[This Transcript is Unedited]
The National Committee on Vital and Health Statistics
Hearing on the Health Plan Identifier
– an identifier under the Health Insurance Portability and Accountability Act (HIPAA) –
May 3, 2017
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
CASET Associates, Ltd.
TABLE OF CONTENTS
- Welcome and Introductions – Alix Goss and Nick Coussoule, Co-Chairs
- Overview and Background of HPID – Madhu Annadata, CMS, and Laurie Darst, WEDI
- Part 1: Health Plans and Providers
- Session A: Health Plans: Private sector, government, and self-funded plans will provide information about use, need, and purpose of plan identifiers, and impact of the current HPID rules
- Committee Q&A
- Session B: Providers will offer their perspectives about use, need, and purpose of plan identifiers, and impact of the current HPID rule
- Committee Q&A
- Part 2: States, Clearinghouses, Vendors, and Standards Development Organizations
- Session C – Other organizations will give their perspectives on use, need, and purpose of plan identifiers, and impact of the current HPID rule
- Committee Q&A
- Session D – Standards Organizations
- Committee Q&A
- Committee Discussion
- Public Comment
P R O C E E D I N G S (9:00 a.m.)
Agenda Item: Welcome and Introductions, Alix Goss and Nick Coussoule, Co-Chairs
MR. COUSSOULE: Good morning everyone. Welcome to the National Committee on Vital and Health Statistics, Standards Subcommittee meeting. We are glad that you are all here today. We have a busy morning today. You can see the agenda. It is online and it is also available for all of you in the room. We have a number of different panels that we will go through, a couple breaks in the middle, and adjourn at roughly two o’clock this afternoon.
My name is Nick Coussoule. I am a co-chair of the Standards Committee. I guess we will first do kind of around the room to introduce ourselves. Again, I am Nick Coussoule. I am a senior vice president, chief information officer of Blue Cross Blue Shield of Tennessee. I am co-chair of the Standards Committee, also a member of the full committee. I have no conflicts.
MS. GOSS: Good morning. I am Alix Goss. I am co-chair with nick Coussoule, of the Standards Subcommittee and Review Committees. I am a member of the full committee. I also work for Imprado. I have no conflicts.
MS. DOO: Lorraine Doo, with the Center for Medicare and Medicaid Services, Division of National Standards, lead staff to the Standards Subcommittee. No conflicts.
MS. HERRING: Janelle Herring with the Centers for Medicare and Medicaid Services, National Standards Committee, staff to the committee. No conflicts.
MR. LANDEN: I am Rich Landen, member of the full committee, member of the Standard Subcommittee Review Committee. No conflicts.
MS. KLOSS: Linda Kloss. Member of the full committee. Member of the Standards Subcommittee. Co-chair of the Privacy and Security Subcommittee. No conflicts.
MS. STRICKLAND: Debra Strickland. Member of the full committee and the Standards Subcommittee. I am working for Conduent. No conflicts.
MS. HINES: Good morning. Rebecca Hines. I am the executive secretary for the NCVHS. This is a meeting of the Standards Subcommittee, not the full committee. Just wanted to clarify. I am with CDC, NCHS, where NCVHS is run out of.
MS. GOSS: I would just like to welcome Deb Strickland. This is her first official meeting as a member of the Full Committee and more especially, of the Standards Subcommittee. Welcome, Deb.
MS. SQUIRE: I am Marietta Squire with CDC NCHS.
MS. DORSEY: Good morning. Rashida Dorsey. I am the executive staff director for the National Committee on Vital and Health Statistics. I am with the Department of Health and Human Services.
MR. STELLAR: I am Charles Stellar, president and CEO of WEDI.
MR. BOWMAN: Bob Bowman, associate director of transactions at CAQH CORE.
MS. KNAPP: Katie Knapp, Department of Veterans Affairs.
MS. SMITH: Gwen Smith, Department of Veterans Affairs.
MS. WILSON: Carol Wilson, Department of Veterans Affairs.
MS. BURCKHARDT: Laurie Burckhardt, WPS Health Solutions, representing X12.
MR. RYDER: Matt Ryder with the Healthcare Business Management Association.
MS. TUREK: Kelley Turek, Americas Health Insurance Plans.
MS. JACKSON: Debbie Jackson, National Center for Health Statistics, committee staff.
MR. WALL: Gregory Wall, Deloitte Healthcare Informatics.
MS. SIMONE: Arianna Simone, also with Deloitte, and supporting Danny Sawyer.
MS. WEIKER: Margaret Weiker, NCPDP.
MS. KOCHER: Gail Kocher, Blue Cross Blue Shield Association.
MS. SPECTOR: Nancy Spector, American Medical Association, representing the National Uniform Claim Committee.
MR. DECARLO: Michael DeCarlo with the Blue Cross Blue Shield Association.
MS. JONES: Katherine Jones, CDC, NCHS, and committee staff.
MR. SAWYER: Danny Sawyer, Defense Health Agency.
MS. MEISNER: Debbie Meisner with Change Healthcare.
MS. GERHARDT: Christine Gerhardt, CMS, Deputy Director, Division of National Standards.
MR. COUSSOULE: Okay. Again, welcome everybody. Just one detail, we are here – any members on the phone, please? Going once. We will likely have another member come eventually.
Just to clarify, we are here to talk a hearing on the national – on the health plan identifier. If that is not why you are here, then you get to find something else to do today. Otherwise, we will get started with Madhu, please.
Agenda Item: Overview and Background of HPID, Madhu Annadata, CMS, and Laurie Darst, WEDI
MR. ANNADATA: Good morning. I’m Madhu Annadata. I am the Director for the Division of National Standards, formerly the National Standards Group.
The Division of National Standards is responsible for HIPAA administrative simplification policy through the development and publication of regulations and guidance materials implementing applicable provisions of the Health Insurance Portability and Accountability Act of 1996, HIPAA, and the Affordable Care Act of 2010.
The Division of National Standards is also responsible for the communication of HIPAA administrative simplification information with affected stakeholders through collaboration, outreach, education, and technical assistance. Lastly, the Division of National Standards is responsible for the enforcement of HIPAA administrative simplification policy through complaint investigations, audits, and compliance reviews.
This morning, I will be presenting a high-level overview of the health plan identifier by walking through the timeline of HHS policy development of the same. The graphic before you, depicts the timeline of the health plan identifier policy development from 1996 to the present day. In the following slides, I will discuss each milestone of the health plan identifier policy development in greater detail.
As this committee knows very well, the HIPAA legislation called for the Secretary to encourage the healthcare industry to find a way to simplify the manner in which it conducted its business and become more efficient and less costly. That is how the term administrative simplification was coined. I am not telling you anything new about one of the key provisions of HIPAA, which required the adoption of standards to enable the electronic exchange. It is the reason we are here today, though all of this began about 20 years ago.
One of the standards required for adoption were the unique health identifiers for each individual, employer, health plan, and health care provider, for use in the healthcare system. In the original law, there is a statement that asked the Secretary to take into account multiple users for identifiers and multiple locations and specialty classifications for healthcare providers and health plans. HHS completed the tasks of adopting standard identifiers for employers in 2002 and for healthcare providers in 2004. Though initial efforts were made to adopt a health plan identifier in 2005, no regulation was published. HHS agreed with industry that more work was needed to come to an agreement on what it should be and what it should do.
In 2005, CMS drafted a proposed rule, creating an ind. plan ID, which was vetted with industry stakeholders, including the entities required for consultation, the NUCC, the NUBC, The WEDI, and the ADA, which viewed the initial proposal favorably. However, as this work was underway, at the same time as implementation of the national provider identifier, the work was halted. When the work reconvened, nearly ten years later, the original proposal was not pursued. Other solutions to the identification of the health plans has been successfully implemented.
Because no plan identifier was adopted under HIPAA, the Patient Protection and Affordable Care Act of 2010 required the Secretary to adopt the unique health plan identifier, HPID, based on the input of NCVHS. As I mentioned in the earlier slide, a unique national plan identifier was originally called for under the Health Insurance Portability and Accountability Act of 1996. Therefore, the ACA of 2010 reauthorized the requirement.
Your committee conducted two environmental scans in the mid-2010, one for the HPID, to uncover more of the background and history for the identifier, and one for operating rule, to understand the history leading up to their development and purpose. The committee held hearings in July of that year to obtain stakeholder information about characteristics, features, uses, and needs for NHPID, implications for routing information, costs, data accuracy, impacts on current processes, and other players. Testifiers in 2010 described a number of key characteristics, features, uses, and needs for NHPID, including being able to correctly route transactions, reduce the cost of managing financial and administrative information, improve the accuracy and timeliness of claims payments, and reduce dissatisfaction among providers and patients by improving communications with health plans and their intermediaries.
While testifiers describe their needs from different perspectives, all who stand to be impacted by the HPID observed it is important to ensure that the new identifier can be used in existing standard transactions. There was also consensus that the enumeration, maintenance, and use of HPID be kept simple, but robust enough to achieve the desired impact and ensure a smooth transition.
On September 30th, 2010, this committee prepared a letter of recommendation to the Secretary of HHS. The letter outlined the recommendations you see on the slide, based on the hearings and the environment scan. The bulleted list on this slide lists the key themes found in the 2010 letter of recommendation to the Secretary. I will go ahead and read the bullets. The recommendations were provide definitions of types of eligible entities for enumeration, allow for levels of enumeration, the format and content of HPID, the directory database, retail pharmacy issues, implementation time, ensuring adequate testing, and improving standards and operating rules in support of the HPID.
In the next couple of slides, I will walk through, at a very high level, the provisions from the health plan identifier final rule, which was published on September 5th, 2012. The HPID Final Rule can be viewed as having two independent and separate categories of requirements: enumeration and use of HPID in HIPAA transactions. In addition, the final rule allowed HHS to use the HPID for any lawful purpose.
The controlling health plans or CHPs, health plans that control their own business activities, were required to obtain an HPID by November 5th, 2014. Small health plans or SHPs were to comply by November 5th, 2015. Sub-health plans were not required to get an HPID, but there were various options and requirements for sub-health plans. For example, a CHP may decide to obtain an HPID for its sub-health plans or direct its SHPs to obtain one.
Based on the covered entity type, the rule established compliance dates for obtaining an HPID or an OEID and the compliance dates for use.
The Final Rule also adopted a data element that served as the other entity identifier, the OEID. The OEID was intended to function as a voluntary identifier for entities that are not health plans, healthcare providers, or individuals, but who need to be identified in a HIPAA standard transaction.
In 2014, this committee began to hear the growing concern about HPID. In February 2014, testifiers indicated that there was confusion on how the HPID/OEID should be used. Health plans faced challenges with respect to the definitions of controlling health plan and sub-health plan. There were also significant concerns from associations representing self-insured health plans, indicating that those entities were not aware of the requirements and should not be required to comply because of how they contracted and operated.
To mitigate some of the concerns, HHS increased its outreach and education and posted FAQs on its website, hosted webinars, and met with stakeholder groups. NCVHS met again in June 2014 to discuss ongoing HPID concerns. According to the September 23rd, 2014 recommendation letter to the Secretary, this committee reported that the consistent message heard strongly across the industry was the lack of benefit and value in the use and reporting of HPIDs in healthcare transactions. Testifiers were in consensus that HPID should not be required for use in transactions and it should not replace the payor ID.
On October 31st, 2014, HHS announced a delay in the implementation of the HPID rule, what we call as the enforcement discretion. The purpose of the enforcement discretion was to allow HHS time to review the September 2014 recommendations from NCVHS and consider our next steps.
In May of 2015, we have still not determined how to move forward with the HPID policy. We decided to send out a short request for information to solicit public input about whether policy changes were warranted. We recognized that since publication of the rule in 2012, there had been many changes in the healthcare system, including implementation of the Affordable Care Act’s marketplaces.
We asked three questions in the RFI: the HPID enumeration structure outlined in the HPID Final Rule, including the use of CHP and SHP and the OEID concepts, the use of HPID in HIPAA transactions in conjunction with the payor ID, and whether changes to the nation’s healthcare system, since the issuance of the HPID Final Rule, published September 5, 2012, have altered your perspectives about the function of the HPID.
HHS received a total of 53 unique comments. About five of these comments were out of scope for the RFI. Since we never published the results of the RFI, I will share that information with you here.
An overwhelming majority of the commenters stated that the HPID enumeration structure was confusing. Many acknowledged that the intent of the HPID Final Rule was to offer health plans the flexibility in determining their enumeration structure through the use of the following classifications, the controlling health plan, the sub-health plan, and the other entity identifiers.
Based on the provisions of the Final Rule, however, it was not clear how health plans would identify themselves as a CHP, SHP, or how to use the OEID. Adding further to the confusion was the publication of the Certification of Compliance Proposed Rule or NPRM, in January 2014. As a result of that NPRM, health plans realized that how they enumerated themselves in transactions could have been different than how they would enumerate for other lawful purposes. That proposed rule was never finalized and is not on the docket.
Another concern cited by commenters were the operational disruptions and costs resulting from the requirement of using an HPID in routing the transactions. Lastly, commenters stated that if HHS decided to keep the HPID, it should not be required for use in standard transactions.
I would be remised not to include those minority of commenters who suggested uses for plan identifiers, such as for validation of compliance for government programs, as a number on the health insurance cards, and in a patient medical record to help specify a patient’s healthcare benefit package.
So, today, HHS is before this committee and our colleagues, eager for your insights about the health plan identifier. It has been three years since we implemented the enforcement discretion policy. We believe this is a good time for us to finally resolve the issues associated with the current HPID policy. Thank you.
MR. COUSSOULE: Madhu, thank you. Denise Love, are you on the phone?
MS. LOVE: Yes. Can you hear me now? I’m sorry. This is Denise Love, National Association of Health Data Organizations. I am a member of the Full Committee, Standards Subcommittee, and Population Health Subcommittee.
MR. COUSSOULE: And no conflicts.
MS. LOVE: No conflicts. And also, a member of the APCD Council, a learning collaborative.
MR. COUSSOULE: Okay, welcome, Denise. Madhu, thank you. Laurie, please?
MS. DARST: Members of the Subcommittee, I am Laurie Darst. I am the current chair of the WEDI Board of Directors. I would like to thank you for this opportunity to testify on HPID.
As many of you know, WEDI represents a broad industry perspective of providers, clearinghouses, payers, vendors, public and private organizations that partner to collaborate on industry issues. WEDI is named as an advisor to the Secretary of HHS under HIPAA, and we take an objective approach to resolving issues.
Many of my comments are going to be echoed of what you just heard from CMS, but I would like to go through these. Just a little bit of background. WEDI has collected feedback from its members on HPID and reported to the Subcommittee since the hearings in July of 2010. Over the years, we have engaged our members through several Policy Advisory Groups or PAGs, Technical Advisory Committees or TACs, and sessions during our conferences/forums on this subject.
Initially, WEDI submitted several sets of recommendations on how HPID might be formulated to meet industry needs, based on that proposed rule. We believe the agency did consider and incorporate some of these recommendations as part of issuing the final rule. Once health plans started to delve into the enumeration requirements from the final rule however, there was a realization they would need to enumerate to a much greater granularity than they perceived to from the proposed rule. The realities of the impact to the existing HIPAA adopted transaction base started to become more understood because of these industry discussions. More and more challenges to business as usual started to emerge, which I will cover in greater detail.
In July 2015, as we heard, CMS issued a Request for Information on the requirements for health plan ID. At that time, WEDI held a TAC to provide a forum for healthcare organizations to convene and discuss in detail, relating to regulatory provisions for health plan ID. The outcome of the discussions was a set of comments that were reviewed and approved by the 2015 WEDI Board of Directors’ Executive Committee. WEDI found after holding many discussions with its members upon publication of that Final Rule that perceptions of what Health Plan ID would provide the industry versus how health plans intended to enumerate had changed.
We have not heard any new feedback from our WEDI members that would modify our comments. In response to that RFI, our comments were Health Plan ID should not be used in transactions. We further indicated that Health Plan was not needed at all. That there was no need for Health Plan ID or OEID.
I would like to cover some of the questions that you posed. The first one, what health plan identifiers are used today and for what purpose?
WEDI’s collaboration with ASC X12 on the “What is the Difference Between a Health Plan and a Payer?” issue brief, which is attached, in 2014 highlighted that health plan identifiers are not used in standard transactions currently. Rather, it is a payer identifier that is used to drive the routing of the transactions between the different trading partners. Health Plans are defined under HIPAA regulatory provisions as individual or group plan that provides, or pays the cost of, medical care, while Payers are the intended entities that are responsible for the transaction or final processing of claims in order to return a remittance advice, inquiries in order to return the corresponding responses like eligibility or claims status, enrollment of or premium payment for its members.
Two, what business do you have that are not adequately met with the current scheme in use today?
WEDI members have not identified any business needs, which are not being met by the identifiers currently in use.
Number three, what benefits do you see the current Health Plan ID model established by the HHS regulation provide? Does the model established in the final HPID rule meet your business needs?
WEDI members have not identified any benefits to the Health Plan ID model as established by the final regulation. Implementation of the provision within the Health Plan ID regulation would create challenges and barriers to workflows and transaction streams currently used.
What challenges do you see with the current Health Plan ID model established by HHS?
We found two. The first was use of Health Plan ID in transactions. As we indicated previously, the industry has long ago solved the routing issues that were prevalent before moving to electronic transactions under HIPAA. Providers, payers and clearinghouses have worked through identifying the entities to move the transactions from provider to payer and vice versa very efficiently.
Infrastructures were built around these known relationships and a significant number of participants agreed that existing Payer IDs meet stakeholder needs for transaction routing. Even if the Health Plan ID to Payer ID relationship was a one to one, which we know, ultimately, would not be the case, exchanging one set of numbers for another set of numbers is – that is currently functioning efficiently – affords no administrative simplification. Rather, it creates the potential for greater disruption in the current flows. There is an overwhelming agreement that there are potential risks and disruptions in the event transactions would change to use Health Plan ID in lieu of the Payer ID.
The second challenge was the enumeration structure. Many self insured group health plans do not directly administer their health plan operations, employing a third party administrator today. Under the Health Plan ID business model, these plans do not conduct standard electronic transactions and with the provision of Health Plan ID Final Rule applying to health plans, not just health plans that conduct standard transactions, there was concern that many of the self insured health plans would continue to be unaware of the requirement that would apply to them.
In addition, coupled with this confusion of self insured plans, the concern over the greater granularity as referenced earlier, continue to be a major industry concern. When WEDI convened its TAC in 2015 to respond to the RFI, we found no change in the industry’s level of confusion over enumeration requirements in terms of which entities were required to enumerate and the level of granularity required by the rule. Confusion was apparent across the entire spectrum of stakeholders.
Health plans had varying interpretation of the degree that they would have to enumerate, but for many, it was a much greater degree of granularity than the current payer IDs they were using to exchange electronic transactions with their trading partners. There were reports of payers who were using one to five identifiers today that would have to enumerate to over greater than 50 to meet the requirement of that final rule.
Providers expressed confusion on how these new identifiers would relate to those they currently used to identify their payers in trading partner agreements. It was the lack of understanding of Health Plan ID’s true intended use – what was that business case and value – that caused the most confusion across stakeholders. As a result, WEDI modified its prior comment in support of Health Plan ID enumeration to no longer support a need for further Health Plan ID enumeration beyond those that were already issued and no longer support a need for their use.
What recommendations do you have going forward regarding health plan identifiers and Health Plan ID Final Rule?
WEDI’s comments stand. Health Plan ID should not be used in transaction. In fact, Health Plan ID should not be used at all.
WEDI strongly supports the continued effort of all stakeholders towards achieving administrative simplification within healthcare and supports focusing collaboration and communication amongst industry participants that bring value to the industry. Thank you for the opportunity to testify on behalf of WEDI.
MR. COUSSOULE: Laurie, thank you very much. Questions from the committee members for Madhu or Laurie, please?
MS. GOSS: I don’t have any comments or questions at this point – no questions, but I do have a comment. I think that was a tremendously helpful level setting. Thank you for giving us the bookends of the history. It is amazing that we have been working on this for – now, for seven years, from an NCVHS perspective. I am looking forward to further testimony so we can produce recommendations.
MR. LANDEN: Distinct from the Health Plan Identifier, the payer ID that is currently used in the transaction sets, what is the source of that, the payer ID, now?
MS. DARST: I think it varies by payer. Obviously, since I am not a payer, I would look to them. I think the majority of the payers – my understanding is using the NAIC number or they are creating those numbers.
One thing I just would share with you is some of the discussion. There was, I think, a perception that many times, different clearinghouses use different numbers or there are these numbers that are just randomly assigned. The reality is the provider industry does not switch clearinghouses all of the time. Once things are set up, they are pretty much set up. This is not an ongoing problem to use those payer IDs. Once they are set in a system, everything is set.
MR. LANDEN: If I am – just to repeat back what I think I am hearing you say, is even though there is no federally designated single source of truth for issuing payer IDs that WEDI believes it is not an industry problem. The payer ID solution in place now is satisfactory.
MS. DARST: Absolutely. Don’t fix something that is not broke.
MR. COUSSOULE: Words to live by. Other questions? Any questions on the phone? Okay. Thank you very much. We appreciate the good information and the time. We will now try to set up for our first panel, if you will.
Agenda Item: Part 1: Health Plans and Providers
Agenda Item: Session A: Health Plans: Private sector, government, and self-funded plans will provide information about use, need, and purpose of plan identifiers, and impact of the current HPID rules
MR. COUSSOULE: I think we are ready to start our first panel, Health Plans and Providers. I think we have some timing information that Lorraine will explain to us, keep us on track a little bit.
MS. DOO: Most of you have been here before. So, you know – I think we gave everybody five minutes to do your presentations. We will help you. Everyone has been great thus far. We have props, as usual. This is your starter prop. Your friends will help you. This is your start. You are good on time. This is to begin to slow down. It is a wagon train, in honor of Margaret. Happy trails. Those of you on the phone can’t see. This is surrender.
For those who might just need visualization, this is also slow down and this is please stop. I don’t think we will need those at all. Your friends will help you, too, those that are sitting next to you. If you need an extra few seconds, obviously, we will be gracious about that, too, because we know you have good things to say.
MR. COUSSOULE: With that, we will get started with Kelley. Please, for each of the speakers, please introduce yourself and your role so it is clear for everybody.
Agenda Item: Commercial Plans, Kelley Turek, AHIP, and Gail Kocher, BCBSA
MS. TUREK: Sure. Good morning, everyone. My name is Kelley Turek. I am Executive Director of Products, Commercial, and Employer Policy at America’s Health Insurance Plans.
AHIP represents health insurance companies across the country that provide coverage for individuals and employers to provide healthcare related services.
My comments today are slightly abridged from the written testimony that I submitted. You will see more detail there. Hopefully, I modified them so I can meet the five-minute mark.
Today I am testifying on behalf of AHIP’s members with respect to the future of the health plan identifier. AHIP has been actively engaged in conversations related to HPID throughout the implementation of the Affordable Care Act. We provided insight both to CMS and to NCVHS during the regulatory process leading up to the 2014 compliance date. We supported the enforcement delay announced on October 1, 2014 due to significant concerns about the overly complex enumeration requirements, as well as the lack of a clear business case or value proposition for HPID. We simply don’t think that the HPID model finalized in regulations meets the original intent of such an identifier.
While health plan identifiers are not used in transactions today, the industry has widely adopted payer identifiers for routing transactions and this solution is working successfully. Stakeholders have built infrastructure around payer IDs and they are embedded in transaction routing throughout the industry.
We have not identified any unmet needs with payer IDs, nor have we identified any value in using HPID in transactions. Implementing HPID would undermine the current use of payer IDs and create unnecessary disruptions. Specifically, we anticipate the use of HPID in transactions would lead to misrouted transactions, create privacy concerns, and impact payments, creating added administrative burden and cost across the industry. We believe HPID is an outdated solution looking for a problem that has already been fixed by the industry. Implementing it would be counterproductive to the goals of administrative simplification.
In addition to our significant concerns over using HPID in transactions, the HPID model established by regulations is unworkable in its current form. The enumeration structure of controlling health plans and sub-health plans is too granular and would require a complex web of HPIDs and other identity identifiers that does not reflect how claims are processed. There is no one-to-one mapping of payer ID to HPID. For example, one of our plans that enumerated early on uses around ten payer IDs, but had to obtain over 50 HPIDs that would then have to be mapped by payers, providers, and clearinghouses. This level of granularity would create unnecessary complexity if you implemented it in routing transactions.
I would also echo the WEDI comments earlier about the lack of clarity in enumerating requirements for self-insured, fully insured, and ASO groups. We feel that there is still a lack of awareness around this requirement and that the regulation would require entities that don’t conduct transactions to obtain HPIDs. This would create significant downstream administrative burden for the third-party administrators who conduct transactions on their behalf.
Finally, CMS proposed to use HPID for purposes of health plan certification in the proposed rule several years ago. While we fully support the goals of health plan certification, we do not support use of HPID for this purpose. The enumeration structure of HPID does not align with the goals of certification. Health plans would have to certify compliance at a very granular level, as opposed to at a system or company level that would better match the way that they conduct transactions. Instead, we recommend other existing identifiers, such as NAIC IDs or employer identification numbers, be used for certification purposes.
To conclude, we recommend that CMS not move forward with implementing HPID for use in transactions, health plan certification, or for any other purposes and withdraw the existing HPID regulation. This is consistent with prior HPID comments to CMS in response to the 2015 request for information on the future HPID, as well as recommendations provided to both CMS and NCVHS in 2014 in advance of the enforcement discretion announcement.
Since we last made these comments, there have not been new developments in the industry that would create a new need for HPID. We do not see any value in requiring health plans to enumerate or use HPIDs in transactions. Doing so would be counterproductive to the goals of administrative simplification resulting in significant administrative costs and disruptions to the current flow of transactions without an expected return on investment.
Thank you for the opportunity to testify today. I am happy to answer any questions.
MR. COUSSOULE: Thank you, Kelley.
MS. KOCHER: Good morning. My name is Gail Kocher. I am the Director of National Standards for the Blue Cross Blue Shield Association. We are a national federation of 36 independent, community-based, and locally operated Blue Cross and Blue Shield companies that collectively provide healthcare coverage for one in three Americans, across all 50 states, the District of Columbia, and Puerto Rico.
I will try to abbreviate, as well, the written testimony that you all have in your hands. We do thank you for the opportunity to testify today. We strongly support the goals of HIPAA administrative simplification to promote efficiency and reduce cost. We do not believe, however, that implementation of the requirements as specified in the HPID Final Rule will meet these objectives.
We believe that policy changes are warranted. We recommend HHS retract the rule for the following reasons. The industry does not need enumeration requirements for the HPID. The industry does not need the ability to obtain OEIDs. The industry does not need to use HPID in HIPAA adopted standard transactions.
With respect to the specific questions that the committee asked of us, Laurie already did a really nice job, today, of explaining the difference between a health plan identifier and a payer identifier. What we see is that our plans tend to use the NAIC identifiers that were previously mentioned. Some of them also use federal tax IDs. There are some other “proprietary” codes that tend to be used, but they are used widely through clearinghouses and billing services today.
I am going to skip to question four. So, the challenges that we see and Kelley alluded to, again, the enumeration schema. It is predicated that there is one entity and one HPID, but that was not the reality that the plans saw when they tried to enumerate. There was this perceived issue that transaction routing was the problem.
If plans had to modify their current processes and procedures to use an HPID than either a payer ID or the identifier they are using today, it would actually be disruptive, costly, and add no value for any stakeholder. Not just the plans, but it would not be valuable to their providers or to the clearinghouses that are in that continuation stream.
Regardless of what schema a Plan ended up with, it becomes costly for all stakeholders to implement that. The introduction of the enumeration requirement, also including self-funded plans that are not even conducting these standard transactions, created significant industry burden and confusion.
The burden is primarily on traditional payers and third-party administrators that support those groups, but would likely then be passed onto the provider community if HPIDs were subsequently used in standard transactions. As most self-funded plans do not conduct those transactions, they found the HPID Final Rule requirements highly confusing, from whether and how the requirements were applicable to them and to what they would need to do with the HPIDs they obtained.
Finally, HHS should retract the rule. The industry does not need enumeration requirements for the HPID. It does not need the ability to obtain them – the OEIDs, and it does not need to use HPID in the HIPAA adopted standard transactions. While there have been a number of changes in the healthcare system since the issuance of the Final Rule, we are not aware of any that have changed our perspective on the HPID.
What has changed since September of 2012, is our awareness of the complexity and lack of value of the HPID, including little or no opportunity for the positive return on investment that was indicated in the Final Rule. As Plans were developing their enumeration strategies, they became increasingly aware of the complexity associated with enumeration decision making, especially for large organizations with numerous subparts. This was further complicated with confusion surrounding self-funded, fully-insured and the combination of fully insured and self-funded groups. Coupled with the projected cost and lack of ROI, that has significantly changed our perspective on the need, value, or benefits of fully implementing the rule. These concerns were well articulated by this committee in their September 2014 letter to the Secretary.
Lastly, we would wish to reiterate that the widespread confusion and concerns encountered by the industry, especially from many self-funded plans, as a result of the HPID Final Rule. We anticipate that many self-funded plans are still not aware of the current obligation to enumerate with the HPID. HPID has and will continue to impose a significant burden on self-funded groups who are not familiar with HIPAA transactions, which causes a downstream burden on third-party administrators, many of which are Blue Plans.
Given the number of mandates with implementation dates in the next few years and the objectives of the recent executive order, we do encourage CMS to consult the National Committee to develop a strategic road map. It should limit imposition of private expenditures required to comply with Administrative Simplification provision regulations.
We do thank you and appreciate the opportunity to testify. Again, I can answer any questions as needed.
MR. COUSSOULE: Thank you, Gail.
Agenda Item: Government Plans, Daniel Sawyer, DoD
MR. SAWYER: Microphones are my friend. Excuse the voice. It is a neurological condition. I may be reading just a little bit slower.
Thank you for inviting me to present today about the HPID Initiative on behalf of the Military Health System and as a representative of the Defense Health Agency. My name is Danny Sawyer. I am the Chief of Business Information Management for the Defense Health Agency. I will also modify my verbal presentation from the written somewhat, just in consideration of time.
Military Health enterprise is within the United States Department of Defense. It provides healthcare and healthcare services for about 9.5 million beneficiaries, including active duty, retired U.S. military personnel, their dependents and other categories. The MHS, Military Health System, serves beneficiaries as both a direct care provider in our military treatment facilities and also through private sector care as a TRICARE Health Plan. The MHS functions as both – in that provider role and as a health plan role. DoD healthcare is identified in the text of HIPAA, through other means – other designations, such as OCHAMPUS.
And in answering the questions – what health plan identifiers are used today and for what purposes? From this testimony, I will be addressing it from a health plan even though we are a provider and a health plan. TRICARE transactions between DoD business associates. Benefit Eligibility Inquiry/Response conducted between TRICARE Managed Care Support Contractors and Defense Manpower Data Center. In that case, we have business associates who are conducting transactions using what are called Health Care Delivery Program codes. They are codes that are identified which healthcare programs we have within TRICARE. Again, those are self-identified codes that are used between our Managed Care Support Contractors and our Defense Manpower Data Center.
In beneficiary enrollment to TRICARE between our Managed Care Support Contractors and, again, through DEERS, DEERS Online Enrollment System, which is called DOES. Again, Managed Care Support Contractors are using a healthcare delivery program codes that are identified for which programs are within TRICARE.
TRICARE transactions between non-DoD private sector care providers and TRICARE Managed Care Support Contractors.
As it was mentioned earlier, even by WEDI, we use identifiers – payer IDs that are for the managed care support contractors, their fiscal intermediaries. As I understand it, the TRICARE Managed Care Support Contractors have each established two payer IDs for use in HIPAA transactions with non-DoD providers, a code identifying the TRICARE Managed Care Support Contractor’s Fiscal Intermediary sub-contractor, and a code identifying an applicable region of the United States for TRICARE regions. We currently have three TRICARE regions within the United States: North, South, and West. The TRICARE Dental program also has a code identified with it.
The payer identifier approach has been successful and works for TRICARE. We are not experiencing any issues with the payer ID schema that we are using.
Number two, what business needs do we have that are not adequately met with the current scheme in use today?
None. We have not identified any unmet business needs related to our current use of Payer or Plan identifiers.
What benefits do you see the current HPID model established by the HHS regulation provide? Does the model established in the final HPID rule meet the business needs?
We did not find any specific benefits to our – excuse me – we did not find any specific benefits to our business processes as associated with the HPID model established by the 5 September 2012 Final Rule. Based on functional business process workgroup engagement within the Military Health System, we determined that existing identifiers were working and effective, and we did not identify specific challenges for which HPID may provide added benefit. The model established in the HPID Final Rule appeared to take an existing and functioning process and interject a level of uncertain use and value-added for organizations.
What challenges do you see with the current HPID model established by HHS?
The HPID model, as identified by Rule, leads to a level of uncertainty and some industry confusion. We had questions in our internal workgroups about intended use, and to what level of specificity was needed and appropriate. We saw and heard there were similar questions by others in the U.S. healthcare industry. The HPID model, as was prescribed, did not appear to resolve any existing problem and would require substantial work and resources to implement.
After receiving and reviewing the HPID Rule, I began facilitating workgroup meetings within the Defense Health Agency Direct Care and Purchased Care stakeholders to assess functional business process impacts associated with replacing existing payer identifiers with the Health Plan IDs, develop requirements, evaluate systems implications, and request cost estimates. Based on initial assessments, the cost estimate for implementing HPID for the Military Health System enterprise would have been approximately $9.1 million in systems costs alone, which did not include costs for Defense Health Agency to pay TRICARE Managed Care Support Contractors for their work associated with the change or for man-hours associated with program management and workgroups. We would have met compliance, but this appears to be a compliance effort that didn’t provide the MHS, Military Health System, any direct or known benefit.
Last question, number five, what recommendations do you have for going forward regarding health plan identifiers and HPID final rule established by HHS?
We recommend HHS not require implementation of HPID in HIPAA adopted transactions as currently prescribed, and take the time and actions necessary in the healthcare industry to determine if there is any need to address an HPID issue, current or on the horizon, that requires a nationwide solution toward providing administrative simplification.
Thank you. It has been my pleasure to present this information to you today on the topic of HPID, and on behalf of the Military Health System and the Defense Health Agency. We are a medically ready force and ready medical force. Thank you.
MR. COUSSOULE: Thank you. Next, we have, I believe, on the phone, Melissa Moorehead.
Agenda Item: Medicaid, Melissa Moorehead, NMEH, and Debra Dixon, California Medicaid
MS. MOOREHEAD: Thank you very much for the opportunity to address the committee today. Again, my name is Melissa Moorehead. I am a policy analyst and project manager for Michigan Public Health Institute. I have co-chaired a National Medicaid EDI in Healthcare Workgroup, otherwise known as NMEH, on Operating Standards since 2012.
I have some slides submitted that I am not necessarily seeing on my screen. Hopefully, you have access to them. I will be referring to them as I go forward, which also contains the bulk of my testimony.
For decades, NMEH has encouraged states to work together along with CMS and other regulatory entities to ensure that transactions, standards, code sets, and operating rules include Medicaid viewpoints and provide – promote administrative simplification in a cost-effective and efficient manner for states.
This group, my Operating Standards group, had extensive conversation on this issue, ultimately concurring with many other stakeholders and the recommendations of NCVHS in its letter to the Secretary of September 23rd, 2014, that there was no clear business value to implementation of the HPID and that its use in the certification of compliance for health plans was not clearly enough defined. Enforcement discretion was welcomed. The general sense has been that this compliance-driven project could be put aside in order to focus resources on Medicaid IT projects that solve business needs.
As you may know, however, each state and territory has a unique Medicaid environment. In order to check in with the state of the state, I did field a brief survey on adoption and use of HPID, which I am presenting here. I would like to also point out that I tried to tease out some difference between HPID conceptually and the actual implementation system with the health plan and other entity enumeration system.
I got a total of 20 responses, 3 of which did not identify as states. I did not ask why this field was left blank. I do think there are two clear possibilities. The first being that the respondent was a vendor, which many states rely on for various aspects of Medicaid, IT systems, and compliance projects. The other possibility is that there are enormous penalties associated with non-compliance, which can create a reluctance to share negative and potentially damaging information.
My very first question was basic, in terms of did your state Medicaid agency enumerate? There was a 100 percent response rate. 17 different states identified. You can see that there were 16 yes responses, a couple of no’s, and not all states that identified themselves had, in fact, enumerated. Of those yes responses, I did ask whether they had enumerated anywhere past the basic or highest level enumeration. I had 17, 100 percent, response rate of no, they did not enumerate past the highest level.
I also thought it would be interesting to know whether state Medicaid agencies were using HPIDs in transactions, beyond for their own purposes, in order to tease out possible emerging use cases. As you can see, none emerged. I did have yes as an option on this question.
Since there were no yes responses for use of it and no workflows were received, I did ask why you were not using HPIDs, and got a number of specific comments, which you can peruse later.
The common themes are that the HPID, conceptually, were very confusing and seemed to be a lot of work to implement and maintain. Didn’t have any specific purpose in Medicaid. Cost was an issue. Other state and federal mandated changes, particularly at the time, were seen as a higher priority, which placed that project on the back burner. And that, obviously, as we have heard several times, other solutions had been developed, either internally or industry-wide, to address enumeration issues. Trying to change this midstream would create more problems than resolutions.
I tried to cover all of the basic questions proposed in the call for testimony. Some of them were not as successful as others. For example, what benefits does the current HPID model didn’t yield very much response.
Others created quite a good deal of feedback, with the challenges of the HPID model. Here, we see that there are challenges with both the HPID conceptual model and the implementation, with the comments generally supporting the sense that there was little perceived value to implementing an HPID and that the actual implementation in the system had some challenges, as well, chiefly, the inability to access or validate HPIDs in a systematic manner. There is no public access to the HIPAA system to enable people to validate the HPIDs.
I asked what could make the whole system and the concept more useful to Medicaid agencies. While most states agree generally that standardizing elements of Medicaid information systems would have clear benefits for Medicaid providers and Medicaid, as a payor, when coordinating benefits and payments, no strong ideas about how to improve the system emerged, probably due to the lack of perceived benefit.
Finally, I did ask for recommendations. I proposed some responses in a multiple choice that fell within what NCVHS might want to recommend, including continuing the current enforcement discretion, which got the majority of responses. Again, I had a 100 percent response rate on that. I got one response each for proposing a new HPID model through rulemaking and to start enforcing the use of HPIDs as currently described. Again, I have tried to note where the respondents did not identify as states. Neither of those identified as states. Finally, I got a robust amount of other answers, which tended to revolve around things that would require legislative action. I steered away from offering that as an option, but as you can see, two respondents would appreciate the certainty that would come of knowing that the HPID was not going to move forward.
Again, I welcome the opportunity to testify and will stick around to answer any questions. Thank you.
MR. COUSSOULE: Thank you, Melissa. Next, we have Debra Dixon.
MS. DIXON: Good morning. Thank you. My name is Debra Dixon and I am the Chief of the Information Technology Branch in the Office of HIPAA Compliance at the California Department of Health Care Services, known as DHCS.
Like those ahead of me, I will do an abbreviated version in the interest of time.
DHCS is the single state agency responsible for California’s Medicaid program, known as Medi-Cal. We serve about 13 million beneficiaries in a complex and diverse population. The enforcement and adoption of any regulation is of great interest to us. We have an eye out for responsible use of funds and access to our benefits.
Thank you for the opportunity to respond to the questions and provide some information on the HPID regulation.
HPID regulation leaves a number of unanswered questions for us and would be difficult to implement as it currently stands. If the regulations were fully enforced, DHCS has several concerns. Some of those you have already heard today. There are multiple unanswered questions with respect to the proper approach to HPID enumeration for the State Medicaid Agency, particularly for the sub-health plans, which might be areas not distinct from the State Medicaid Agency. The difference between payer and plan is also unclear as it pertains to fiscal intermediaries and other similar service organizations.
Those and other concerns have been raised by industry leaders, such as WEDI, as you have heard today, and the Council for Affordable Quality Healthcare Organization. DHCS generally agrees with their concerns and we do so in this instance as well. We see little benefit to the HPID regulations. We have already resolved all payer identification problems within Medi Cal. Any changes would result in unwarranted expense, as well as the potential for new problems.
Today, we have a process in place that works well for all parties. DHCS refers to ourselves by the Tax Identification Number or TIN, and the TIN is provided to our trading partners through our Companion Guides. Certain DHCS program areas that have specialized adjudication rules, like behavioral health, use identifiers that are specific to that program. DHCS expects our managed care organizations to identify themselves using a composite identifier that includes a three-digit prefix from the agreement with DHCS followed by that plan’s TIN. These payer identifiers effectively describe the origin, the receiver, and the corresponding relationship for all applicable HIPAA transactions.
Given that we have got this system and it is working well for us, if a stakeholder were to transition to the HPID, there would be ripple effects throughout the entire system. All of our immediate trading partners, our Managed Care Plans, Fee For Service Medi-Cal Providers, dental, behavioral health, clearinghouses, et cetera, as well as our entities upstream and downstream, may need to update databases, applications, and processes. We see that as an expense and also a disruption, potentially, of service to our beneficiaries.
Healthcare industry has long ago solved the routing issue, as WEDI has noted. That was necessary in order to move to electronic transactions under HIPAA. Providers and payers and clearinghouses have worked through identifying entities to move the transactions from provider to payer and vice versa as necessitated by adopting electronic transaction standards.
Our current scheme used by DHCS meets all of our known business needs. Trading partners are able to differentiate Medi-Cal from other payers, and we are able to distinguish the submitters as well. Systems on both ends have been tuned around that system. It is working well for us. No business issues or impediments have been identified.
So, analysis has shown us that implementation of the HPID would adversely affect both DHCS and our trading partners since that framework is working so well for us. We have no business needs in this area, so the model established in the final HPID rule, as it currently stands, adds little value.
To conclude, while DHCS is very supportive of national standards, we have solved the identification issue in the way previously described and it is working well for us. We are concerned that the regulations, as proposed, will create a significant burden in our overall system and to our trading partners. We recommend HHS maintain the existing enforcement discretion and work to rescind the regulations pertaining to the establishment and use of a national health plan identifier. Thank you for the opportunity to testify on behalf of DHCS.
MR. COUSSOULE: Debra, thank you very much. Now, we have one last on the phone. Kristy Thornton.
Agenda Item: Business Groups, Kristy Thornton, PBGH
MS. THORNTON: Good morning and thank you so much to the subcommittee for inviting me here, today. My name is Kristy Thornton. I serve as Senior Manager of Transparency at the Pacific Business Group on Health. I would like to express our appreciation again for this committee convening this hearing on the Health Plan Identifier. I would like to present a bit of an alternative viewpoint.
PBGH is a coalition of large health care purchasers, including both private employers and public agencies. Our coalition drives quality and affordability improvements across the U.S. health system. PBGH consists of 75 organizations that collectively spend more than $45 billion each year purchasing health care services for almost 12 million Americans. PBGH members include many large national employers such as Walmart, Boeing, Tesla, Target, