For that we
have Nancy Spector, Margaret Weicher, and Lynne Gilbertson. Nancy.
MS. SPECTOR: Thank you. Good afternoon. I am Nancy Spector, Director of
Electronic Medical Systems at the American Medical Association. I am also Chair
of the National Uniform Claim Committee and I was the 2012 DSMO Steering
Committee Chair. It is that role that I am here today delivering the annual
On behalf of the members of the DSMO I would like to thank the NCVHS
subcommittee on standards for the opportunity to present our 2012 report on our
work to address changes, challenges, and opportunities affecting the HIPAA
Administrative Transaction Standards. I would also like to thank the
subcommittee for your ongoing support of the work of the DSMO.
As you are aware, the DSMO is comprised of six organizations. The three
standards development organizations are ASC X12, HL 7, and NCPDP. The three
data contact committees are the ADA’s Dental Contact committee, the National
Uniform Billing committee, and the National Uniform Claim committee. The
Steering Committee is made of two representatives from each of the six
organizations as well as representatives from the CMS Office of the E-Health
Standards and Services.
Collectively the DSMO reviews any changes or requests that come in for the
current HIPAA designated standards and for new standards and code sets to be
adopted. Change requests can be made by anyone by going to our website and
completing the change request form. From that each DSMO organization can opt in
on whether or not to review and comment on that change request. Each
organization has 90 days to complete that initial review and then there is an
option for a 45-day extension if additional time is needed.
Once the DSMO organizations complete their review, the steering committee
comes together and reviews each of the DSMO organizations, their disposition,
their reviews, and then creates a final disposition for each change request.
That is then published out on the DSMO website and I did not include this in
the report but then there is an opportunity for the requestor to make an
appeal. We have a whole formal process around that as well.
During the period of January 2012 through December of 2012, there were a
total of 14 change requests submitted. Two of them were withdrawn by the
submitter and one was withdrawn by the web administrator because it was not a
valid DSMO request. The final 11 were subsequently reviewed by the DSMO. One
request was approved as a modification necessary to permit compliance with the
standards and/or law. Two requests were approved as modifications to the
existing standard. Two requests were approved as maintenance to the existing
standard and the final six requests resulted in no changes for the standards. I
am going to take a few minutes. You have the full report, the printout that
lists the complete requests, the full response by the DSMO but I am going to
walk through and just give you a high-level overview of those different
categories. The report also breaks out and shows you by the DSMO categories and
there is an explanation of what the categories mean. It is broken out by how
those requests were categorized by the DSMO.
The first request that was approved was 1182 and this was a modification
categorized and determined to be a modification necessary to permit compliance
with the standard or law.
This is the request that came in from NCPDP requesting the naming of an
enhanced telecommunication standard version D.0 to distinguish incremental
fills as scheduled to prescriptions. The need for this information was
identified through government audits of the Medicare Part D program and a
letter was submitted to NCVHS Subcommittee on Standards on November 15, 2012
about this request. Luckily, Lynne Gilbertson is here today and is probably
going to speak more about this in a few minutes but clearly she can field any
questions you have about the need for this change and what it means.
The next category of requests that were approved is the category that is a
modification of the current standard. Requests 1166 and 1175 were both approved
in that category so 1166 will add an additional eligibility information for
dental services in the transaction. Request 1175 will correct issues between
the NUBC coding rules and the reporting requirements in the Institutional Claim
Implementation Guide. Those are two requests that we will need further work by
the standards development organization to implement those.
Request 1178 and 1185 were approved as maintenance fixes to the existing
standards. So these are usually minor typos or just errors that are found and
need to be fixed but are not going to make any changes to any of the reporting
or any of the data elements that are within the Implementation Guide.
So 1178 will add a code value that will allow for the use of the contract
information in the post-adjudication data reporting Implementation Guide.
Change request 1185 will add a loop in the professional claim to allow for the
reporting of the provider for whom the Locum Tenens provider is substituting.
That was brought forward as a business need to understand not just who the
substitute physician or provider who is doing the actual service but also who
are they substituting at the time that they performed that service.
Then the remaining requests 1171, 1173, 1174, 1176, 1180, and 1181 all
resulted in no changes to the standard. So 1171 was brought forward and was
asking to have a segment added to the professional claim for the provider to
report if the patient had met the deductible. In looking at this, it was
disapproved because the DSMO agreed that providers could not be expected to
track and report this information back to payers in terms of whether or not a
patient’s deductible had been met. They do not have necessarily information on
every service this patient is having done and how that is being applied to
Request 1173 requested to have data elements added back into the remittance
advice and the request was disapproved because the requestor did not clearly
state the business need for this data and how the current data that is supplied
failed to meet their need.
Request 1174 was a request for specific vision prescription information to
be added into the professional claim and this was disapproved because there was
no business justification found for reporting that data in the claim. It is not
data that would actually be needed to adjudicate the claim and the payers who
were participating in the review felt that is that type of information was
needed for any reason it would not be needed to come in on the claim. They
would have a different way of requesting that information.
Request 1176 was disapproved because the requester had incorrect information
about the reporting of condition codes so they had made a request and in the
end their understanding of the reporting of the condition codes was not
correct. It just was not a valid need for making a change.
Request 1180 asked to have the National Drug Code information reporting of
that expanded beyond what the current regulatory requirement is for it. Right
now, the requirement is that it is reported for Medicaid payers in specific
situations and the request was asking to have that extended beyond so that
commercial payers could request and get that information on the claim as well.
In this case, the DSMO actually failed to reach consensus on a response so no
change was initiated for that request.
Request 1181 asked to have a qualifier added to report national health
related items codes and this request was denied because this code set is not a
HIPAA adopted code set. Therefore, it cannot be reported in the Implementation
Guide. The requester would need to first bring forward or it could be done at
the same time but we would need to have a request added as a HIPAA code set and
then to have it added for reporting.
That is a summary of the requests that we reviewed during 2012. As for other
work that has been done by the DSMO since our previous report to you is we have
continued to file the work of NCVHS, the standards development organization
data content committees and the operating rules authoring entity as their work
relates to the provisions of administrative simplification.
In March of last year, we spent quite a bit of time reviewing the four
letters that NCVHS sent to the Secretary. We specifically were paying attention
and gave a great deal of review to the letter that had to do with additional
analysis of the update and maintenance process for standards and operating
rules. As you are well aware over the years, DSMO has provided extensive input
on this topic about the update and maintenance process for standards. We are
ready and available to continue working with you on that topic.
We also continue to review potential enhancements for our websites and this
was topic that had come up and feedback we had gotten from NCVHS in 2011 and so
we have continued to look at ways that we can make our information more user
friendly and more readily available. We worked on an educational presentation,
a PowerPoint file that goes through and explains the DSMO and what our scope of
work is, the goal of our work. That is posted out on our website so it is
something that the public uses to review and it helps walk them through change
requests and how to do that. It is something that will help educate the public
on our work and how they can make the request through us. A link for that
presentation all of the DSMO organizations have made that available on their
websites. It is something we are trying to provide it in as many outlets as we
So with that we look forward to continuing to work with you on our joint
interests for administrative simplification and we thank you for allowing us to
present our report today.
DR. SUAREZ: Great, thank you so much. I think we probably want to take a
couple of minutes to see if there is any questions about the DSMO report before
we go to the AX-12.
MS. GOSS: How well is the quest for changes in operating rules that track
back to Implementation Guides and standards be handled?
MS. SPECTOR: We have had a lot of discussions since the ACA language came
out and just how the complementary aspect of standards and operating rules will
work. But Margret, do you have a little more of the specifics on that?
MS. WEIKER: If you have changes that need to be made to the actual operating
rule, you would submit those to CAQH CORE EFT on their website and I think
there are instructions on the website of where you email your change. Then you
say, how do the changes from an operating rule, and then the complementary
standard. Our workgroups review the operating rules and through our consensus
building process determine whether to make any change through the actual
Transaction Standard and Implementation Guide.
MS. SPECTOR: I think just to tag onto that and saying that any operating
rule requests will go directly to CAQH CORE. If somebody is confused and does
not know exactly where to go with that information and they do put that into
the DSMO website and if they are clearly quoting an operating rule or they are
specifically talking about an operating rule. Then we will behind the scenes
get in touch with the requester, let them know where they need to direct that
question. We will not put them through a 90-day review, tell them it is
disapproved because it is an operating rule, and then we will try and get them
connected immediately to where they need to be.
But if it is something that is a little bit more of a gray area where it is
a general request. It is unsure if it is something that should go into the
standard or the operating rule then that is something we will follow through
the DSMO process to look at from a standards perspective.
DR. SUAREZ: Let me follow up on maybe that point. Have there been so far any
specific changes made to the standards from adopted operating rules? In other
words, there is a series of operating rules in place for say claims status and
eligibility, the two that have been adopted. At some point, we had discussions
about the expectation that some of those operating rules would be now
incorporated or as appropriate of course incorporated into the standards. The
operating rule would be potentially not anymore needed because now it was part
of the standard. Have there been any adopted changes at this point?
MS. GILBERTSON: One particular one is NCPDP had an operating rule guide for
the 270/271 that is used in E-prescribing. Those changes have been incorporated
in version 6020 of the 270/271, which when we move forward we will negate the
use of that operating rule document.
DR. SUAREZ: Okay, that is exactly the kind of example that I was thinking.
MS. WEIKER: We didn’t go back to 5010 and make any changes because the
operating rules were supposed to look at what was already in 5010 and not
duplicate what was already in 5010. It has been passed that point in time
forward that we then look.
DR. SUAREZ: Exactly the point moving forward.
MS. SPECTOR: So from an orchestration perspective building on Walter’s
question, how do DSMO and CAQH CORE barter out those negotiations of
grandfathering in, closing things out, moving to new iterations of the standard
own operating? How are you working synergistically together to keep things lock
MS. GILBERTSON: It is definitely new territory. From what we have seen so
far we have seen that any kind of modifications in operating rules has not come
to the DSMO at this point. I think the operating rules that are currently in
effect and the ones that are going into effect as of January 1 are ones that
when you look at them actually a large number of them are truly outside the
scope of what an Implementation Guide would. Communication standards, response
time for doing something in real time, enrollment processes.
There is so much of it where it is outside and it enhances the flow of those
transactions, which is really great. I think it is not a bridge that we have
hit yet to cross. I think there are so many of us are involved in so many of
these different initiatives or organizations and I think it is a group effort
in terms of making sure that especially for somebody who is outside of these
groups and outside of the know of how things run. For those of us who are
involved to make sure that things are getting directed in the right place.
I think between X12 and CORE, I do not know if there is a formal process but
there is definitely communication lines that exist there.
MS. WEIKER: There is not really a formal process there. ASC X12 has taken
the initiative to look at what CORE has adopted as operating rules, what the
government has adopted as operating rules, and then make a determination
through whatever workgroup is appropriate whether we make a change or not. We
are taking the initiative to do that and put it in the guides as appropriate.
DR. SUAREZ: I do have a quick question but maybe I do not know Rachel, if
you want to.
MS. FORRESTER: Since I am the only one here today for CORE.
DR. SUAREZ: Introduce yourself.
MS. FORRESTER: Rachel Forrester for CAQH CORE. There are a couple of things
to Alex Goss’ question. If I remember correctly and I do not have it in front
of me, I think that Section 1104 of the Affordable Care Act does require some
management or maintenance review committee or something to be established by
HHS. I believe that OESS is working on that and no details obviously are
available to us but I think that ARCA requires form of maintenance for
standards and the operating rules in terms of moving them forward on a prompt
In terms of coordinating and activities between CORE and ASC X12, CORE has
an official request process and it is not unusual for requests to come into
CORE about an aspect of an operating rule. Whenever something is specific to
the Implementation Guide or the X12 standard, the requester is officially
referred to the ASC X12 RFI process for those because CORE does not have the
authority to answer questions about that. I believe similar activities take
place from X12. If something goes into the X12 RFI process and is specific to
an operating rule then the requester is referred to CAQH CORE.
