[This Transcript is Unedited]




June 21, 2012

Doubletree Hilton Hotel
8727 Colesville Road
Silver Spring, MD 20910

Proceedings by:
CASET Associates, Ltd.
Fairfax, Virginia 22030


Agenda Item: Welcoming and Introductions

DR. SUAREZ: We are going to go ahead and start our subcommittee meeting. I know there are people with pressing time. We want to work through several of the issues. The agenda is displayed on the screen. Originally — you know, talk about dynamic adaptation — our agenda was to do three thing: a brief recap and discussion of next steps from our hearing yesterday, and we can still do that, review and discuss the prioritization of the Affordable Care Act areas — but I think what we are going to do is take some time to discuss what we want to do next.

Not so much jump into the prioritization, itself, but really discuss what do we want to do next with respect to the Affordable Care Act Section 10109. Then the review of the subcommittee priority areas of work for 2012/2013. That, I think, it something that we really want to focus on to try to identify what are the areas, the topics, the tasks that we need to do? What are some of the — stepping back and stepping higher, what are some of the larger issues that we want to address?

Is there anything else? Any changes? Any suggestions of changes that we need to make from the subcommittee members? I think, procedurally, we should probably go around and introduce ourselves. My name is Walter Suarez. I am with Kaiser Permanente and one of the co-Chairs of the Standard Subcommittee. I do not have any conflicts.

MR. SOONTHORNSIMA: Ob Soonthornsima, BlueCross BlueShield, Subcommittee Chairs, member of main committee. No conflicts.

DR. WARREN: Judy Warren, University of Kansas School of Nursing, member of the Subcommittee. No conflicts.

MS. KLOSS: Linda Kloss, HIM consultant, corresponding member of the Subcommittee. No conflicts.

DR. CARR: Justine Carr, Steward Healthcare, member of the Subcommittee, Chair of the Full Committee. No conflicts except for the fact that I think we all live in the world that we are talking about — at every juncture, everything that we are talking about. Other than that, no conflict.

DR. SCANLON: Bill Scanlon, National Health Policy Forum, member of the Committee. Truly no conflicts because I don’t live in any of your worlds.

MS. DOO: Lorraine Doo with the Office of E-Health Standards and Services at CMS. No conflicts.

MS. SQUIRE: Marietta Squire, staff to the Subcommittee.

MS. JONES: Katherine Jones, staff to the Committee.

DR. SUAREZ: We are going to go around.

DR. LAZARUS: Steve Lazarus, Boundary Information Group, representing CAQH CORE.

DR. THOMASHAUER: Robin Thomashauer, CAQH.

MS. THORNTON: Jeannette Thornton with America’s Health Insurance Plans.

MS. BANKS: Tammy Banks, American Medical Association.

MR. BIZZARO: Tom Bizzaro, First Data Bank.

MS. WEIKER: Margaret Weiker, Hewlett Packard, representing ASC X12.

MS. FLAGLER: Lauren Flagler, Department of Veterans Affairs.

MR. BARDOS: Pete Bardos, PWC, contractor to the Department of Veterans Affairs.

MR. CROWLEY: Kenyon Crowley, University of Maryland and also on the Data Access News Working Group.

MR. WANG: Eric Wang, Social Security Administration.

DR. SUAREZ: There are a few members on the line. Who do we have on the line?

DR. PICKETT: Donna Pickett.

DR. SUAREZ: Hi, Donna. Thank you. Anybody else? With this agenda — oh, I’m sorry. Justine?

DR. CARR: I do want to just say think about — I mean, all that we heard yesterday and we have talked somewhat about it, but just sort of fill that in of when are we going to kind of de-brief hopefully in the not too distant future or whether we bring the themes out today. We just don’t want to lose sight of what we heard yesterday in the hearing.

Agenda Item: Brief recap and discussion of next steps from June 20, 2012 hearing

DR. SUAREZ: That is what we were going to do next exactly. We are going to spend the next ten minutes or so in a big recap of themes that we heard yesterday during the hearing and the plans. What are the next steps? Those are the two items. To start with, let me just mention a few of the themes that I think I heard and then we can go around and add to those.

First of all, one of the things — and Ob was highlighting this as we were finishing the hearing — was how interesting it was that even though the topics on paper appear to be so unrelated to each other in some respects, they ended up showing a number of consistent themes in many areas. That was quite interesting. I think it was good. There are some process points that I think we all know and will make different in future hearings, particularly the concentration of topics in a single day and making you all come out so early.

I think the main themes that I heard or at least some of the main things I wanted to point out were, number one, emphasizing the whole concept of openness and transparency in all of the process. This is not just a committee open to some transparency, but actually the processes that organizations and entities and trading partners use in defining their own policies and communicating them to others, their trading partners. Openness and transparency was one.

The convergence theme — the convergence of administrative and clinical, the convergence of various initiatives and activities, and, actually, the opportunity to see them not as competing initiatives, but perhaps seeing them as opportunities to build from each other, each one of those initiatives. Again, not try to do silo type of activities, but more coordinated and convergent.

Continuous collaboration. Collaboration was a major theme, I think, across the board. We need more. We need more extensive and encompassing. We need more often collaboration across, between, and within all of the various health care industry participants.

Enhanced communication, education, and outreach. I think those were three important themes. Communication between the trading partners and between regulators and the industry, as well. Education and outreach — that continues to be a major emphasis. We heard testing, of course, and what was interesting was testing on all of the topics we heard. It was not testing of 5010 or testing of ICD10, but testing on UDI and all of the other topics that we talked about.

Another one was to push harder on preparation for the transition. Establish and define transition points, parameters, and milestones. I think that was another major theme across all of the topics.

Very quickly, to highlight one or two of topics and the highlights, I think the 5010 and D.0 clearly we heard that industry struggled with the transition. They still somewhat are struggling with completing that transition. All of the issues — this was one interesting point — all of the issues were implementation interpretation and really not issues with the actual standard, problems with the actual standards, themselves, even though there were comments about the timing of the publication of the errata that pushed the transition a little bit into a harder to achieve timeframe. The actual standards — there wasn’t any point. It was all about implementation and interpretation of the standards.

The other one that I thought was to me the biggest pull-out of the whole session was that all the issues that we heard, particularly with 5010, and this is a major lesson to think about for ICD10 — all of the issues that we heard with respect to 5010 could have been addressed had the industry done a full and formal testing. What we were finding out was that people were starting to implement the transaction very close to the time of compliance or even as compliance was starting. That is when people started to find issues. Had there been testing, I think my understanding of it from the hearing was that pretty much the vast majority if not all of the issues could have been solved during a full formal testing period if everyone would have tested.

We heard that, you know, I guess now that we are six months into the compliance, many of the issues have already been addressed. There are still many issues, but there are many that have been addressed. Someone actually pointed out, you know, what is, at the end of the day after six months of transitioning after the compliance data, really are we — on January 1, we have hundreds of thousands of claims rejected and all this. What is the volume now? Is it still very high? It seems like now it is more sporadic, perhaps, and a lot less in terms of rejections. It is existing, but not as significant.

I think it was very good to hear some short term recommendations and long term recommendations with respect to this transition and how those apply to the next one, which will be ICD10. Those were some of my takeouts of that particular panel. At the same time, we can go through some of the other takeouts from each of the other panels, but rather than going down that path, I can stop here and then go around and see if others can add to it. Then we can talk about how are we going to cross this over.

MR. SOONTHORNSIMA: I want to repeat all of the ones you mentioned. Maybe I will clarify a couple ones. This thing about testing is such a big, big topic. Just to try to summarize at a higher, there was a sense of there is no common definition as to what do we mean by ready. Readiness has different meanings from different entities. That is a comment where when you are talking about end to end there are varying degrees of how that is interpreted. Clearly, it is not done across from provider all the way roundtrip back to payment.

Timing of testing — that is another issue because what we also heard as a recommendation was don’t even begin to do testing unless — any real industry testing until people really completed the work, the project itself, the capability is ready to be tested because testing periods kind of overlap with the project, itself, for the various entities.

We also heard there are perhaps more innovative ways for us to do testing. We heard from a plan yesterday around maybe we focus — for ICD10, instead of doing transactional testing, let’s focus on medical — what was it? Justine’s thesis? Use cases. That is right. Scenario-based testing.

Another one — I am not going to repeat the rest. Another one was, alongside the readiness issue, there is still some significant dependency on the vendors and non-covered entities, such as PMS vendors. That is an interesting point because while they have made claims that they are ready or some of them are not even ready, there are varying degrees of software versions that cause major issues for the providers.

DR. WARREN: To build on what is being said before, the one thing that hit me was not only can’t we define readiness, there is no definition of what end to end testing is. Everybody had different ideas as to what was involved. The one group that seemed to be successful was Florida — so BlueCross BlueShield. Wasn’t that that group? That came up with the idea of doing scenario-based testing. That surprised me because we have been teaching that in graduate programs for quite some time. My students will sit there with their hands up if I know the answer.

I guess the other thing that came up is we need to find out if that is real. I can’t imagine that that many people are testing that don’t know what testing is all about or how to create test scenarios that will uncover problems. Something else must be happening in that or maybe some of the people that are testing really don’t know about some of these strategies about how to do that.

To me, I thought it was pretty obvious that if we are testing that I can send a bill on something, then I would start with the encounter and come up with here is the encounter, now can I take the data from the encounter? Can I put it into the system? Will the system then send it to the clearinghouse or to wherever it is to whatever? Do I get a check back when I am done? To me, that is the end to end.

The other piece that I thought was interesting is that when I asked the question about things worked well in testing and then when they went live they fell apart — well, the whole reason you expend resources to test is so when it goes live they don’t fall apart or a little bit falls apart. I have done enough testing a implementation of new code to know it always breaks something that you didn’t expect and you have to go back and work with your vendor. I am wondering what about the testing are we still having code breaks.

That brought up the whole discussion with many people were depending on their vendor to do the testing. They got into trouble when they expended money, they thought they were covered, and now they are not getting paid. They are in arrears payment by months and months and months with reports of people not being able to pay their rent and physician offices not paying the rent, not being able to make a payroll. There is something really wrong when you start hearing those kinds of consequences to implementation.

A couple of people responded with we really need to have a certification process of these management systems, much like we have with the EHRs. We need to give some guidelines to, especially in the small practices, as to which ones of these are good and will support their business arrangements so they can stay in business, evidently.

Then there was the issue of — back to education — of not only do we need to do education about testing, but education about how to complete the fields and what they are for. It kept coming back to this big triumviri of we have to have the right software that meets all of the specifications and how do we know that does and not only that, when we do upgrades — because there will be upgrades in everybody’s life — why it is important to take the upgrades and not wait four or five years and then take a big upgrade. Even though it may seem cheaper, in the long run, it usually is not.

Those were the things that I was picking up in that.

MS. KLOSS: I won’t add to that list except to underscore the recurring recommendation on setting timelines, setting deadlines, and sticking with them. I think that was — I would add that.

It seems, though, that when you listen to everything we heard, there is just this overall theme of complexity of the system in dealing with, you know, changes that affect more than one part of the system and the difficulties of doing that.

As I reflected on what I heard yesterday, it seemed to me maybe there is an opportunity for the Committee or the Subcommittee to step up a level and maybe do a mini version of what you did with ICD 10 and kind of a post mortem, based on the testimony yesterday about 5010 on what sort of some pitfalls are in implementing these complex changes and doing that in the spirit of guiding future changes. Maybe stepping up and laying out some of the lessons learned from 5010 and how those inform going forward.

DR. WARREN: Can I just comment? One of the things in doing post mortems and stuff — and there were several speakers that spoke to it — it is about this whole roadmap, which I didn’t mention before because I knew we would get back to it. There have been profound changes because of legislation that specify due dates in it without anybody going back and taking a look at what are we asking these people to do.

I remember Walter and I working on a slide deck. Walter came up with this perfect storm slide, which I have stolen from him shamelessly on several presentations. We really expected the same group of people in each of these organizations — they were the only ones who had the talent — to work on multiple enormous implementations and changes. There was no effort at any of the higher levels to say can we really expect people to do 5020, ICD 10, Meaningful Use one, two, and three, and, oh, by the way, NQF is coming out with the quality data model and that is requiring use of ICD 10 and other terminologies. Are people ready for those? Meaningful Use is going to require NQF endorsed quality measures. Those are getting more specific.

Those are only the ones I know of. I am sure there are many other federal regs with due dates that are coming out that are all around the same time between now and 2015/2016. I think the effort to come together with a consolidated deadline list and to be willing to go back to Congress and say we can’t make these deadlines so let’s renegotiate is key.

MS. KLOSS: I think there are two things, though, when you look at it just as a straight change management. This is the world we live in — wave after wave of deadlines. In some ways, that is not going to go away. There should — each one we should get better at. It does seem like each one is as painful as the last. That is a paradigm that is probably possible.

DR. WARREN: I think we do need to look at — because if you have the same workforce, which is already inadequate, responding to each and every one of these, then the quality of the work is going to decline dramatically with each one. The failure rate —

MS. KLOSS: I think it is both. I think it is looking at whether the pace and the sequencing is reasonable, but then how well guided are people to do it right the first time.

DR. SUAREZ: Let’s finish up with going around.

DR. CARR: 5 Cs and 4 Ts: convergence, communication, collaboration, complexity, coordination — that is what everyone has been saying — and on the T side, transparency, transition struggles, testing, and timelines. I couldn’t help but put it that way.

Back to what I said earlier, where are the regional extension centers in helping sort out these details that we are not aware of at the high level?

DR. WARREN: The regional extension centers are overworked. They are funding —

DR. CARR: I am not saying that. I am saying the concept or that middle man that has got to take these lofty concepts and not just figure out the tying out, but also communicating the importance of it. I don’t think — I keep going back to this. I know Raj was unable to be here, but so often Raj brings us everyman’s perspective.

It is so discordant with policymaking and, yet, it is exactly the reality of a practitioner in a solo practice does not understand administrative simplification until you show him you won’t have three clicks and two rejections, you will have seamless flow. Somehow we — it just seemed like — and even when they said the providers and the practitioners don’t understand each other. To me, that was the biggest takeaway. That is the missing piece to ensuring the execution, meaningful execution.

DR. SCANLON: I don’t have anything to add to the list. I actually would — at the risk of offending you all, let me give you something about sort of the perspective or the framework that I have when I think about these things, which is — you know, one question that was going through my mind during the hearing was, okay, what is the public sector role? What should HHS do about these different things?

There were various times when somebody said we would urge you to recommend X. I am not sure that I would necessarily agree with all of those, but there is a question about sort of that. Part of it is that transitions are always costly. They are not unique to this sector. Every industry sort of is engaged in transitions virtually all of the time. You can go out and study sort of firms in different industries and you can find out that there are various suboptimal positions.

Part of why they stay there is because they know it costs money to change. If they can hang on in their current state, they will do that. Sometimes the demand side of the world sort of won’t let them do that and so then they have to engage in the transition. That is what is happening here. We have some change on the demand side. This is a change that is also, in some respects, meant to be beneficial to the two significant parties here, providers and plans, ultimately. There is that sort of issue of ultimately.

I wasn’t sure kind of how much of this is natural or normal transition costs and how much of it is something that we definitely could avoid. One of the things we heard was that — someone said — and I don’t think it was in the first group, but it was if we had only sequenced things instead of asking for multiple things at the same time. Well, I could imagine if we had sequenced things, people coming in and talking about if you had only asked for these things simultaneously — the wheel like sort of when we did step two.

That is the reality. There are interactions in all of this. Whether you are better off doing them sequentially or whether you are better off trying to bite the bullet and do them sort of all at once, that is sort of another issue.

The other thing about sort of the experiences and this particularly relates to the public sector role, the public sector — let’s be honest — is a huge — it is the 800 pound gorilla. When we hear about a problem we should be asking what is the magnitude of it. How prevalent is this before we bring the public sector in in a significant way? Public sector education is not a heavy hand. You can do that. That is just putting the information out there. When you go beyond that and you start to get to the area of where, in some respects, you are coercing, sort of, behavior that is very, very different. I think we have to have a higher standard for when we do that.

That was the kind of thinking that was going through my head. I, frankly, was left with thinking my God, how do we sort out all of what we heard? There was an incredible amount there. Yet, I am not sure there was enough there to kind of give me the answers to those kind of questions. I am thinking that at one point we might want to put together a list of the recommendations that we heard that were being requested and ponder them.

Which of these seem like it is a reasonable thing to do with respect to this? I think what Linda was talking about earlier, that big roadmap kind of idea or the full design, which of them makes sense in that context? I think, ultimately, that is where we have to be.

MS. DOO: I just had two comments. One was a question or a hypothetical. If we hadn’t delayed the start of each of these, what do you envision would have happened? If we had simply said the date is January 1st, what would have happened?

DR. WARREN: Screaming and yelling.

MS. DOO: But we had screaming and yelling anyway.

MS. KLOSS: The same thing that did happen.

MS. DOO: You don’t think it would have been different. There would have been volumes of more claim rejections.

DR. WARREN: The issue is some of the industry was ready and on target to go with ICD 10 and some of the industry wasn’t.

MS. DOO: 5010.

MS. WARREN: Oh, we are talking about 5010.

MR. SOONTHORNSIMA: I think the industry was already prepared to accept 4010 because they didn’t want to have any disruptions on the provider side. That provider cash flow is a major, major issue.

DR. SUAREZ: I think, regardless of whether there are delays, whether there are delays in enforcement, whether there are no delays or no delaying of enforcement, the industry is always going to be in that situation, unless we change certain structural ways in which we look at the industry in transition. I can see in 2014 when ICD 10 — if that is the date that gets set, organizations — we heard it from the testimony — they are going to have to still have dual systems because on October 2nd, 2013 or 2014 or whatever date is going to be the date, there are still going to be people sending ICD 9s and on October 3rd and October 4th and probably December, maybe even March of the next year.

As I said, one of the realities is we might still have to do ICD 9 with worker comp. It is going to be a period of time where people are going to still have to do this.

DR. WARREN: I have a question and maybe you can help me understand, Ob, since you are on the insurance side. You made the comment that insurance companies probably would have accepted a 4010. What happened to these instances that we were told of where payments were delayed — like six months worth or something — and people were not able to pay their rent? What happened in those instances?

MS. DOO: Some payers –- this is not to lay blame because the issues were — and Tammy can attest to it — they were sort of all over the place. We were doing a lot of individual services. Personally, I was doing a lot so I can attest to it as well. The issues were all over the place. Some payers were being very, very strict and were rejecting them. The errors are with your clearinghouse or the errors are with your software vendor so there is nothing else I can do. They would continue to reject those. Whether it was a 4010 or a 5010, if it was the error, they were being rejected.

Some others — there was actually a health plan here yesterday — they were using what is termed as operational compliance. If they didn’t need those edits that were in 5010, they simply weren’t using them. Those claims went through like a breeze. That is why they didn’t have problems.

DR. WARREN: There was one example of some instances where people were reverting back to paper.

MS. DOO: We didn’t hear a lot of that.

MR. SOONTHORNSIMA: That is why health plans won’t accept 4010 because they don’t want —

MS. DOO: We didn’t hear a lot of that.

DR. SUAREZ: We didn’t hear — there might be some cases out there, but we didn’t hear that patients were not able to get service or patients were rejected. That is the good part. We heard of providers that were not being paid, for example, which is a concern, or pay delayed.

DR. WARREN: Didn’t we hear that some practices closed?

DR. SUAREZ: Yes, some practices closed.

DR. WARREN: That is people not getting service — whoever went to that practice.

DR. SCANLON: Whether the practice closed or whether the person that was in the practice merged into another practice and brought all of their patients with them —

MS. DOO: It is situational.

DR. SCANLON: This is the data issue. We know the practice is closing, but we don’t know what the consequences of the closures were.

DR. SUAREZ: It is like if General Motors establishes that they are going to use the X12 standard for suppliers and some suppliers can’t handle it. They go out of business if they can’t handle it.

DR. SCANLON: Or some of them actually will then merge with somebody who can handle that part, but they can provide a service to them. I think Lorraine’s question — it came up when someone argued stick to your dates — I mean, the issue is what is the distribution of compliance between the two strategies?

If you stick to a date and you have a slightly higher failure rate at the beginning, are you still better off than if you pushed it out? You are probably still going to have a failure rate. The question is which of those produces the best result?

MS. KLOSS: Right. That is what they were saying. Plus, if you take into account the additional cost of delay, then sticking to your dates —

DR. SUAREZ: The risk into the future is once we have required compliance — certified compliance like by health plans, that possibility of allowing — you know, we are going to let a 4010 pass by or a 5010 that is not necessarily a completed form pass by. I might be now considered out of compliance and I just certified that I was going to be in compliance. In fact, that is probably a point of clarification that I think will be important to know. That might close the flexibility of the system to deal on the healthcare side.

DR. SCANLON: I would argue it increases the incentive to comply, but it doesn’t necessarily lead to full compliance. We have all kinds of certification requirements in the world. We have all kinds of people who are operating continuously without being fully compliant.

MS. DOO: We won’t have a way of checking right away. The follow up to that and just for us to think about because we don’t have to solve it today — the follow up to my question then is we asked one person the question — this is something that we have wanted to do some research on. We don’t have the funding yet, but I have been asking for it — is we never get past the question of what are the other transactions you are using. We asked the guy yesterday and we know that it is small for the other transactions.

Here, we are going to start with operating rules in January — right? — for eligibility and claims status. We don’t know the volume of use. For prior authorization, for enrollment, we know it is small, but we need to get at that N of how those other transactions are being used.

DR. SUAREZ: I think that is really important. Most of the things — of course, the most important transaction we heard about were 835/837s —

MS. DOO: Because you have to get paid.

DR. SUAREZ: And then maybe some of the eligibility. Okay. I know we are moving along. What we want to do is just briefly mention the next steps. Normally, how we handle this — to your point, Bill, too — we prepare — I mean, I took copious notes. I know Lorraine did and others. What we usually do is put together a summary of observations first — a summary of purely the observations summarizing this is what we heard based on the questions we originally asked the testifiers.

We do actually what you pointed out, Bill, which is pull out — that I always do. I always go back one by one and say there is a recommendation here from this testified. It takes some time with 39 different testifiers. It is really very enriching to see all of the recommendations in one list on different topics. We always do that so we will do those two next. The idea is to convene the Subcommittee to work through the observations and recommendations that we heard and then look at what are the possible recommendations that we might want to bring out.

We would do the first draft of the observations and pulling out all of the recommendations. We normally don’t kind of draft right in the very first draft what we think are the recommendations. We only use that to discuss in the Subcommittee so that we can then begin to say, well, we think we can do this recommendation here or there.

That is the idea. I think the timeline — I am hoping that we can have basically between now and September, since September is the next meeting of our full committee, September 20, is have a draft letter to present. To do that, we would probably need at least three conference calls between now and September just on this topic. That is an interesting point. That will be one call every month in July, August, and early September just to try to resolve and address this hearing. Then we would want to talk about what else we are going to be doing.

DR. WARREN: I was looking at my notes. There is the whole issue of the dental codes. I was thinking does that need to be addressed in a letter with everything else or should we do a separate letter to address the dental code issue?

DR. SUAREZ: I think what we were going to do, at least initially, was put into one document all of the domains. Then we can decide whether it makes more sense to write five different letters, one on each of the topics, or three letters, but one document that has the summary of all of it.

MR. SOONTHORNSIMA: I think one of the themes, again, that I keep going back to in gearing up for ICD 10 — and you know we are going to have some formal announcement. The point is teeing up these very valuable input and then summarizing in such a way that it is going to be very useful, not one-off stuff, trying to identify what are the core recommendations that would be helpful for the industry.

DR. CARR: We have the transcript and we can have a summary of what we heard. I think the letter has to be that information in service of what. I think your idea of lessons learned/what we need to do — I think it shouldn’t just be here are all of the things we heard. This comes up in Quality all the time. It turns out recommendation have less and less to do with the exact testimony, but it is these are the themes that make us think about this opportunity for intervention.

I think that is the way we ought to think about it. I don’t know that we have to spend — I think the themes were very resonant. They repeated. We don’t even need a call, almost. We have them all today — to talk about that. I think our deliberation has to be so what did we learn? What should we do?

MR. SOONTHORNSIMA: The point is the big next one is ICD 10.

DR. CARR: Exactly.

DR. SCANLON: Part of what we say about that may be determined by what the Department says. Timing is a part of this issue.

DR. CARR: That is going to be announced in a week or so?

MS. DOO: Yes. They are supposed to meet with the administrator next week. To be honest, I thought that yesterday’s meeting was really eye opening for them. We had talked about this a couple weeks ago when we were looking at all of the comments. It was very clear yesterday if we keep looking at dates as if there is some magic sign versus this bigger picture of what are we really trying to get at. I think that resonated. I don’t know that it will change anything, but I think it was a very powerful message. They have scheduled still to meet with her next week with the recommendation.

MR. SOONTHORNSIMA: Being prudent doesn’t mean we take away the sense of urgency, either. In other words, the date may be what it is. However, these are the issues that we have to resolve by whatever means, such as regional extension center — the like support or what not.

MS. DOO: It is a much different education than it’s coming, it’s coming.

DR. SUAREZ: As I mentioned, what we will do is we will summarize this. The most important, as Justine pointed out, is really in the calls focusing on what do we want to do. What do we want to recommend, basically? We will set up a series of conference calls. We might set up maybe three or four — at least three, but maybe more over the next three months to cover this and to cover some of the other issues that we want to talk about.

That is the letter. Unless there is anything else on the hearing and the letter, we can move to the next item. Anything else?

Agenda Item: Review and discuss as necessary prioritization framework for ACA Section 10109 areas

DR. SUAREZ: The next item is the discussion about 10109. We just heard very valuable input from the rest of the Committee, which was, I think, valuable in the sense that they are at a much different, higher level — different perspective level. It was valuable from that side. Sometimes we might be too much into the weeds and in the detail.

The sense that I am starting to get is that there is clearly a need to think more strategically into the future. I think that is one of the themes that resonated with people that we need to really step back, step higher and think of what are some of the larger issues that we need to look at. In the scheme of things, if you will, some of these areas of possible standardization might get resolved by the industry, itself.

That might be a point that we might want to make to the secretary is that there is an opportunity — there is this idea of having Tiger Teams and having these activities that don’t get precluded if the industry wants to do it, itself, and organize into something that can come up and come back to the Committee at some point saying, hey, you remember that hearing you had on this day and you decided to not do your own Tiger Teams? Well, we went back and thought it was valuable to have a group of people get together and talk about this issue because we think there is significant value and here is what we found out. They might send us a letter saying we would like to present to you some work that we did on this topic that might help the Committee understand the importance and perhaps even develop some recommendations.

I think that is possibly a strategy. Rather than us committing and moving forward with any initial set of Tiger Teams, hearing the importance of having to really think more strategically, step back, step higher, look at some of these larger issues, certainly our roadmap of all the areas. We can bring this up as a way of saying, well here is a challenge for the industry. If the industry really thinks there is value in each of these, they can group and get together and come back. If they think there is opportunity for standardization, they can present those to us.

In some respects, that will actually create a market based relative value of the benefit of having to do something. If there is enough work and enough stakeholders that one will see some of this happen. I don’t know how people feel about that approach — if that makes some sense. Does that allow us to not rush into it?

MR. SOONTHORNSIMA: Yes. That is the end game, right? I thought we still need to have the high level discussion.

DR. SUAREZ: No, we won’t forget about the high level discussion.

DR. SCANLON: My sense is we are leaning to implement Linda’s proposal for this high level discussion. I guess I would put on the table and hope this could happen that we could have a meeting, either half a day or a day, before the next Committee meeting — like the day before we meet as a full committee — and to have that high level discussion.

I think that, ultimately, for 10109, this is where the right place to be is for the moment. Part of 10109 I see, again, attached to the issue of attachments, as well as the merging of clinical and administrative data. As those things evolve, some of the questions in 10109 — sort of how you want to answer them changes.

It is better if we start at the sort of higher level and deal with this bigger question and then see for these others sort of what the consequences are going to be. In the meantime, it is always incumbent on us to be open to people giving us information. If anybody wants to take it on and provide us information, we should feel sort of obligated to consider it very carefully. I think it is the issue of our developing the information is too costly to really resolve these bigger questions.

DR. SUAREZ: How do others feel about it?

MR. SOOTHORNSIMA: I agree. I think — would we want to wait until September or could we use conference calls to tee this up and really look at it?

MS. DOO: I just wanted to add — I think I only told Walter and Ob when we were just passing around the initial PowerPoint. I am not the arbiter of the statute, but in one way, I think you have essentially met your baseline obligation to the statute by having the hearing and making the recommendations. NCVHS has done its base job of making that. We have the recommendations.

We, at CMS, are obviously looking at those. We will do some recommendations to our administration about what we should look at. I am putting that package together internally to look at the claim edits issue because we do have the National Claim Coding Edit project already underway for Medicare. Medicaid is going to be looking at it. There are some initiatives that you could leverage if you were to do some more work — so if you waited until later in the year.

We have the same issue you do, in terms of bandwidth. There are a few other things going on. It is what can we accommodate also. It is the same kind of issue. There is going to be other work at CMS that may go hand in hand and probably wouldn’t be starting this year either, just because of the other things happening. Then, of course, there are other industry initiatives like Colorado Claims Initiative. I don’t know if Barry Keene is on the phone. I know he wanted to listen in on the meeting today. I don’t know if he is actually on the phone or not.

DR. SUAREZ: He might be listening in. I don’t know if they can — no.

MS. KLOSS: I am sorry that I had to step out for a minute. Were we talking about claims attachments just now?

MS. DOO: This is just on the 10109 concept. There is just that little bit of a reprieve, if you will, in terms of work effort and the urgency for when we might have to do something this year.

DR. WARREN: Can you see CMS doing that work? Back to Ob’s thing, if they are doing that work this summer, it might be beneficial in September for all of us to get together.

MS. DOO: It won’t be this summer.

DR. SUAREZ: Do you mean the letter?

DR. WARREN: No, the dialogue about what CMS has to do with our recommendations that we have set for 10109.

DR. SUREZ: That is a plan that Lorraine is working on.

DR. WARREN: What she is telling us is as far as CMS is concerned we are done with one another and we don’t have to do anything else with it.

DR. SUAREZ: Exactly. That is in a sense —

MS. DOO: It would be at your option to do more is how I am saying I might interpret it. You don’t have to interpret it that way.

DR. SUAREZ: It is part of an interpretation. When you read the actual language it kind of points to the fact that, you know, there is going to be some investigation done by someone. NCVHS along with the HIT Standards Committee and Policy Committee would make recommendations to the Secretary about possible standardization.

DR. WARREN: What I am suggesting is if CMS already has that on their plate to do that investigation, for our bandwidth purposes, maybe it is better to wait until they are done and then meeting conjointly with them to find out is there something there that we need to think of more from a strategic perspective.

DR. SUAREZ: The thing is the timing.

DR. WARREN: So that it frees us up to do some of the other things on our plate.

DR. SUAREZ: Absolutely. The difference is, I guess, one thing is the development of the CMS plan. The other thing is the interpretation of that plan. CMS is probably looking at — just what you said, Lorraine — the development of the plan is coming out in the next several weeks over the summer, but the actual plan they might delay until next year.

MS. DOO: Probably.

DR. SUAREZ: Probably. In other words, doing actually the look at provider enrollment, the look at clinical edits and all of these topics, they might not get into them until 2013. They will just pull out a plan that says we are going to look at these issues, but we are going to be really looking at them next year.

DR. SCANLON: I didn’t interpret it that you were going to do an interpretation in the summer as much as our letter says that we looked into this and here are observations on this topic. They are worthy of consideration as you move along. But there is no schedule there.

MS. DOO: We are already looking at some things in provider enrollment, for example. Not particularly substantive, but there is some very good work going on.

DR. SUAREZ: In a sense we can follow that approach. We are going to wait until — I am just framing the concept of what we would report tomorrow to the Committee. We will just let the Committee know that CMS is going to be developing a plan based on the first letter and the hearing, which was very rich, as well, with a lot of information. We will just wait to see the plan and see how we fit into that plan, whether we provide additional opportunities.

MS. DOO: We could ask for hearing or form a Tiger Team on a particular topic.

DR. SUAREZ: Great. I think that’s perfect.

DR. SCANLON: I thought Ob was raising the question of whether or not, in terms of this big picture discussion, we should try to do it in a conference call or start it in a conference call, maybe, versus — we are meeting on the 27th, I think, of September —

DR. SUAREZ: We are meeting the 21st.

DR. SCANLON: So like the 19th. Would it be better to sort of be together for a longer period of time — at least four hours, maybe it is a day — and have this discussion? I think of it not just as a bigger picture discussion, but also planning for what we really hope to accomplish in that attachment hearing in January — that we really think through what it is that we want to learn for that because that is the next big step.

DR. WARREN: See, that is what I would like to have is that extended conversation that we never have enough time to really get into here. We could start pushing ourselves to be more strategic in our thinking instead of responding to the tactical demands.

DR. SUAREZ: Absolutely. We can schedule it in a way that says this call is only going to be about claim attachment, not three topics. When we get into three topics, it means —

DR. WARREN: I wasn’t thinking about a call. I was thinking about coming in a half day before the September meeting for us to meet.

DR. SUAREZ: It is using some of the in between time to prepare us for some of these things.

MR. SOONTHORNSIMA: To his point, I think if we meet on a monthly basis and focused on that very topic or other topics and kind of tee it up in addition to meeting face to face the day before.

DR. SCANLON: We have a history if you look at the agendas for our conference calls of never completing an agenda. One of the things that we should do is we have talked about the letter coming out of yesterday’s hearing and get that done and then see what is left over in terms of the monthly meetings. Simultaneously or today, plan that we are going to meet the day before the full Committee meeting.

DR. SUAREZ: The only problem I have, at least, is that I have the HIT Standards Committee meet on the 19th. I think we decide to — we are starting the meeting on the 19th.

DR. WARREN: Is there time to do it after?

DR. SUAREZ: No. It is Thursday and Friday, the 20th and the 21st.

MS. DOO: They are starting to get close to our meetings — the HIT Standards. They met yesterday, too.

DR. SUAREZ: I was in yesterday’s meeting of the Standards Committee. One thing we know is that we are not going to have a hearing in September. There is a possibility, depending on how — well, one possibility could be that we meet the afternoon of Friday, a whole afternoon. We might want to do a whole day on the 19th and just schedule it and I will certainly try to make it to the meeting.

DR. WARREN: The other thing is, since we are meeting on a Friday, maybe we could meet after the full Committee until five — kind of like the workgroup is meeting tomorrow. That would give us the time on our phone calls and then the time face to face during the meeting and then another block of time there.

DR. SUAREZ: You mean Friday, the second part of the day?

DR. WARREN: The 21st. Yes, that afternoon.

DR. SUAREZ: Usually, we end if we end on a Friday — the only thing is I presume that afternoon is going to be used by this new data use analysis meeting. They said they were going to meet.

DR. WARREN: See there are too many things happening.

MS. KLOSS: I think this work could be highly creative and need to be with some white board and flip charts or whatever — a different kind of meeting. It would be really hard to do that.

DR. SCANLON: How about noon to six?

MS. KLOSS: That makes sense.

DR. SUAREZ: Let’s do it that way. I think that is a great idea.

DR. WARREN: Will you be able to make most of your meeting?

DR. SUAREZ: Sometimes the meeting is — if it goes by, I can even be at the data standards committee for the morning. Usually, we end at three so I will probably miss a couple of hours, but that is fine.

DR. WARREN: If your meeting ends at three, we could start this one, depending on the location, at 3:30 and go to 6:00 PM.

DR. SCANLON: We need more time on that. This is an exercise.

DR. SUAREZ: I think we should plan for noon. I am fine with that. I will just coordinate my meeting with the Standards Committee. We are setting up an afternoon session.

Agenda Item: Review Subcommittee priority areas of work for 2012-2013

DR. SUAREZ: How we might want to spend the rest of the time that we have here together is on some of the topics that are going to be important. We had, also, a presentation that we had shared, I think with the entire Subcommittee, of the work plan. You all probably have seen that presentation of the work plan.

This presentation had — the first couple slides are basically 2011 activities. We are going to skip those because those are the ones that we completed. The third slide has the work that we have already done in 2012. We have completed letters on claim attachments and section 10109 — all of these things that we already achieved all the way through the hearing yesterday. Those that say scheduled now have been completed.

If we go to the next slide, this includes the topics at the top there. One activity we do have is our 11th HIPAA report to Congress, which, I think, we have hear blocked for April through September. We don’t have to deliver it now it looks like until November basically since we delivered the 10th report in November of last year. We can take the time between now and November to work on that, as well. Again, this would be one of the topics that we would put in one of those day blocks or hour and a half blocks of conference calls.

DR. WARREN: I would recommend on that one that we at least put together a slide deck for the September meeting so we can let the full Committee know what we expect to have in that report.


DR. WARREN: I also think we need to take a look at the report since we did such an extensive one on the 10th report. This one might be shorter. I think we just give an update of where we are and set that trend and hope that events don’t overtake us and turn it into another book.

DR. SCANLON: Aren’t there a whole set of prior reports that are relatively short.

DR. SUAREZ: Yes, every year.

DR. WARREN: Each year they get longer and longer and longer.

DR. SCANLON: There was a discussion last time, as I remember, that this was the 10th report and so, therefore, it should be more extensive. There was a real effort to do that. I think there is no reason not to go back to the model of the 9th report.

DR. WARREN: The 9th report was atypical, too, because we missed the previous two years. People didn’t pick up that it had to be done. It had to cover three years.

DR. SCANLON: That is the model we have to go back to — like 2015 we have to do this.

DR. WARREN: Go back to the seventh or the eighth report. That one was a good model.


MS. DOO: Nice try.

DR. SUAREZ: How about we develop and outline, John — we will work on that with Ob and Lorraine, an outline of the HIPAA report and then present it to the Subcommittee in one of these calls that have coming up. By September, we will have an outline with more specifics about expectations from the other members of the Committee.

DR. WARREN: It just dawned on me that when we did the 10th report part of our recommendation was should this report continue to be a Standard Subcommittee activity or one of the full Committee because it was impacting so many other things? Was that decision ever made that there should be a writing team selected from the full Committee that does it? Is it still ours?

DR. SUAREZ: It has not been done — the Executive Committee has never really — that is something that we could bring up to the Executive Committee, too, and say this should be really an Executive Committee report. At the end, someone has to write it. My suggestion is we put together an outline to identify where are the areas where the other subcommittees can participate and then we distribute it to them and bring it together. We will develop this outline and then discuss it as a subcommittee.

That was one of the activities. The other one was — in the remaining of 2012, we had talked briefly about the possible other areas to consider, including the public health data standards. We have really never — NCVHS is the National Center for Vital and Health Statistics, a premier Committee on standards in public health. We have really never focused our attention on the public health data standards in the sense of messaging and vocabulary standards.

We thought we could have — we even noted here a possible hearing in September to bring in public health representatives to talk about the status of the standards, in terms of vocabulary standards — CDC, the PHIN, the Public Health Information Network, vocabulary standards, and then the consortium, the Public Health and Data Standards Consortium, others. This is something, again, that we can see postponed, considering the fact that we really want to step back and look at some of the larger issues.

This could be one of the larger issues, actually. That is an important issue, standardization for public health messaging. That was another topic. That is the end of the — really the work of the Committee in 2012.

Then there is the sort of anticipated 2013 activities. Here is sort of a rundown. We intended to have and still plan at this point, I guess, to have a second claim attachments hearing in February of 2013. At that time, we would hear recommendations from the industry with standards and then pass those and recommendations to the Secretary. Then the rulemaking process will be done.

We would be looking at, in 2013, also the process for evaluating and recommending operating rules for the next round of standards. We just made recommendations about naming an authoring entity. The expectation is that there will be operating rules to be prepared and submitted to NCVHS so NCVHS can evaluate them and then make recommendations to the Secretary so that then they can be incorporated into regulations. The timeline you see there. That is still the first part of the year of 2013.

We had reserved some time, also, for any follow up activity on section 10109 —

MS. KLOSS: Could I ask a question? When are those operating rules — when do they become —

MS. DOO: They actually need to be recommended in 2013 because we have to adopt them in 2014.

MS. KLOSS: And they go into effect?

MS. DOO: 2016.

MS. KLOSS: Oh, my. Why would they be ready so early? Why would they have to be ready?

MS. DOO: Because somebody wrote a law. It is a regulation.

DR. WARREN: And it’s the same issue as ICD 10. You need to be able to get the systems ready and do the testing and the education.

DR. SUAREZ: This part says the regulation is to be published January 1, 2013. That is the deadline for CMS to publish the regulation. From that point, the industry has two years to comply. We, as a Committee, need to receive it by sometime in quarter one of next year.

MS. KLOSS: Receive what?

DR. SUAREZ: Receive the operating rules.

MS. DOO: Or quarter two.

MS. KLOSS: Oh, I see. I didn’t realize that.

DR. WARREN: It was very specific in there. It was one of the things I questioned. The law says the NCVHS will look at and approve the rules. That is why Cora has been so busy is trying to get all of this stuff cued up and ready.

DR. SUAREZ: That is one activity. Then, again, we had some follow up at the bottom there — follow up of section 10109. Again, it has changed now. The next slide is the remaining other topics. Normally, around the middle of the year — like in June of 2013 — we would want to consider having a hearing on the status, again, of 5010, D.0, ICD10, any planning.

We want to hear about the implementation of the first set of operating rules we started six months before. January 1, 2013, we would like to hear about the preparation for the implementation of the next round of operating rules, which would be January 1, 2014 for EFT and ERA. We would look at, again, the same type of activity that we have in our next HIPAA report to Congress.

This last item there is the possible rule of the Review Committee and the ACA. If you remember, the Affordable Care Act calls for the Secretary to convene a review committee, which could be NCVHS, to review the implementation of standards and operating rules and make recommendations for any adjustment or changes.

HHS is to name that review committee by January 1. The committee is to convene a meeting by April 2014. This is already staging the 2014 possible activities in this case. Then every three years from there — or actually, bi-annually, from that point. This would be the activity of looking at how are we doing with 5010? Do we need to change the standard? Can we stay with the same standard for another two years or another year?

Anyway, that is the schedule of activities. This only considers the main things that we have in the current plate, I guess. This does not include, of course, any larger issue kind of like the roadmap concept and that entire discussion.

Looking back, again, at the remainder of this year, the good thing, again, is we really don’t have any specific, except for the HIPAA report to Congress, any specific actual review or development of a letter or anything like that. We can take the time to identify what would be the core topics we want to spend time on. I guess we heard already a couple of them.

In the next couple of months, we need to finish the observations of this hearing that we just completed. That is one. Number two, we want to do claim attachments and have a number of sessions — at least one or two sessions — with the subcommittee, to have longer discussions about claim attachments, not just the standards, but actually some of the more overarching questions and policy issues related to claim attachments. That is the second major topic.

MS. KLOSS: Would that come out after the bigger picture is laid out?

DR. SUAREZ: I think it should, right? What we want to do is really take a breather — step back and breathe and then say let’s not even start talking about claim attachments. Let’s go for a higher concept. That is something that could be done over the next three months as we prepare for this half a day session. At the half a day session, we can focus part of or most of that session to claim attachments, but also to the kind of completion of the larger discussion.

I guess any other topics would probably come out of that discussion of the larger picture.

MS. KLOSS: I think the one that seems to me to have that urgency no matter what this higher level standards picture looks like is whatever the aid or focus the Committee might do on ICD 10.

DR. SUAREZ: On what?


DR. SUAREZ: That is still going to be important. That is another major —

MS. KLOSS: Maybe that is something that gets considered for later this year.

DR. SUAREZ: Yes. Just to -– I know we have one or two more minutes. I know the Executive Subcommittee and Justine, particularly, wanted to cover a few of the things that all of the Subcommittees should be thinking about to develop really a strategic plan, I guess, for the Committee. Can I go over this?

DR. CARR: Yes.

DR. SUAREZ: A lot of them were already some of the things that we have discussed. What are the topics that you are addressing? We have already a list. Why was this chosen? Pretty much we have a purpose. Who is the customer? What is the work needed? Calls, hearings, webinars. We have listed here in our own plan a lot of the information. What is the deliverable? A letter or report. What is the timeline? All of these points are kind of already answered. Some of them might need more detail like what is the work needed on each of these items. It can be explained as conference calls and hearings.

Is there a specific urgency? In our case, mostly it is really the timeline for the Affordable Care Act. What additional resources will you need? Here is more to determine whether we would need some technical assistance from a research or from a consultant or facilitator.

I think we can fill in this based on the information that we have. We can certainly discuss the details in our upcoming calls. I suppose once the Executive Committee retreat comes together, we can present our perspective there. With that, anything else? Any other comments? We have a couple minutes for public comments. Any public comments? Anyone want to say something?

Agenda Item: Public Comment

MS. BANKS: I appreciated being here and hearing the debate. I just want to reiterate that administrative simplification is low hanging fruit. I understand quality is important. I strongly believe that quality is important. You know what? If we don’t get this administrative claims process fixed, the trust between the payers and the physicians is not going to be around.

I will tell you what — how many reports do you believe coming from entities that you don’t trust? I am not saying the payers are at fault. I am saying when you send a payment or a claim to an entity and you don’t get it back you blame the entity you sent it to.

There is a lot of intermediaries in the system. We need to find out why. Is it appropriate? Is it appropriate to have more than two entities? There may be, but could there be a study finding our why and when? I know in the old days, a lot of clearinghouses could not get direct access into payers for whatever reasons — maybe a payer clearinghouse or they would hire attorneys to threaten them under HIPAA to get connected to the payer. Is that a reason there are so many intermediaries? I don’t know. Maybe that was resolved.

The point is there is a lot of paying points that could be investigated. I am not saying it is NCVHS’ role, but all I am saying is the industry as a whole is looking to quality, is looking to the future, and, guys, we don’t even have that infrastructure done. We don’t even have claim acknowledgements. That is sad.

How do you have an end to end system when each of these points don’t even have standard communication back that they have received it? Where do you find it when it is two, three, four intermediaries? We don’t have attachments? I know that down the road we are looking at HL7 attachments. There are a lot of different ways of doing it. We are just talking about an envelope that you can put different things in.

Everybody looks to HHS for mandates. That is what HIPAA brought on this industry is let’s mandate it or I will wait for a mandate to do it. I know that is sad. Take a look at the workers comp industry that you were just talking about. Do you know that they have state laws that mandate attachments, mandate acknowledgements, and mandate that they play under the HIPAA rules? This is a voluntary effort — well, state law. I guess I can’t say that. It is being pushed by an industry that is not covered under HIPAA because they understand the value of getting the cost out of the system.

I really encourage you guys to get away from the idea that the future is now. The standard transactions — there could be other ways of doing this. Right now, bundle payments, you still have to identify what procedures and services are done even if it is bundled. You can identify that on claims and ERAs right now. I know value-based purchasing is coming. We are working on figuring out how to revise these standards to be able to send this. We have to get that infrastructure. We need your help.

The thing that came to my mind as I was driving — I forget what the company is — it could have been about garbage; I don’t know — there was a big billboard on the sign and it said you might not think whatever garbage is sexy, but it had a huge model and it said we do. I don’t know how to make this enticing because it is technical and it is really hard to understand. The end point is these are investments for payers. These are investments for clearinghouses. But the buck stops at the doc’s office — I am sorry, the physician’s office.

The physician has a choice. They can’t go the patients. Bad debt is rampant already. I have a feeling, but maybe the payers will pay them more. Probably not. The only option they have is to go to the banks. That is pretty nice to borrow money, which is what they are doing to cover salaries to wait until this is hammered out.

You are right. The collaboration and communication — I heard them crying about it. It is so important. When you have that direct connection and you can talk about these issues you can resolve them. Unfortunately, in this industry, the way it is set up it has to come here to express that instead of work it out voluntarily.

I strongly urge you not to sweep this under the carpet and say the future is important. We are talking pay checks. We are talking documenting what procedures are performed using a dictionary. The code edits, just so you know, were intended to be correct coding edits because you heard the payers say they want claim payments coded correctly. This is not about fraudulent use. This is not about utilization review. This is not about medical necessity.

The bottom line of where we want to get to — it is not about getting docs paid, it is about talking to patient. It is consumerism — point of service pricing. Don’t you think that is just as important as having the patient benefit information on the exchanges? We have to get to that point, folks. This is the way to get there. I don’t mean to belabor the point, but I really hope you seriously understand the importance of this underpinning and don’t get caught up in the sexy nature of quality and all of the other issues that are going on that are just as important.

This is a low hanging fruit that can build that bridge between all parties — to take Jeanette’s phraseology — even though the providers see half the bridge, too, because they send the clients. An electric circuit is probably a better way to phrase it.

DR. SUAREZ: Hopefully, the two parts of the bridge connect.

MS. BANKS: Exactly. Right now, we are questioning that. I think the acknowledgement sent the wrong GPS positioning on both of those. Again, I just want to go on record. Please, guys, we really need your help.

MS. KLOSS: May I ask a question? Do you have a picture of this? Do you have a diagram? You see where I am going with this.

MS. BANKS: Yes. I would love to. I will give you as much information as you want.

MS. KLOSS: I know you have a lot of information.

MS. BANKS: Can I give you one picture? Yes, I will get you one. I want to tell you how valuable this is. I know some people groan when I say the National Health Insurer Report Card, but I want to tell you we have the major commercial payers for five years. First year, one payer was at 60 percent accuracy. We only looked at contracted match rate where the rate that came from the payer matched with what the physician’s expectation was.

They hired a Six Six Sigma team. They took a large university. They took a practice management system. They looked at every claim that went through and found out where the errors were. They were exactly what we predicted — thank goodness. Now, they are over 90 percent, actually rivaling Medicare.

There is a commitment. I will tell you what, there is ROI as well. The value is there. That is the best picture I can give you without paper.

MR. SOONTHORNSIMA: Any other comments? Any comments from people on the phone? With that said, the meeting adjourns.

(Whereupon, the meeting adjourned at 5:00 PM)