There are activities taking place to coordinate and exchange information and
provide appropriate information from the correct authority on whatever is being
inquired about by the organizations. It seems to me it is working well and I
know that at CAQH CORE we are handling many requests and I know that X12 is
doing the same thing.
DR. SUAREZ: Actually, I had a quick follow-up before. This request they have
not approved. Are they being incorporating to the next version for the most
part? All of them? Maybe there is something we will be covering later today.
MS. SPECTOR: Yes, two were modifications, two were maintenance. Those will
be incorporated. X12 is working on those and those will be incorporated into
the next version of those transactions. The NCPDP one is different and I
believe Lynne is going to speak more specifically about that.
DR. SOONTHORNSIMA: I was curious how do the requirements and changes as a
result of the health insurance marketplace, the federal facilitated
marketplace, the exchange. How will those requirements get translated to the
work that you have to do. Can you anticipate more coming down the pike? We do
in the industry but I just do not understand how that would work out. The
requirements are not always complete to Ken’s point earlier.
MS. WEIKER: That is so true. We in X12, we formed a special appointed
committee or SAC as we call it that deals with the health insurance exchange
information. X12 has a change request process that you can go to our website
and actually enter a change into. That is where if you had something specific
to the exchange marketplace whether it is a state based or federally
facilitated you could enter your change request there.
If you have a question about how do I do X or whatever it may be there is
the RFI process and there is the capability to ask a question in regard to the
exchanges. Originally, when they first started coming out and working on things
we did create an 834, which is the enrollment transaction guide specifically
for the exchanges. As well as an 820 which is the payment piece of it
specifically for the exchanges. But due to the regulation it mandated that it
be the HIPAA adopted version so therefore the 834 that is adopted under HIPAA
will be the 834 that is used in the exchanges.
We do know that there are some gaps in those and they are being placed in
fields where it is allowable within the transaction but it is not as automated.
Those types of things are being brought forward to where we can put them into
the HIPAA version of the transaction. It was also determined that the 820
transaction the business purpose is different from a HIPAA point of view so I
believe they have adopted the 820 HIX at the SACDEV(?).
We are very much involved. The chairs of that group actively participate in
there as well. We try to keep it all coordinated as best we can but it is an
ever-changing evolution type of thing with the exchanges.
DR. SOONTHORNSIMA: And that is done at X12 not DSMO?
MS. FORRESTER: Right, they are being done at X12.
DR. SUAREZ: Okay, let’s go to Margaret.
MS. WEIKER: Good afternoon. I am Margaret Weiker, Chair of the ASC X12
Insurance subcommittee. When Lorraine extended the invitation from this
committee to me it was in regard to the timeline for the next version, much
anticipated long awaited timeline. We developed a project schedule breaking it
up into bigger chunks so to speak. At the top level is the actual planning. How
do you plan for the next version?
First, you come up with a schedule. You come up with all the tasks
associated with it. You determine which guides will move forward at that point
in time. What will be the next version of the actual standard because the TR3s
are based upon the base standard. First, you have to have a base standard and
then you look at the actual Implementation Guide. We are doing that right now.
We have change requests that have been entered. Several, many actually change
requests that have been entered. We are reviewing those right now at a
high-level to determine is there a critical change request that would cause a
change to the underlying base standard. If so what version could we put that
in, et cetera.
What you will see on the slides as we go through this, you will see the
task. You will see who it has been assigned to and then I have a very
high-level description of that task. Obviously there is much more detail than a
project schedule but it is very hard to put the whole schedule on a PowerPoint
At a high-level, we have done the planning. Then the next slide and I think
you all should have the handouts is what you can see on this side is the actual
representation of it in more of a bar chart. At the top there is a legend that
says who is responsible for the activity. This is color coded by those
responsible as well as the date. You have the description on one side. The next
slide would show it visually on a timeline. It is the same task just a
different presentation method.
Then the next activity is the development activity. We have announced the
close at the change request. That was done at the end two weeks ago. Once that
is done and we do the evaluation and determine the next underlined base
standard, we will load that into our tool, which is called Only Connect and you
will see that several places in the slide deck.
We will then go through our process, which is we have a change request. We
must have the business requirements for that change request. Once we have those
requirements then we send it to the technical sub task group and they go
through and determine what is the technical solution to this business
requirement. Once they come up with a technical solution, it goes back to the
business to ensure that the technical solution does meet the actual business
requirement and that they did correctly understand the business requirement.
That goes back and forth to ensure that it is correct. Once everybody signs
off on yes, the business requirement is met by this technical requirement and
we understood the business requirement. Then that is actually entered again
into the tool that would indicate what change would need to be made. Whether it
is changing a situational rule, if it is adding a code value it could be adding
a new segment, a new rule whatever it may be then that is entered.
Once all of the changes are entered for a specific guide then they are
closed. The guide is then in turn published in a draft form and then at that
point we would review it and say is there enough business drivers, enough
business requirement, enough business needs to actually move forward to the
next version so to speak of HIPAA with the TR3.
Again, this is on the timeline but I do want to point out one thing and it
is hard to see on the screen and I hopefully it is okay to see on the handout.
You will see in this step where we are defining the business requirement. What
we plan to do and I have already done one so far is to have joint Webinars with
WEDI to one notify the public what are some of the change requests that have
come through. Some of the bigger, higher level ones and gain feedback. One, it
provides the industry with a place to go hear what the changes are so when the
guides come out and they are doing a public review hopefully it is not as much
of a surprise as it has been in the past.
As well as then to garner input to ensure we do have everyone’s business
requirements. We have already held one Webinar with WEDI with some of the
change requests that were entered early on and that we have already processed.
But then go forward where we will be scheduling these periodically when we get
a certain number of change requests to where we feel we have not flushed out
enough to actually have a joint Webinar with WEDI.
We have captured the business requirement, we have developed the business
technical solution, we entered it into the tool, we have produced TR3s. These
are draft TR3s at this point in time. The task groups must review the drafts to
ensure that the changes were applied correctly. Typos are fixed, those type of
things. It goes through a process where X12 must review the drafts first.
Once we say the drafts are good to go then there is a notification sent to
the industry to say we are now having our public comment period. This is where
you go to get the guides, this is where you go to enter your comments kind of
thing. When we released some of the 6020 guides we did it in a big bang
approach where we said here is all the 6020 guides. What we plan to do this
time if it works out okay is to actually stagger them. As soon as one guide
gets done and we look at the change request system and say there are no code
change request with another workgroup, then we can say we can go ahead with
that guide and put it out for public comment. That way the industry is not
inundated with thousands of pages if you put all the HIPAA TR3 guides out for
comment at one time.
Wanted the last people to focus in on especially things that are not claim
related or remittance advice related because that is typically what people
focus in on and comment. When time is precious and the other transactions slide
and that is unfortunate but it is what it is.
We go through the public comment period where people can review, enter a
comment. As comments are entered, we review them to see if we need to make a
change. Maybe it is a new business requirement that would require a different
change or another whole process. Maybe it is another code we need to add or
whatever it may be as the comments come in we process them. Even if it is no
change we say there is no change. Here is why it can already be done in this
standard type of thing and the answers to the comments. I comment I want this
then X12 will post the response to that comment. Every comment that somebody
enters we must post an answer back whatever it may be.
DR. SUAREZ: How long is the public comment? Is it 60, 90?
MS. WEIKER: It is 60. We can actually make it 30 or we can make it 90. There
is no hard and set rule. We typically go with 60 but we also look at other
factors like the holiday. We try to avoid having them come out during a holiday
period. Sometimes we are more successful at that than other times. We also look
at what else may be coming out for review if we know about it. If there is a
huge NPRM coming out and we kind of word it might come out. We might consider
holding and see if it does come out on that date and then figure out where we
need to. But by having the TR3s done in a more staggered approach versus big
bang it gives us a little bit more flexibility too of when we can release it
for the industry.
Once the comment period closes, all of the questions have been answered. We
do what is called an informational form. Basically that is a place where the
workgroups at a high-level go through all of the changes, what the responses
were. This meeting is what X12 calls a hybrid meeting which is both a
face-to-face as well as virtual meeting. Since anybody can comment on our TR3s,
we allow the industry via WebEx type of tool to listen in on what the changes
were and that type of thing. We hold our informational form and people can
comment there. Maybe they disagree with the solution. Maybe there is another
factor that was not considered or something. There is also the opportunity at
the informational forum for people to also comment.
MS. GOSS: Margaret you were talking about the informational form that is
really the accounting of we got these comments, this is what we did with each
of them. Can I step you back to the business requirement Webinar that you
noted? This sounds to me that you are doing with WEDI and it sounds to me like
what you are doing before you actually make a change in the Implementation
Guide. Is that you go to the marketplace sort of like an informational form but
in a different venue that says calling all hands tell me if we have it right.
Is that also open to anybody and everybody?
MS. WEIKER: Yes.
MS. GOSS: You are doing it jointly with WEDI to promote getting a broader
consensus before you start making a change?
MS. WEIKER: Right.
MS. GOSS: Is this the first time you are going through this process?
MS. WEIKER: Yes.
MS. GOSS: I will be very curious to hear how it works and I think it is a
really great idea. Could you also explain to me the names of A, B, C, TGA, TGB.
I used to know those acronyms. I do not know those anymore. If it works in your
organizational structure that correlates with those. CGA to CDC.
MS. WEIKER: A is the PMO.
MS. GOSS: Project Management Office.
MS. WEIKER: B is the business and C is technical. Where I used to have and
Alex where you used to know of four task groups there are now three.
MS. GOSS: The other thing is that I noticed that there are some places that
look like WG3 and some of them say WG, little S. Are they all supposed to be
workgroups, little S?
MS. WEIKER: No.
MS. GOSS: Still think like worker 1, 2, 3.
MS. WEIKER: In all of the task groups there are 1, 2, 3, 4, 5 workgroups.
MS. GOSS: Did those change? Did you sequence them in numeric data?
MS. WEIKER: Yes, there are some changes in the sequence.
MS. GOSS: But just general structure is still the same at the workgroup.
MS. WEIKER: General. The TGA workgroup three, that is a specific workgroup
and where you see TGA workgroup three we mean TGA workgroup three.
MS. GOSS: What is workgroup three?
MS. WEIKER: That is our documentation public facing workgroup.
MS. GOSS: Thank you.
MS. WEIKER: Then the TR3s are update. Any changes that we had to make we
enter those into the tool. We update them and then we produce a final draft.
Again, there is another chance for the workgroup participants to go through to
ensure that any change that was made was also applied correctly to the actual
Once that is done then we go through our approval process so to speak. I
have what we believe to be a final TR3. First, the task group approves it. Then
you will notice task 7.2 and there is a TBD. That is a to be determined. You
will see the actual description and that is called pilot test. As part of ACA
as well as other discussion that has occurred there has been a need before this
committee would recommend the next version that there be pilot testing. We have
accounted for it in our schedule but what we have not accounted for is the
actual amount of time that will take because we, ASC X12 at this point do not
know how long that would be. I know the contractor has been looking at that and
they have our timeline. I have seen their timeline but until that is all more
flushed out and agreed upon right now it is a to be determined.
My timeline goes up to a point and then we kind of wait. Once the pilot
testing is done though we are not closing the TR3 per se. We have what we
believe to be a final product. We then give it to the pilot testers, whomever.
It is still open so if there is something they find we then could go back to
that TR3 and make a change. The reason that we do not finalize them is one
there could be a change from the pilot. Two, if there is a change we do not
want to start the errata process right out of the gate. We keep them open to
where if we have to make a change we can to that guide it will be just a new
version date on it but it would still be the same underlying base standard.
Once we have either made a change or we do not need to make a change then it
finishes the X12 process.
MS. GOSS: So Margaret just a question. What you just described to me kind of
correlates to what I know they do in HL7. HL7 has their DS on draft standard
for trial use, DS2 you have a two-year period once you publish that. Now you
are beginning to incorporate something like that in X12.
MS. WEICKER: Right. Once that is done then it just goes through the
remainder of the X12 process. If we determine to move those forward to the DSMO
we would submit a DSMO request and that would start the whole DSMO process for
What we also did was to take the high-level task and the dates associated
with them still knowing that we have a TBD sitting here and we do not know the
finish date at this point. But what we did was then in turn plot it to some of
the industry due dates that we know exist today. They may change tomorrow but
as of this slide deck, this is what we knew in that point in time. As you can
see on the top piece of it is the X12 development cycle. At the bottom is other
industry type of things that have to be done health plan, ICD-10, claims,
attachments, and the other operating rules, all that type of thing. The bottom
and it is not inclusive by any means, the bottom has more of the industry.
Right now when you look at the bigger picture and keep in mind I still have
a TBD on it, we are into the July 2015 timeframe.
DR. SUAREZ: Quick question on that Margaret. Looking at the big picture and
understanding the process for recommending in the next version what I am
hearing is that this committee would probably or likely hear about a
recommendation to go to the next version sometime in 2015?
MS. WEIKER: Yes.
DR. SOONTHORNSIMA: I sound like a broken record here but I keep going back
to FFM again, the facilitated exchange. I do not see that in here. Is it
because of the changes that may come down the pike?
MS. WEIKER: Right now there is the due date of 2014 where people can start
enrolling in October. I know there is testing that is happening now and people
are coding now. But at that point in time right now it impacts two of our
transactions specifically. It could be more but any changes we would do would
be incorporated into this version we are working on now. So we did not actually
put the all of the associated dates with that here.
DR. SOONTHORNSIMA: That would be for 6020?
MS. WEIKER: I have not picked the underlying base standard at this point. I
am going to hold a press conference and charge people for that information.
MS. GOSS: So you do not know if it is going to be 6020 Version seven,
MS. WEIKER: It will not be 6020 because that version is done. We do not go
MS. GOSS: Okay so how far forward are we talking? Seven, eight, what are?
MS. WEIKER: In the sevens.
MS. GOSS: In the sevens. Okay and when you answered Walter’s question did
you about 2015, did that factor in the wild card of the piloting timeframes? Or
MS. WEIKER: No, not at this point.
MS. GOSS: It could be 2015 but it is more likely to be 2016 because piloting
takes a while.
MS. WEIKER: Yes. Unless we do more unit testing versus end-to-end testing
with the pilot.
MS. GOSS: Will that discussion of unit versus end-to-end versus modular or
whatever kind of testing you want to talk about, is that going to be discussed
later this week? I am expecting you to cover it Margaret but are we having a
report out on that?
DR. SUAREZ: We probably have to follow-up on that.
MS. GOSS: Now I am getting a no from the audience. Okay, thank you.
DR. SUAREZ: We will have time to discuss it as we move forward. Any other
questions for Margaret? In fact, we are running out of time a little bit.
Anything else Margaret?
MS. WEIKER: No, I am done.
DR. SUAREZ: Okay so we are going to go to NCPDP and we are going to steal a
little bit of time from the break and just adjust a little bit the schedule.
MS. GILBERTSON: Thank you for the opportunity. I am Lynne Gilbertson with
the National Council for Prescription Drug Programs. Slide one is an overview
of who we are if you are not familiar with NCPDP or ANSI-accredited standards
development organization. We serve the pharmacy and the electronic prescribing
services sector. That is more overview for you. We were asked as Margaret also
noted to address these two items on the agenda, the state of development of
upcoming versions and then the incorporation of operating rules. We will give
you a couple of slides on that.
New versions? Quick answer, NCPDP has not been asked to come forward with a
new version yet for the telecom, the batch, or the Medicaid subrogation
standards. We do not have anything yet to even offer. It has not been
discussed. We continue to receive change requests on a quarterly basis. We have
updated the standards past the version D.0 but at this point the industry is
using the telecom standard and none of the changes that have come forward have
been a real trigger to think about moving to a new standard. One of the reasons
is because we learned from HIPAA-1 and we became more nimble at what the
industry requests are. The types of requests that we have to deal with the most
are code values or qualifier values, things like that to address emergency
needs, or perhaps Medicare Part D, and other businesses cases. We have the
ability to add those to what we call our external code list at a quarterly
basis with a timeframe the industry has set-up for their implementation. We
have not had the need as a showstopper for a new data element. It has been
mostly values that have been added.
The other thing we did during the HIPAA-1 learning was the incorporation by
reference of our Version D editorial document. We have spoken about that before
and this is our document that provides questions and answers, examples, further
clarifications, notification of typos, just things that go into this document
so it is a living breathing quarterly updated document with what the industry
is addressing at that moment. It is a great reference guide. When the industry
is ready, we will submit a DSMO change request, start the process, and let
everybody know the industry is ready. There might be multiple depending on
whether or not telecom, batch, and subrogation all choose to move at the same
time or not. None of that has been discussed at this point.
Of the important note we did come across a situation back in 2012 that we
have notified because of some OIG audits of the Medicare Part D program. We
were asked to look at how to solve some problems in what are called the
prescription drug event files that are exchanged which are post-claim reporting
information. There was a serious problem found with an interpretation of a
field that comes in on all the claims that was not being audited as the
appropriate use of what the industry was using. The industry met a lot in 2012
to try to figure out what kind of solution they could come with. Surprisingly
they came with what seems to be a very simple solution. Obviously,
implementation takes a while but this is the use of what is called the quantity
prescribed field and it is going to be and has been opened for use in the claim
billing transactions for schedule to prescriptions. It has a narrower focus on
what it is needed for but it was not a field that was used in the claim billing
transactions in telecom in D.0 as named in HIPAA.
In November 2012, we started the process. The membership approved the
change. We updated the version D editorial document. We updated the telecom
D.0. We put out a DSMO change request 1182 that Nancy mentioned. We started
notifying the industry. We notified NCVHS and we notified OESS. It was
important enough of a change that we have got to get this field in use so that
it is properly used so that it flows all the way through the claim process to
the audit process.
The status of this ended up that we received a response letter from OESS
saying proceed. Notified the industry, prepare because the industry had asked
for an implementation date of 1-1-2014. Back in November 2012 that sounded like
a long time. At that point, OESS thought they would be able to publish a notice
in the federal register that this change was taking place. We learned in the
last two weeks that it does not appear that a notice is going to be the process
and that it will have to go through rule making and they are still discussing
whether this will have to be an NPRM or an in term final rule or an IFC or
whatever. But it is not going to be as simple as the July notice that was going
to come out next month.
Our ask for the committee at this point is what we thought when we asked in
November that there would be no action. We really think we should have on the
books a recommendation from NCVHS saying that you would recommend this process
go forward as well so that all the I’s are dotted T’s are crossed. We are
continuing to notify the industry of this change coming forward and working
with OESS on what the next steps are. We think we have got all the I’s dotted
and T’s crossed but if the industry is going to prepare for a 2014
implementation to get this problem solved we have got a little bit more work
than we thought we were going to have.
DR. SUAREZ: What would be the timeframe for that request from NCVHS? As soon
as possible, I guess?
MS. GILBERTSON: Yes. Hopefully it is just two paragraphs or something but
yes. We do truly appreciate that. We are continuing as I mentioned the outreach
to the industry. We are continuing our SNIP committee, which is Strategic
National Implementation Process, SNIP, which is a sister to the WEDI SNIP
functions. Working on guidance to the industry because the use of this quantity
prescribed field will be in use with coordination of benefits. It is very
important that all the players understand the impact and move in lock step. So
any guidance, timeline, anything we can provide to the industry besides what
the Implementation Guide will be of educational benefit and get it out there as
soon as possible. They are working on that and so that is the status.
DR. SUAREZ: I have to just to clarify number four. It should really read
request NCVHS send a letter, right?
MS. GILBERTSON: Exactly.
DR. SUAREZ: All right, okay. Like this one.
MS. GILBERTSON: Yes. Exactly, thank you. Switching gears, the second
question was on operating rules and this little dovetails with the question you
asked earlier Alex. NCPDP staff and members participate in the core meetings
that take place so the review of operating rules that come forward for the ASC
X12 transactions. We have task groups that stand behind those participants to
help work through any questions. We have worked through the 837, the 835, those
types of transactions. We have two workgroups that spend extensive amounts of
time analyzing what the industry uses for provider enrollment which is using
the X12 274 since we know that is provider moments coming up in the
regulations. Our workgroup that did the analysis then sent that to the
workgroup that is more experienced with the X12 transactions and they provided
the mapping of where these data elements might go in the 274 and then brought
it forward to X12 for input into the process of what are we going to need for
We have a workgroup that is busy looking at a mapping document we have that
if in the E-prescribing world a patient presents their pharmacy ID card or
their dual card to the prescriber office so that they prescriber might wish to
do an eligibility check on what the patient’s benefits are under their program.
It actually gives guidance of here is the information that would show up on the
standard card and here is where you plug-in in the 270 transaction. A pretty
simple mapping but it is one of those that why not tell somebody rather than
have them ask where do I put it.
We have another workgroup that is looking at whether or not there is a need
for operating rules for the pharmacy and/or ID card Implementation Guide. Since
this Implementation Guide has been around for many years and we do not know
based on the regulations if there will be a need for operating rules for the ID
cards. They are doing the analysis now. I mentioned during discussion about the
E-prescribing updates that were made to 6020. That is it. If you have any
DR. SUAREZ: Any questions? Thank you very much. I know we are a little
behind the schedule. We are going to take a quick ten-minute break so we will
come back at 3:10. It is about 3 o’clock so we will come back at 3:10 and
resume. Thank you.
DR. SUAREZ: We are going to start our next panel. This panel is going to
focus on the status of implementation of the 5010, D.0., 3.0 standards. We have
a great group of people and we have added to the agenda of the list of
presenters. Cathy Carter from HHS, from CMS, from Medicare to talk about the
status of implementation there as well. We also I believe have Don Oaks on the
phone. Can you hear us Don?
MR. OAKS: Yes I can.
DR. SUAREZ: We will cue you in when we are at the point of having you
present. I know Michelle here is going to be driving your slides so if you
could let us know to move to the next slide. I know and I have been monitoring
this is it is working really great the webcast of the slides. Hopefully you
will see your slides as they go along as well.
MR. OAKS: I do not have the URL for that so I am kind of sitting in the
dark. Let me see if I can find it.
DR. SUAREZ: If you go to the NCVHS website, NCVHS.HHS.gov and then on that
home page there is a little calendar and there is a link that says subcommittee
and if you click there, it will bring you to the agenda. I think someone here
is going to send you here the link via email.
MR. OAKS: Thank you much.
DR. SUAREZ: Okay let’s move on. We will start the Health Plan update,
MR. FIRFER: Thank you, I appreciate the opportunity to be here. My name is
Jordan Firfer and I am the Senior Director of Information Management with
Florida Blue with primary responsibility for leading Florida Blue’s Master Data
Management Strategy. During the majority of the 5010 migration however, I was
the Senior Director of Provider Connectivity Solutions where our primary role
is managing and monitoring the efficient and effective processing of electronic
transactions to ensure business continuity. Florida Blue is the largest health
plan in the state of Florida with over 4 million members and covering over 15.5
million lives across 16 states through its affiliated companies.
Like most plans Florida Blue began it’s planning for the 5010 implementation
along with the rest of the industry very early and understood the need to
successfully implement 5010 by the January 1, 2012 original mandate date. This
required that certain steps had to be taken through heavy collaboration both
internally and externally. These included a controlled migration, communication
plans, and a focus on continuity. Additionally, Florida Blue and plans
nationally had to adapt on the fly to two 90-day extensions leading to a final
implementation date of June 30th.
The primary theme across all providers was that initially across the
industry stakeholder collaboration was low. In fact, it was very low. However,
the primary driver for overall success was actually the rapid increase in
collaboration leading to greater transparency, leveraging of root cause
analysis and resolution, and a more unified level of communication.
Florida Blue engaged in something that we refer to as a controlled
migration. It is somewhat of an industry standard term and we implemented a
production validation process in 2011 with select vendors and providers. This
PVP process by definition was a highly successful controlled migration into the
HIPAA 5010 production environment to provide for a stakeholder wide, end-to-end
test capability. This was accomplished through identifying a percentage of our
top submitters scheduling two or more 5010 flash cuts and flipping back and
forth as necessary until we get it right. The Florida Blue, the submitters, and
the various layers in-between monitored and analyzed the process results.
Submitters were moved to a full 5010 production submission following successful
processing of controlled files.
Success here was defined as no material impact to internal and external
parties. The controlled migration method was highly successful and it overcame
the limitation of many stakeholders, which still exist today through other
mandates that we will and are currently experiencing implementation for and
that limitation was around true end-to-end testing not within our own
organizations but through all of the layers from start to finish.
We also engaged in very powerful business continuity monitoring which was
highly proactive and was a precursor to what most would consider to be
operational readiness. The production validation process allowed Florida Blue
to collaborate with submitters, providers, and others to ensure efficient and
effective processing of their transactions while providing reasonable assurance
of business continuity and that is across many different business areas and
We also put together a cross-functional team that monitored these
submissions and results that is internal and external and internal that is
across the business and IT and even included areas such as sales and marketing.
The cross-functional team identified systemic and operational issues assessed
business disruption through a very consistent rating system. We worked
collaboratively with internal and external partners some of which are at the
table today, monitored and managed issue remediation. Most importantly, we
communicated these issues in remediation efforts across all the industry
participants we were collaborating with so they also can take advantage of some
of the issues that we had experiences and some of the resolutions that we had
put in place.
I am going to take a moment to talk about collaboration because I think it
is so critical to the success. Florida Blue understood the need to engage and
collaborate with both internal and external stakeholders to experience a
successful 5010 implementation. We conducted provider and vendor outreach on
implementation through various channels. Very successful were open line Friday
calls. This included providers, vendors, billers, and other stakeholders across
the industry. It was not just in Florida. We had attendance from all over the
country. We hosted internal 5010 Thursday calls which is where all of the
people within the company knew exactly where we were, the challenges we were
facing, and how to better communicate to our customers and clients.
We established public mailboxes and we were responsive too. More than just
putting the mailboxes out there, we were very responsive to questions that came
into that mailbox. Our communication plan did not end. It continues, it is now
reverting into an ICD-10 mode but it is something we decided with all the
compressed waves of compliance coming through that we would continue that
process and not stop it and start it.
As a result of the high levels of collaboration, there were many issues that
we were able to work on together. A few of those samples were the PO Box issue
for billing and rendering provider, impact of errata in the midst of
implementation, data redundancy issues, and issues related to automated
business rules. By working cross-plan, we were able to come to solutions that
we would not have come to on our own.
We also experienced many challenges some of which were of course providers
and vendors were slow to accept any type of production testing due to
operational risks. Some were too small to accommodate it. Some did not have
enough control over their vendors to make it happen. We had a limited ability
to test high volumes of transactions in a production like environment. Vendors
and payers were out of sync for testing efforts and timing due to the issuance
of errata. Very important here as we think about the compressed waves of
compliance into the future and that is competing projects. Also the impacts,
which we were able to overcome quite a bit but that is a marketplace in which
the people who have to collaborate in many cases are fierce competitors in the
marketplace. I think that many folks would be proud of the way that many of
those engaged in co-opetition and worked together despite the fact in another
place and another day they may not even sit next to each other.
After the first extension, many providers lost momentum or further delayed
implementation. The additional time applied compression to future mandates
including ICD-10. It reduced available funding for other mandates due to the
increased cost of continued 4010 maintenance and support and had limited impact
at least from the Florida Blue perspective for 5010 readiness due to
clearinghouse up coding and moving target syndrome. Which in many cases refers
to the fact that as dates get delayed people begin to take advantage of that
and say you know what? I do not know when the final date is going to be. I am
not going to invest in it until I know for sure.
The results for Florida Blue and by the way we have reached out to many of
our peers and many of our peers are mimicking much of this success. Our 5010
submission rate is very high across all transactions so we are looking at 99
percent plus. There really are no exceptional and material issues that we are
experiencing remaining from the migration from 4010 to 5010. Some of the issues
that we have experienced actually are unrelated to moving to 5010 and more
related to just other issues that come up that happen to be associated with
5010. We also learned many lessons and that is from Florida Blue and with a
level of industry validation through continued collaboration and industry
conferences the key elements for a successful industry mandate implementation
are industry stakeholder collaboration.
I know it sounds like I am really beating a horn over that but that is
because that collaboration was so key to success. We have to ensure that we
include some of those that we may not think about and that is there are billing
systems. There are clearinghouses that are doing great work behind the scenes
who may not be recognized. Then of course fellow payers that may be competitors
and then the many layers of vendors and practice management systems that are
engaged in all of those layers.
Continuous proactive monitoring and management rather than reactive. Ability
to function where applicable in a dual mode so that you can engage in some of
those controlled migration activities. Continuous transparency between all
industry stakeholders and adherence to mandate timelines. I would like to add a
little context to that. I know there is a lot of debate around mandate
timelines. What I am trying to say here is timelines should be set initially by
a process that is based on industry benchmarking and a collaborative
understanding that identifies the ability to be ready. Additionally, this
process will allow stakeholders to have reliable plans, budgets, and resources
available, which is even more critical as we approach compressed waves of
compliance and mandates.
My commentary here is not about any dates that are currently in place or
prior dates that moved in 5010. It is more of a commentary on how we think
about these things as we move forward to think about that impact as we think
about ICD-10. Florida Blue is not saying whether or not dates should move but
Florida Blue’s opinion is along with several of its peers is to make sure we
are very thoughtful about that and we base it on quality benchmarking and
understand the resource impacts when we do shift those dates.
In closing, I want to thank the subcommittee, stakeholders, and other
attendees for the opportunity to provide one payer’s perspective on lessons
learned throughout the implementation of HIPAA 5010. Thank you.
DR. SUAREZ: Thank you very much. This was a great way to get us started.
Thank you for sharing those experiences. We are going to go next to Annette.
MS. GABEL: Good afternoon everyone. I am Annette Gabel, I am with Express
Scripts. I am here today as the Chair of the NCPDP SNIP committee which Lynne
Gilbertson explained the committee’s responsibilities at NCPDP and I Chair that
committee. We are the entity within NCPDP that provides guidance to the
pharmacy industry. I am not going to go through this. This is a brief
description of who NCPDP is and Lynne did that earlier so I will move onto the
I think I was here last year. I do not remember I might have been here by
phone and not in person but we were here last year giving you an update on
where the pharmacy industry was in the implementation of the three standards
the 5010, the D.0, and the 3.0. When we were here we had reported that we were
at 96 percent of our pharmacy claims being transmitted in the NCPDP health
communications standard. I could say confidently at this point and we have been
for a while at 100 percent. Back in June we were having reports that trading
partners had completed their installation of the 5010 transaction standards and
that entities were also processing the Medicaid subrogation at 3.0 standard
back in June of 2012. This information was received through us conducting
surveys and also having entities self-report this information.
Moving on to the lessons learned and potential opportunities for our next
round of standards. With the implementation of D.0 we saw that there were a
number of entities that had not read the detailed documentation in the
Implementation Guide. I think there was a presumption that the information that
was previously used in the submission and the responses in the version 5.1
standard could continue to be used in the version D.0 standard and that was not
the case. We had introduced extensive changes to existing fields. We added new
fields. We added new functionality but it became evident during the testing and
then in production that the use of these new fields and the enhanced
functionality was not embraced consistently throughout the industry.
So what we decided to do is that in future versions we are going to add a
section to the Implementation Guide that will help entities basically instruct
different sectors of the industry on which sections are relevant for their
business functions and use. So we are hoping that if we bring those parts of
the industry, get them to look immediately at the beginning of the
Implementation Guide, and then focus them on specifics that are going to be
important to their business use that some of these issues will be eliminated.
We also had created a new payer sheet template which we thought would help
the industry because it was more detailed than the previous template. It was
created based on input from the industry but we found that even with all the
work that we put into these payer templates that it still was not sufficient
and that we had issues between trading partners. Just to give you a little
background on the payers sheet template there are a number of fields within the
standard that are situational. So in some cases the payers that are receiving
the transactions might not be using these fields because they are situational.
So they create these payer templates that give instructions to the pharmacies
as to when the fields need to be submitted.
What we found is that there was a lot of confusion because we had payers
releasing the templates at different times. The pharmacies were not sure. If
they found in testing that they made a mistake and they had to update the payer
sheet they were not providing information to the pharmacies to say we gave you
this template but we are on this template. We said we definitely need to make
improvement to that communication so that the next time we tell the plan put
specific version and release dates on those payer templates. The other issue
that we heard from the pharmacies is that the information was not plan specific
Obviously in the case of Med D there was a Med D specific plan sheet but
when it came to some of the smaller entities there were not specific profile
sheets by plan. We said we would need to advise the industry to create some
specific plan sheets, which will help the pharmacy. Also, add a section to the
template that allows for revisions and change logs. Then make sure that the
directions that we provide at NCPDP for completing the payer sheets are clear
and we would use the questions that we received during the testing to help
improve the information that is on the payer sheet.
What we also found is we were trying to be thrifty in the creation of the
new standard so we thought about using fields. Repurposing fields and we
quickly found out that that was not the best approach. There is one example
where we were working on Medicare D fields where there was some additional
information that we needed to get more specific about the patient location and
also to have a separate field for place of service. We used an existing field
for one of those intentions and we found out that that became very confusing to
the industry. Now we know for the next version that we will not repurpose
fields that we will take old fields, delete them, and create new fields to
avoid that confusion.
As Lynne mentioned earlier we came up with a new process that would
eliminate some of the angst, we were having with the last version. Like X12
does with their codes committee, we came up with an external code list and that
was great except that we did not have a way to implement those code lists. As a
result we had payers and their partners coming up with different implementation
dates so that it was making it almost impossible for a pharmacy because they
would have to keep a grid to know if that payer A was implementing this ECL on
this day and payer B was implementing it on this date.
We formed a task group at NCPDP and came up with a process that Lynne
described earlier that would explain when you implement codes. We approved
codes on a quarterly basis and then those codes are implemented there is a date
assigned to their implementation and the only variance is when we have a Med D
specific requirement. We call those emergency change controls and then we have
specific dates associated with those ECLs.
One other issue that we ran into actually it was two. Looking at some
transactions that are a very small percent of the total overall claims that are
submitted and those are our favorite compound and coordination of benefit
transactions. Because they represent a small percentage overall of the
transaction volume a lot of us made the mistake of holding off the development
and testing until later on in the implementation process. Basically trying to
iron out all of those bigger issues that have a lot more claim volume involved
so that when we finally got to developing the compound and the coordination of
benefit transactions we had a lot of issues surfacing very late in the testing
process and as a result some of those issues flowed into production.
What we came up with is we should have addressed earlier in the development
and testing process that we were going to have implications as it related to
providing individual ingredients in a compound transaction that was new to the
industry so there were some entities that were doing it but they were very
small in number. For the coordination of benefit standards we probably should
have addressed those earlier as well in the development and testing process
because we did create a lot of detailed definitions around COB and new methods
for how they should be used.
I believe that is it. I will be happy to take any questions that you have
when you are ready to ask questions. Thank you.
DR. SUAREZ: Thank you. Thanks Annette, we are going to do questions at the
end after we hear all the testimony. Debbi.
MS. MEISNER: Good Afternoon. I am Debbie Meisner with my Emdeon hat on
today. We are pleased at this time to offer the following comments to the
subcommittee regarding the issues, approaches to solutions, and lessons learned
during the implementation of version 5010. Emdeon has been instrumental in
testing the new transaction standards so we hope that our experiences and
observations will be helpful to you as we review the industry’s experience with
these critical initiatives.
Today I would like to discuss our experiences in the status of the
implementation efforts and some important considerations for the industry as we
look ahead to other administrative simplification initiatives. Our focus will
be on the following experiences. The current state of the industry
implementation of 5010 the current ongoing implementation issues and approaches
used to address those issues. Our lessons learned with respect to transition
and implementation and the goals that have been set for moving forward to new
versions of the standards that have been achieved.
The industry has made tremendous progress toward a full implementation of
5010 transactions and the following is a summary of the claims transactions
provided by 19 clearinghouses through a cooperative exchange survey that was
done last week. I would just like to share some of those numbers with you. On
the submitter side professional claims we have 75 percent of the industry 5010
capable. There is a little nuance there at least from Emdeon’s perspective.
When we say they are capable some of our vendors are capable of getting 5010
but not every one of their customers has moved to that version but they are
capable of giving us 5010 so some of their providers are submitting 5010.
That 75 percent represents 87 percent of the volumes so clearly it is the
small volume providers that are still straggling behind on the submitting side.
Twenty-five percent are using 4010 or some Legacy formats so it might print
image, NSF, or some former format that they have continued to remain on
representing 13 percent of the volume. In the institutional world we have 79.5
percent that are 5010 capable representing 89 percent of the volume and 20.5
percent with that around 4010 or some other Legacy proprietary formats. This is
representing 11 percent of the volume. I will say because of the late notice
that we gave folks we really focused on the claims since it is our biggest
Looking on the payer side of things those same clearinghouses and, by the
way, I was told that we had a couple of stragglers come in but they did not
impact the numbers so we are pretty much in line with everything. The payer
side of things is looking a whole lot brighter — so we have 97 percent that
are doing 5010 only and 3 percent better still on 4010 and that more than
likely represents very small payers. Everybody reported 100 percent of their
Medicaid volume is going out in 5010 and 100 percent of their Medicare volume
is going out in 5010 representing 100 percent of volume. I think that was
We did ask in the survey what implementation issues still remained out there
and we were told there were no new identified issues and that nothing has come
up since we reported to you last June. That was also very good. In June of
2012, Emdeon testified along with the cooperative exchange on the lessons
learned. For the sake of your time, I did not repeat those slides. If you
really want to you can go back and look at that testimony. But we did at that
time address the need for a transition period being very critical in order to
help the industry manage the asynchronous implementation and avoid a bottleneck
as you get toward that compliance state which is what frequently happens.
To this we talked a lot about the fact that we might have as a clearinghouse
4010 coming in but you have to convert up to 5010 or 5010 coming in that you
have to convert down to 4010 because of the trading partners on either side
having a different timeline for their implementations. We did include in that
testimony a transition strategy that was again presented to the X12 workgroups
in June, two weeks ago in Indianapolis. We will be looking to roll the rules
out in the future versions that allow for consideration of the transition and
have it more date driven to the compliance date versus early adopters not being
able to implement because they cannot get the data.
We also talked about focusing at one thing at a time. Get the formatting
correct and then address the way the content is used with the edits and the
need to be implemented in that asynchronous mode. Get your syntax things. Bring
your formats up to worry about whether all the content is there, the new
content or the deleted content is still present. Let the industry get through
that educational turmoil of what changed, what are the rules, how am I supposed
to now handle the content?
We also stressed the need to align policy changes with the guides when the
policy goes into effect. We found this with NPI, 5010 took a lot of hits on the
alignment of NPI and some of the security and privacy regulations when the 5010
aligned with those that were two or three years old. It seemed to have caught
the industry by surprise and so we struggled a little bit with getting people
to understand you cannot ask for that Legacy identifier. NPI went into effect
three years ago. We strongly recommended at that time that when a policy like
that goes into effect that work be done within the standards development
organizations to support those policies closer to the effective dates.
We also talked about implementation timelines need to consider and include
and this was a big hit on 5010 the testing of the acknowledgement transactions
and more education needs to be done on that. The acknowledgement transactions
come out of their translators. They had no idea what was being done in those
translators. We found disparate ways for those translators to handle the 999
acknowledgement transactions and some were at different levels of using the
999. There was not consistency but more importantly, there was no testing of
the 999. They testing the inbound transactions and said okay we are good to go,
move it into production, and then we started getting fileable rejections that
caused the industry to have some serious issues.
In addition to the issues that we addressed previously, we did feel that it
was important for future versions to be pilot tested. To identify transition
issues prior to the adoption of the standards and we also feel that a
transition period should be named during which early adopters can move into
production with the new versions without the strict enforcement of the TR3s.
This will allow for the asynchronous way the industry migrates and if this is
not considered then we will again see that bottleneck and continue to miss our
compliance dates resulting in delays.
You did ask earlier about this and I said no but I really was kidding. I am
not going to cover a lot. On September 26, 2012, Emdeon was awarded the
contract by CMS to pilot test the 6020 transactions recognizing that these will
not be the next version to be adopted under HIPAA but would be the foundation
for the next version. This is a one-year phased project that included Gap
Analysis, translation, testing, and then reporting back to CMS on the results.
We are currently in the testing phase and we will be providing full reporting
of the results and recommendations for testing future versions of the HIPAA
transactions once we get through the whole project.
The purpose of the pilot test project is to develop and execute a method of
testing the updated versions for the standard transactions prior to adoption
under HIPAA and the Affordable Care Act. The process or the system developed
may be considered for testing the viability of any new versions of the
standards being considered for adoption. Such validation in advance of the
recommendations for adoption to the Secretary could result in the avoidance of
errata in the middle of the implementation and ultimately save the industry
millions of dollars.
Some of the obstacles that we faced included that the effect the tools that
you use for testing in translation never came out to market and were not
updated for 6020. We also discovered that we had some less than adequate change
logs and working through the X12 intellectual properties that do not allow
publication or distribution of this information for technical reports. To
overcome these issues Emdeon used the Gap Analysis reports that were provided
that came out of our Gap Analysis and we used those along with our experience
staff to manually build out the translators and the validation tools for use in
the translation and in our quality assurance process.
Our team has worked closely with X12 to provide a better change summary and
has been instrumental in entering the information on the 6020 to bring forward
with the next version. During this process we have worked very closely with the
management team of X12 to come to an agreement on what we can publish coming
out of this project so we have a clear understanding and making sure that we
are not breaching any of their policies. We did take a three stepped approach
that focused on the first phase was the Gap Analysis. We used the standard SDLC
process. We did full Gap Analysis. We did phase two translations and then we
did testing and reporting. Nothing earth shattering. Took a standard approach
We did go over these issues for you and this is a quick summary and I will
not hold us up too long. These are the number of new data elements across all
the transactions that we looked at the number of elements that were deleted. A
number of elements that had some use changes so the situational rule changed
around the way you were to use the content. Sizes changed. Most of those were
due to the underlying standard increasing some of their sizes. We had 234 code
changes across all these guys and we also identified over a thousand what we
call non-substantive changes, typos, rewording of the way something was written
but did not really change anything.
The outcome of that is we have worked with X12 to say let’s not include
those in the change reports going forward and make people look and try and
figure out what changed and it was a comment added or a space deleted or just
rewording. The outcome of what we call our issues and challenges that we looked
at are here for you to see. We did identify 401 transition issues that we have
worked through with our experts in house as well as out in the industry to come
up with resolutions. We had 150 that we considered of those transitions true
issues, 53 that we felt could be handled through extensive education and
outreach. We performed analytics against our current data to find out if you
are deleting something, how many people are really using it, or if we felt
there was a need to change the number of repeats. We did perform analytics on
24 items and we entered 61 change requests into X12 to make recommendation for
change in the next version.
There you go. I will be glad to take any questions and I thank you for your
DR. SUAREZ: Thank you, thank you very much. I think we are going to go now
to Don from Medicaid from Tim.
MR. OAKS: Thank you. I will wait until my slides are loaded and then I will
get started rather late and then I will just give you a little bit of
background on the first slide there. Just for those of you that are not aware
TennCare is Tennessee Medicaid Program. We serve about 1.2 million lives. We
are almost 100 percent management care. We are down to about 5 million claims
and encounters per month from a high of a little over 8 million a few years
back. I will make the comment that my three co-presenters did an excellent job.
Sorry that I was not able to attend in person.
DR. SUAREZ: Don, you can go ahead. We have copies in front of us.
MR. OAKS: I will go ahead then to keep you from waiting there. We did
implement our 5010 D.0 changes on November 27, 2011. We started our process to
get to implementation on January 28, 2009, which was a very significantly long
project for us. We started by doing some planning. We reached out to all of our
statewide provider support groups, Tennessee Hospital Association, Tennessee
Medical Association, TAMHO which is our mental health organization, our Dental
Association, the teaching hospitals, and we worked real close with our managed
care contractors on basically 5010 D.0 implementation. We developed our maps,
our guidelines, our edit rules, and we got those out early. Allowed anyone to
distribute those. It is kind of like CMS, the Medicaid agency sitting in the
State as I referred to it as the 400-pound gorilla. Medicare is the 800-pound
gorilla but we were very successful in getting our maps, our guidelines, our
edit rules out so that everyone understood exactly what Tennessee Medicaid
TennCare was looking for in the 5010 D.0 projects.
We had frequent status meetings. At first, we met once a week, then we got
to the place we were meeting almost daily. We had just an open dialogue.
Anybody that had a question was able to submit a question into us via email or
do so openly in one of our meetings. We tested over 40 million transactions and
20 million of those were step-up claims of one type or another. One thing that
I heard from Jordan earlier was they were talking about setting up a production
test environment. We actually set-up an environment and wound up promoting our
5010 D.0 test environment into production along with our code on the
Thanksgiving weekend of 2011.
One thing that I will second that Deb mentioned was acknowledgement testing.
We created a package with our acknowledgements so we have a TA1, a 999. We have
all of our SNIP edits, we have a summary report, a detail report that we
provide along with any – (teleconference operator interruption)
DR. SUAREZ: Go ahead, sorry.
MR. OAKS: Anyway, the acknowledgement testing is I agree a very critical
part of the testing. Our implementation date was coordinated with our MCCs. You
will notice that I said we implemented November 27, 2011 that does not mean
that all of our managed care organizations did likewise with the step-up
processing that we had gone through and tested we were comfortable implementing
Couple of the items that are listed here we had to make adjustments to
provider selection logic primarily because of the data changes within the 5010
transaction itself for fields that were no longer available in 4010. We also
had to do some adjusting to some of the additional requirements in the TR3
related to physical addresses as opposed to post office boxes and I singled out
zip+4 because I think it caused us as about as much problems as anything else
finding a reliable source for zip+4. Brief commentary, they are very stable in
the urban areas we found that as you move out into rural areas and postal
routes change that the +4s change also.
Working with providers that were behind the conversion curve was obviously
an issue that everyone that went through 5010 D.0 had to take into account and
work with. Coordinating the release schedule with the competing priorities.
That is one thing that I appreciate other presenters bring up. It was something
that we had to consider and that is part of the reason why we implemented in
Our external communications from other entities sometimes conflicted with
TennCare’s project plan. I will discuss this a little bit more on the next
slide so if we could go there please. A realistic enforcement date. I heard
several people mentioning issues with date and the two 90-day extensions. From
a personal perspective, TennCare that is something I know that we would like to
try to avoid in the future is the changing of the date. I think that it had a
very negative impact on our providers particularly those that were on the prior
slide and that curve of they were lingering behind already. They used the
extensions as just as an opportunity to delay implementation even longer.
Project team on point one there we held a lessons learned session after the
project and I think that is something that is very beneficial with any type of
project. Several of the things that we did in the 5010 D.0 project we brought
forward into our ICD-10 open communications testing early. I emphasis the
testing early. That is something or other that is definitely needs to go along
with anything that is going to be a successful project.
We did use step-up processing. We limited it after January 1, 2012 but we
still had to use that for a few months into 2012. We did not honor the second
extension in the state of Tennessee. Just commentary on that one but by that
point in time we were well up into the 90’s on percentage of providers that
were in compliance and the numbers of claims were in the extreme high 90’s at
that point in time. Continued usage of workgroups, town hall meetings, WebEx,
et cetera were all things that definitely suggest on large projects. We found
that the collaboration with some of the external groups, the NIMI, the WEDI was
extremely important and added as much value to the TennCare and to the industry
as a whole.
I am open for any questions at this time like my three colleagues so thank
you for the opportunity to present. TennCare had a successful 5010
DR. SUAREZ: Thanks so much, Don. Thank you for that overview. We are going
to have one more presenter and then we will open up for questions from the
subcommittee. Cathy, up next.
MS. CARTER: Thank you and I can keep this very brief. Cathy Carter, I am the
Director of the Business Applications Management Group in the Office of
Information Services and have responsibility for implementing all of Medicare’s
claims processing systems as well as some other systems related to Medicare’s
business. On the agenda, I just followed the three questions that were listed
for us to respond to.
Status of implementation. Medicare did go live 100 percent. I am glad
whoever was reporting the percentages reported 100 percent because if it was
not I would have been surprised and that was effective last July. We did
leverage our implementation by some people who are in the room here today
leveraged by completely changing our whole front end processing making things
more standardized than they were before. We did implement acknowledgements so
there was a lot of change for everyone in addition to the standard itself. We
did implement the groundwork for 5010 obviously, so we did expand all of our
systems. Although we did find a couple that we missed when we started working
on ICD-10 but we did all of that expansion in this implementation.
These are just a couple of the implementation issues that we experienced and
I think you heard one of them before and that is on the acknowledgements. We
did implement the acknowledgement transaction someone suggested more testing. I
am not sure personally of the exact extent of testing that went on but we could
have used more. It did create issues. We managed to get over them. I think many
of them were with regard to the provider and what they actually saw so when
they were using a vendor there was troubleshooting was definitely an issue
trying to make sure everybody understood what they were supposed to get and
what they actually saw.
The last bullet here is about implementation of the next standard because I
do not remember exactly what month it was but before we were implemented,
before we had 5010 even done we were making plans to implement 6020 because
that was what was coming. We went around like good bureaucrats, we tried to get
workgroups together, and people just refused to participate. People could not
deal with another standard while we had not even gotten to the end of the road.
That was really difficult and we aborted all of those efforts.
Lessons learned. I was at this committee last June and went over them so
just very briefly communication and coordination is really key. We had lots of
sessions nationally for all kinds of providers and I think those are really
helpful. We did standardized companion guides and that was useful. Our
spreadsheets we ought to charge for them because we put our edit spreadsheets
on our website and they are kind of popular to show how we do our crosswalk.
The errata and you have heard people mention the errata was a problem because
we lost probably four to six months at the beginning of that year because of
being on different standards. We decided not to go live until we could get the
right one in there.
We also had an effort to re-verify all of our enrollment with clearinghouses
or vendors for the providers. That I think was a good effort but doing that at
the same time that was I think part of what the testing issue was because when
people tested with us their file exchange was fine but we did not actually test
that portion of it the actual trading partner management. That created some
issues because there was no understanding that was going to be a problem on the
go live date. On NCPDP we do very small volumes of NCPDP transactions and we
had to go through considerable time and effort and expense to implement that
For suggestions for the future suggest that the acknowledgement transaction
be adopted so that everybody is actually using that. We had just two points
here and there could be others. One is on the CARCs and the RARCs that is very
popular discussion point lately because of some of the confusion with respect
to what we already have and then the operating rules and how that is going to
work. We are hoping for improvement and then there is a particular transaction
that is a problem for Medicare Secondary payer. I do not know if that is just
Medicare but there was something that in fact was changed in the 5010 standard
that removed something that now makes it impossible to figure out what the
payment is. Our people that do coordination of benefits have had extreme
problems with that and so that really does need to be fixed probably before the
next standard especially with the timing that we are talking about here.
That’s it so I will answer questions.
DR. SUAREZ: I think we are going to go to questions. Before that actually,
now that I see a couple of new people on the table. Could you introduce
DR. GREEN: Larry Green a member of the full committee. Not a member of this
subcommittee but delighted to be here. No conflicts.
MS. PORRAS: I am Jessica Porras. I am staffing this meeting for a couple of
hours. No conflicts.
DR. SUAREZ: Thank you. I know we have several questions. We will start with
MS. GOSS: Thank you Walter. My question is actually for Debbi. I was
confused by some comments on your slide seven when you talked about your
obstacles that you were facing. The challenge logs provided were insufficient
of identifying the changes and then you said something about the intellectual
property policies. I do not allow you to publish or distribute them and I think
when you had a verbal remarks you something that kind of put those two
together. I want to see if I have got this right. The high-level cryptic
summary notes in the change logs were not helpful.
MS. MEISNER: For 6020 when they were first published, we did not have the
change logs. Then we did get a comparison and so that is what we had to use for
6020 was the comparison from 5010 to 6020 and that gives you every I took a
period, I added a comma, I added a space, and it was very difficult. There was
not a description of what the change was. It just said this was added or it was
changed and so we were challenged with coming up with the descriptions. X12 has
done a tremendous job and in my full report out I cover this of creating new
change logs with business descriptions of what the changes were and they have
been very busy getting those in for the changes that have already been
implemented with 6010. I look forward to some really good change logs coming
MS. GOSS: So there is not an intellectual property issue related to change
MS. MEISNER: Intellectual property issue is in our being able to publish the
Gap Analysis that came out of this project because they are very different but
it has the same information that is contained in the change logs. When we asked
for permissions we were told no we could not publish the Gap Analysis but we
have come to an agreement that we can publish a SNIP of what the work is that
we did and how we derived those numbers and the process that we took. We cannot
actually publish the gap analysis reports.
MS. GOSS: Thank you, it sounds like you are already applying your lessons
learned and you are not even done yet.
MS. CARTER: Alex, I would like to add that we had that same problem. We were
trying to publish what the results of the work that we did on all the cross
walking and we ran into a problem with that as well.
MS. GOSS: Debbi, do you know of anyone else who is having these coordination
of benefit problem that Cathy was mentioning?
MS. MEISNER: I have heard of it, yes. I can get more details for you. I
cannot explain it personally.
MS. GOSS: Perhaps one of your speakers later might be able to help her with
DR. SUAREZ: All right. Linda.
DR. KLOSS: Thank you all. This was very complete and encouraging because it
seemed as if the lessons learned were quite consistent across all of your
experiences. What I would be interested in is maybe a little more expansion on
what the timeframes were like. Jordan you took us through the process but you
did not give us a sense of how much in advance you started or as you reflect
back what the most idealized kind of timeframes for this.
MR. FIRFER: I don’t want this to come off as my being sarcastic but the
ideal timeframe is the longest timeframe possible. With that said, when I said
we started early we probably started before the first of the year, the year
following. We started very early but when we started did not really have as
much impact as when our stakeholders were ready to do some of that controlled
migration with us for those that could even do it. So we were at their mercy
and I will say that through the January first date so for the first delay we
had a lot of migration testing occurring right about the first. Although it was
not a flash cut they were treating it like a flash cut and our problem was
working with fellow clearinghouses and other stakeholders is that no one was
really comfortable saying we are going to flip it on and that is it.
We actually continued those migration efforts into January and February in
order to ensure we had it right. Yes, some of them we got to leave on because
it just worked. Some of them did not work and that was the biggest heads down
work was so many people wanted to do those migration flash cuts right after the
first. We became I would not say overwhelmed, but our resources were very
bogged down in trying to manage that. Into the future if I were to make a
suggestion around the 70 series change it would be to actually identify a
period of time that is actually meant for that purpose. Is that helpful?
DR. SOONTHORNSIMA: Debbi, thank you for sharing with us the statistics. It
seems like over 20 percent of providers are still submitting 4010 or doing the
translator or crosswalk. Could you comment anybody, could you all comment on
what that impact might be in preparation for ICD-10?
MS. MEISNER: It depends on the vendor. Some of the software vendors that we
have communicated with are providing an add-on to the system. The process a lot
of times the software that does the billing feeds a print image or perhaps the
old NSF or a proprietary format into the EDI system that then converts that
over to 4010 to send to the clearinghouse or to the payer at 5010 or whatever
version that we are on. Some people have said it is a quick little pop-up box
for them to put the ICD-10 in and they will plug it into the backend process.
Some vendors are providing cross walking solutions and will be putting the
ICD-10 in the back I have heard that so there is various solutions to that.
Emdeon, so speaking with my Emdeon hat on, has been clearly telling the
vendors we have been putting band aides on for NSF and for 4010 and working
with you to get these upward and downward compatible but ICD-10 breaks that. We
have told our customers loud and clear that they do need to get on 5010 in
order to support ICD-10 within our message. We are having good success with
MR. FIRFER: And I would add to that also at Florida Blue I also wear a hat
for managing our clearinghouse relationship or did until very recently. We are
saying the same thing that you have to make that move that all of these
remediation efforts that we are doing for you for 4010 to 5010 will begin to
fail to have value with ICD-10 comes in play. I will add another note and that
is as we continue to reach out to the limited amount of individuals who are
still submitting 4010, those same individuals are either saying ICD-10 is not
coming. They choose not to accept it or they say I am at the mercy of my
vendor. Whatever my vendor does is what I will do and if we submit claims, you
better pay them.
DR. SOONTHORNSIMA: That would impact I am sorry just a follow on. Would that
not educating a little bit and that impact financial neutrality? That is one of
MR. FIRFER: It could. If they do not properly reconcile the crosswalk, it
MS. MEISNER: Absolutely, they would need to make sure that the crosswalk is
doing what they need it to do. It may also impact all of a sudden their
rejection rate that if they continue sending ICD-9 and we have payers in back
of us that are saying no October first we are only going to take 10. As a
clearinghouse, we cannot do the crosswalk. We do not feel we can do the
crosswalk and we do not have the medical records to make the determination and
that is Emdeon’s view. I am not speaking for all the clearinghouses. I think
different clearinghouses are taking different approaches. We just feel we do
not have the medical.
MR. OAKS: I think that is the system the TennCare has been through our
provider organizations also that you really stay away from a crosswalk if
MR. FIRFER: We also have and this may have been mentioned earlier but we do
not speak in terms of to be honest of financial neutrality. We speak in terms
of financial risk that is what we are attempting to mitigate so that we can set
appropriate expectations with our provider base and that communication has
actually gone pretty well. As long as we can back it up with a real risk
mitigation plan and a very good illustration of good faith that we are doing
the best we can. Otherwise, the clearinghouse we work with is very much in
alignment with Emdeon’s view.
DR. SUAREZ: Great. Any other questions from any member of the committee?
Okay and I just wanted to note too I think Linda said it very well. I think it
was very encouraging to hear the reports of the degree of transition and how
much it has moved. I think it is of some concerns some reports about some
organizations not yet moving there particularly as we move to ICD-10, which
will be a major transition. If organizations do not have 5010 ready and expect
that someone else is going to do the crosswalk it is going to be —
MS. MEISNER: Walter, if I could make one other comment. One of the things
that we are struggling with, not struggling with, but we have acknowledged that
Emdeon is we have always been able to provide you with a view into we are still
getting 40 percent of the claims coming in with a PO Box. We are still getting
47 percent of the claims coming in, in 4010 and people are not moving. With
ICD-10 being the only one that we have done we were able to say okay, when are
only getting 60 percent of the folks using NPI.
We have been able to provide that view and payers have been able to see that
view as Legacy information keeps coming through. We are not going to have that
view with ICD-10 as an industry, it is going to be flip the switch on October
1st and let hope everybody’s done it at the same time and we are all
in good shape. That is something that we struggle with is how do we measure how
the industry is doing in their readiness. So just keep that in mind it is a
DR. SUAREZ: That is something we will be talking tomorrow during our ICD-10
discussion. Thank you for teeing that up. Any other questions. Yes Larry.
DR. GREEN: If Don Oaks is still on the phone I wanted to ask him what
happened when you decided to ignore the delay and enforce it. What sort of
things erupted or did not erupt in Tennessee, when that was the case?
MR. OAKS: Actually, the eruption was considerably less than we thought it
might have been. By the time we got to January 1st, we were already
approaching the 90 percent level with our testing of knowing that the providers
would be ready. That first 90-day extension, while I do not think was necessary
because we already had processes in place to do any kind of stepping-up that we
needed to do, was actually somewhat welcomed. But when the announcement of the
second one, it was like no, we were already at a 97 percent at that point in
time. It was like the remaining portion of the providers just needed to step up
to the plate and some of them did so by using a service like Deb and Emdeon
there, and doing a step-up by paying a vendor to do so.
Very little disruption. As a matter of fact, we had more pushback from the
fact of the extension than what we did by announcing that we were not going to
honor the second extension.
DR. GREEN: To beat this to death, what sort of patient problems came to your
MR. OAKS: Excuse me?
DR. GREEN: What if any patient problems came to your attention during that
MR. OAKS: As far as patients themselves, our recipients still received
services. There was no real delay that I am aware of in any enrollee getting a
service, receiving treatment, or anything of that nature. It was all limited to
provider billing. So I would have to say it did not have any impact, if I am
understanding your question.
DR. SUAREZ: Thank you so much Don. All right, I think with that we are going
to move to our last presentation and this is going to be an OESS/CMS regulatory
MR. OAKS: I am going to hang up. Thank you for allowing me to attend.
DR. SUAREZ: Thank you Don, if you want to hang up or stay with us and listen
to this update, that would be great too.
MR. OAKS: Thank you.
CMS Regulatory Update, Denise Buenning, OESS
MS. BUENNING: Good afternoon everybody. I am Denise Buenning. I am the
Deputy Director of the Office of E-Health Standards and Services at CMS and I
am here to the CMS update. There is only one thing worse than being the before
lunch speaker, and that is being the end of the day speaker so we will go
through this forthwith.
I want to talk a little bit about some related programs. We always focus on
standards, operating rules, ICD-10, but there are some other programs that are
starting to again converge in the world of E-Health, and one of them is the EHR
Incentive Payment Program/Meaningful Use. I just wanted to give everybody and
update as to where we are on this program. There are two important things that
we always talk about and of course, the first is payments and the number of
participating or eligible providers in the program. As of the end of April,
which is the last full report that we have available right now, they should be
coming out very soon, we have almost 400,000 providers with active
registrations in both the Medicare and the Medicaid EHR incentive programs.
We have paid out over $14.5 billion in payments to almost 300,000 providers
in those programs. Of course, whenever we have a program that pays out
incentives we also have audits and audits are very important. CMS takes them
very seriously and we have instituted both pre and post-payment audits to
ensure that providers not only get their 2013 payments but also avoid the
penalty that is coming up in 2015 – not a penalty but actually a payment
Initially a small number of audits were completed and that was just to give
us a feel for whether our audit process worked and made some adjustments to it
and we estimated that approximately 5 to 10 percent of providers will be
selected for both pre and post-payment audits on both a random and a targeted
basis. If for any reason, a provider is found to be ineligible either payment
will be withheld on a prepayment basis, or of course on post-payment it would
be accrued. It is still too early to come to any conclusions. We are still
going through this process and will continue to do this on an ongoing basis and
we will share information as we are able and as it is forthcoming.
Let’s talk a little bit about ICD-10 implementation. I thought I would not
have to repeat this again, but apparently, there is some question about the
date, October 1st, 2014. I do not know how often we can say it. I
thought that perhaps we had gone over the awareness hump on this but apparently
at the ICD-10 Summit this morning Dr. Mostashari, my colleague and good friend,
had to make this comment again twice. Saying the date is not changing and I am
going to be at HIMMS tomorrow morning and I am going to say the same thing, the
date is not changing. We are going forward at CMS on that premise and on that
concept. I can tell you that Medicare fee for service implementation is on
track. We have around 68 percent of our business provisos and 75 percent of our
systems ready for ICD-10. Of course, some of those are going to have wait for
certain business processes and dependencies to take place first, but Medicare
fee for service plans to have everything in place by this coming October, and
that will allow them a year of testing with many internal tests already having
Our State Medicaid agencies. We will talk a little bit more about this in a
second, but 94 percent of our State Medicaid agencies responded to our January
self-reported assessment survey and 98 percent say they are going to be ready
for ICD-10. While we share their optimism, we also know there are many
definitions of readiness and we are actively working with states who think they
may have some risks and we are working with them to mitigate risk, and
providing direct technical assistance.
Health plans, clearinghouses, large provider groups, hospitals appear to be
on target for implementation. We had a payer call the other day and there were
many innovative ways that they are preparing for providers who might not be
able to submit ICD-10 claims at the October 1, 2014 date but they are actively
working outreach and education with them. CMS in fact put out an FAQ from one
of 5010 lessons learned, just reminding everybody that brand new providers
rather than clearinghouses unlike the situation in 5010 cannot make a code
change on a claim. Unless they have a specific contractual agreement for a
clearinghouse to provide that service to a provider they cannot assume that the
clearinghouse is going to make that change and get their claim through the
system for them. We want to make sure that everybody is aware of that.
We are reaching out of course to small providers and we are using a variety
of mechanisms, including our national conference calls, our Webinars, website
materials, implementation guides for small, medium, and large providers, and
other means and we are continuing to encourage vendors to communicate early and
often with their clients on their ICD-10 implementation installations.
I want to spend a little bit of time talking today about working with State
Medicaid agencies because I think that CMCS, which is our Medicaid side of the
house, has done a really fine job of reaching out early and often to the State
Medicaid agencies. As we know, some of them continue to have challenges with
5010, and we are working really hard to make sure that we have every tool
available to them in order for them to be compliant. Some of the things that we
have worked with them on is a quarterly online self-assessment. Again, kind of
a checklist to go through and say have you hit certain milestones that you are
supposed to hit at certain times. If not, what you need to do. We have a really
good implementation handbook. This was developed specifically for State
Medicaid agencies and it has gotten very good response from them.
We have a collaboration site, an online community where they can share best
practices and innovative approaches to ICD-10. We have a bi-weekly State form,
it is a conference call that allows them to actually talk with each other about
some of the challenges that they are facing. We are doing site visits, general
and very specific training geared to assist certain State Medicaid agencies. I
will show you a map in a minute as to where those are taking place. Policy
briefs which support the Triple Aim through state programs for nine different
policies, and of course health condition categories. A foundation for State
Medicaid agencies to define health conditions in alignment with the needs for
their specific agency.
Here is a map of some of the technical assistance and training programs that
we are conducting at State Medicaid agencies across the nation. Of course, some
of them have multiple technical assistance site visits. Some of them are
scheduled to have their site visit. Some of them have policies remediation
workshops taking place and all of this was done with the help of our contractor
and the CMCS staff going out, and also from the regional offices. Actually,
visiting each one of the SMAs and sitting down and talking through their issues
and their concerns. This has been a real boom for the SMAs.
Of course, we have our Implementation Handbook. It talks in general terms
about the limitations of the nine code, the benefits of implementing 10,
milestones, activities, and strategies required to implement ICD-10 during the
five implementation phases.
Then we have our policy briefs to show how ICD-10 supports health care
transformation in State Medicaid programs for these various conditions or
situations for pregnancy, HIV/AIDs, Alzheimer’s, Autism Spectrum Disorders,
coordination of care, and so forth. We have gotten very good response on that.
Beyond the State Medicaid agencies, again you can just see how ICD-10 is
having an impact across the industry not only with the State Medicaid agencies
but clearinghouses, public health agencies, employers, banks, providers, other
types of payers, and how this all really works together. It is not just ICD-10
is a silo anymore, but is a real foundation for health care reform and E-Health
We have some other successes. It is not just CMS out there doing this. At
the department level, there is the HHS Health IT domain steering committee.
This is made up of the various HHS OpDivs who address E-Health issues and
concerns and one of them is ICD-10 which is a separate workgroup on this. As
you can see, the CDC obviously has a lot of interest in ICD-10. They have
developed a data repository. We have been able to share their training with
other HHS OpDivs and in turn CMS has shared their training with them.
HRSA has done a great job on outreach through Webinars and newsletters to
their grantees. The NIH is identifying their impact areas including many of
their registries and their research arms. Indian Health Services, this group
has really been on the forefront of ICD-10. They have a steering committee.
They have a boot camp, Have No Fear of ICD-10. They have included it in their
clinical rounds. They have an extensive communications plan and they have been
a model for other HHS OpDivs to follow.
Pivoting a little bit here from ICD-10. Let’s talk about Admin Simp and we
have been doing some work in this area on provisions of Section 1104 and one of
the things that I know or the health plans are very concerned about is how the
health plan certification. This actually is going to be a proposed rule CMS
0037, it is going into clearance this week. Now when I say clearance do not
expect it out next week. It is going to take a while. It has to go through
multiple rounds of CMS clearance, department clearance, OpDiv clearance, OMB
clearance, and who knows who else looks at this. The dates are pushed back a
little bit from the 2013 dates that were in the Affordable Care Act.
We are really seeking industry and stakeholder comments on a wide variety of
assumptions including what would be appropriate and a burdenless documentation,
certification documentation requirement, our timing proposals, et cetera. Be on
the lookout for that maybe early fall, I am not sure. Again, it depends on what
else is on the docket and what is ahead of us. We have had to retool this a
little bit to synch it up with some other initiatives like the HPID, the Health
Plan Identifier, and also cognizant to the fact that we have a very busy
2013/2014 ahead of us in the health care industry, most notably with not only
ICD-10 but also the launch of the health insurance marketplace.
Operating rules. Again, we are working to implement operating rules at CMS
with a similar approach to what we have undertaken for ICD-10. That is OESS
conducting a program management, monitoring, dashboards, and budget
coordination. I understand that CAQH CORE is surveying the health plans for
workgroup input and participation.
Claims Attachments. This is something else that is coming out of Section
1104. We are looking forward to a recommendation at some point from the NCVHS
and will coordinate that with the timing of meaningful use stage three, but we
do not know exactly when that is going to be. We are trying to make sure that
everything aligns not just among the HIPAA transactions but also among the
other initiatives that are coming out, most notably meaningful use.
This is another area I think we sometimes we forget about E-prescribing. I
think we all kind of take it for granted after a while that it goes so well and
so many of our providers are doing it, but there is a report out on the 2011
programming here for two important programs. One of which is the Physician
Quality Reporting System, which offers incentives and payment adjustments to
eligible professions who report quality data. Over 280,000 eligible
participants were in the 2011 PQRS and a total of $261 million in payments was
paid for that program year.
Then you have the electronic prescribing incentive program, which uses a
combination of incentive payments and payment adjustments. We had 282,000
eligible professionals, 116 percent increase from the 2010 levels, paid out a
total of $285 million in incentive payments, 136 eligible professionals were
subject to the 2012 eRx payment adjustment because they either did not qualify
for an exemption, meet exclusion criteria, or did not meet the reporting
criteria in the first half of 2011. If you want to look at the full report it
is a page-turner, it is great beach reading. Look at the full report and there
is your link on that.
Some other exciting things in E-prescribing. The NCPDP script EPA,
Electronic Prior Authorization Task Force was formed back in 2006 and looks
like we have a standard that has been validated and passed by the NCPDP
membership last May. Had a lot of support from provider groups especially the
AMA. It is going to go to a board vote next month scheduled for
ANSI-accreditation in November. We are already actively looking at this in OESS
to see if and when it could be adopted and we obviously would also look at the
appropriate time for the NCVHS recommendation on that as well.
Other reminder is that we are adopting SCRIPT 10.6 October first. We are
going to retire version 8.1. And that finally the exemption for long-term care
for E-prescribing in long-term care will be lifted on October 1st,
2014. That is going to be a busy day. We are also going to be proposing an
adoption of a newer version of the formularies and benefit transaction in the
2014 Physician Fee Schedule Regulation that will be coming out.
So that in a very fast nutshell is what we are looking at. CMS will
obviously be giving an update to the full committee at its meeting starting on
Thursday. Happy to answer any questions that you might have.
DR. SUAREZ: Thank you so much. Any questions from any of the members of the
MR. FIRFER: It might actually trailoff on some of the stuff we talked about
in EHR or it might be more of a public comment. I will use this time, and that
is as we think about clinical information exchange, health information
exchange, HL7, I will say that to some degree it is a little bit of a wild,
wild, west out there about how we are going to use that data. How are we going
to share it with vendors, partners, RHIOs, private HIEs, the whole works. In
addition to various forms of data governance and really a lack of I know it is
language we took out of HIPAA, but a lack of chain of trust guidance.
Particularly from government entities to help us understand how as that
information moves what the strict obligations will be for those that either
receive that information or plan to pass it on once it leaves the control of
another entity. My humble suggestion would be that at a minimum for next year
that it be added to the agenda. If not sometime sooner.
MS. BUENNING: If I could respond to that? Very good point. Data is big at
CMS, not big data but data is big. As part of the Office of E-Health Standards
This group has been actively involved in not only data use agreements but also
the interagency agreements between all the fed OpDivs and some of the outside
entities like the Social Security Administration, the Internal Revenue Service,
et cetera on the health insurance marketplaces. We are knee deep in this.
I think that as we get into this – I don’t know if you call it data
frenzy, but as you get into whose exchanging what information with what entity,
what rights do they have, and how you track this? This is going to become very
big in the realm of not only privacy, which I know the Office for Civil Rights
has jurisdiction over, but also just in the transactions.
I think that is a very good suggestion and that is something that again,
could be under the purview of this particular subcommittee or with a larger
discussion at the full committee at large. Thank you.
DR. SUAREZ: I do have one question. Throughout today, we heard consistently
the value of acknowledgements as a transaction. We have the debated this
several times in our committee and subcommittee, and we have actually made
formal recommendations to HHS to adopt standards for transactions for
acknowledgements, specifically. Do you see that being part of a 2013 regulatory
effort or is it on some schedule to be considered? Can you comment on that?
MS. BUENNING: I personally do not see it as a part of a 2013 regulatory
effort. I was a famous person who said to my husband how hard can HPID be. One
thousand one, one thousand two – was I wrong. The same thing with
acknowledgements. I think we all think that it is very simple but there are
some questions that our staff has brought up that we still have to work
Also, it becomes in the scheme of things, what else do we want to add onto
the health care community at this point in light of everything else that is
going on. We are trying to reduce burden. We would like to obviously if we
thought it was a low hanging fruit that we could pluck very easily and get out
there and everybody would easily use, we would certainly do that.
I think we have to again, take one step backwards and say what else does the
industry have to deal with and which one do we sacrifice? Do we pushback on
claims attachments or do we stop something else in order to move
acknowledgements to the front of the line. But we are certainly open to
feedback from the subcommittee. I know you have made a recommendation, but I
think in light of everything else that we have going on we certainly do not
want to add to burden it at this point. That is why I think when you will see
some of the dates on the certification, I think you will see that we are
demonstrating that, yes, we need to move forward but we also I think to the
comment that was made earlier, we have to be realistic about this.
We are trying to find a balance between the two but we certainly look to the
subcommittee for guidance and counsel on that.
MS. GOSS: Could we receive a list of those questions or concerns on
acknowledgements because I know there was a lot of work getting to 997, doing
999, and in that world we kicked those tires pretty hard. I would be curious to
understand what are the issues and not now but in a subsequent one so we could
better assist in trying to resolve that matter.
MS. BUENNING: I will discuss it with staff. Again, we will get something to
the subcommittee and just see what some of the concerns were.
MR. FIRFER: In the meantime, by the way one of the things that helps to
mitigate that, and certainly does not solve it is the ability to have time to
do either controlled migrations or unlike flash cuts being able to test those
out. I absolutely agree with Debbie that we probably did not focus on that as
much as we could have but it is one of the most. As we went at least through
our controlled migration that was one of the most beneficial components of that
is whether they were using a 999, a 997, non-compliance 995, or some mix of one
of those. The controlled migration picked that up very quickly as one of the
first findings we would find in our tests. We were able to rectify those and
then distribute communications to all of our stakeholders saying these are the
issues we are experiencing with acknowledgements please keep us in mind. We are
going to need X, Y, and Z.
MS. BUENNING: And you will hear more about testing protocols tomorrow.
MS. GOSS: Just a follow-up to Jordan’s comment about chain of trust
guidance. NCVHS did publish a prepared letter to the Secretary last November on
a stewardship framework for uses of health data outside of HIPAA and I think it
is our intent to move that further. It is interesting we are thinking about it
the context of community use of data but it is interesting without question the
ICD-10 new data will be another lever for the big data.
MS. BUENNING: I think that and not meaning to – I do not want to give
the impression that this is not important at CMS because it is. We have a data
governance board that we are working with and obviously represents a
cross-section of all the CMS components to talk about data release and what the
policies should be regarding it. Who gets what, our researchers a special
group, do they have any kind of special consideration so we use some of the
hard questions that this group is dealing with and I think you are going to see
some expansion of that group with regard to specific workgroups that may evolve
from it? This is what we are using right now to really kind of be the lug pin
for all the data use across the agency.
MR. FIRFER: Just keep in mind that Florida Blue is engaged in it too, that
we are moving forward with HI initiatives. Doing our best to have data
governance with our partners and to protect it but in order to both remain
competitive and endure the best continuity in care for members we have to
engage in the exchange of that type of health information, clinical
DR. GREEN: While Denise is still here and while Linda is still here could
you just talk to each other for a second about this framework thing. I will do
my frame and then you can compare it, okay? This is a big damn deal and it is
just ticking away. We have talked about it in the full committee for four or
five years about how challenging this is going to be. This is another thing of
whether we like it or not this ship is arriving and business partner agreements
are not it. How do we get an update here to where the privacy subcommittee of
NCVHS knows where CMS is in this process and what can you teach us about how we
can be helpful? Could we have a little advice?
MS. BUENNING: I am first to admit that I am not the expert in this area but
I think it might be worth a conversation with a number of people on our staff.
Maribel Franey, who is our Director who is literally negotiating all of these
different privacy agreements and again it is not just the business partner
agreement. It is a myriad of different types of agreements based on the entity,
and what information is being exchanged, and what is happening with that. We
also have ELIPTA(?), which is one of our centers, and again they look after the
data governance board. I think that might be worth the subcommittee’s time to
perhaps at the next meeting or an ad-hoc session or something like that to
invite them in and talk about specific frameworks for data governance. Again,
this is something that is happening very quickly. Some of it is already in the
works but again as we get into this new world. This new health care environment
with ACOs and again the exchanges, the marketplaces, all the rules are changing
very quickly. We need to keep up with them and it is a challenge.
MS. KLOSS: And we approached this from the standpoint of stewardship because
in some ways it is one of those softer cultural issues that we have to find
ways to frame promulgate, help people with practical tools, and educate them to
the consequences for all of us if we do not do this well.
MS. BUENNING: And it is not only from the business perspective the exchange
of the information but it also again the end user or the end recipient,
beneficiary, and what are their rights and what do they need to know to make
sure that their information is protected. Sometimes it is hard to know. We
talked about before the chain of trust, who to trust, and who not to trust.
Also, it is very difficult to know where the line is drawn in terms of data
responsibility. Once you release that data, who then has the responsibility for
ensuring that data is safe and secure once it leaves the confines of your
systems. That is an interesting challenge from a legal perspective, from a
moral perspective, and these are the kinds of things that we are all grappling
DR. SUAREZ: What I think we can do is work between the standards
subcommittee and the privacy, security subcommittee to convene throughout the
session where we can hear that from them.
MS. KLOSS: Maybe a joint session.
MR. BUENNING: We actually probably when the Privacy, Confidentiality and
Security subcommittee meets on Wednesday, one of our thoughts is that we need
to reconvene and do a special hearing on the stewardship framework now that we
have had the roundtable on community uses of data. This might fit very well.
MS. BUENNING: OESS would definitely like to be a part of that conversation.
MR. FIRFER: And I also think that you will find that as you are thinking
about stewardship and communities that you formed from stewardship. Maybe the
idea of things like certified aggregators, et cetera that having some people
more than a few from the private sector there is so many different perspectives
will help you draw out that map of all the places that data can land, how it is
being sent, where it is coming from, and where it is going. I would also humbly
suggest that maybe it is not in the first couple of meetings but when the time
is right that you ask for a lot of participation from the non-government
MR. SORACE: One of the longer term issues I think is stewardship is not just
the very significant issues you raised in terms of the transport of data and
privacy and storing it but it is ensuring that the conclusions from the study
that it underlies are actually statically accurate. There is a cautionary tale
from the OMICS community where there is a very high false discovery made of
associations. They have since gone somewhat put some of this behind them, but
how you actually use large-scale data to draw conclusions is something we have
not had that much experience with. In reality, we do not and people often use
statistical methods and levels of determining significance that you used for a
simple clinical trial when they are trying to find associations in much more
complex data sets. As a reality, a lot of what they post is wrong.
The societal deal here is if you share your data be able to do something
that is right for you. We might want to start thinking about these bigger
statistical issues earlier.
DR. SUAREZ: Any other comments or questions from anyone? I think we can open
up for any public comment. Anyone in the audience want to make any statements?
(No public comment)
DR. SUAREZ: Okay. I think we are wrapping up our first day. Thank you to all
the people that provided testimony. We really appreciate it. It was a great set
of sessions and really set the stage very well for our topics tomorrow.
Tomorrow we will reconvene at 8:30 here and we will go through the agenda
tomorrow then. Thank you again and we will adjourn. For those that are on the
call we will be reconvening at 8:30 tomorrow morning. Thank you.
(Whereupon, the meeting adjourned at 4:53 pm)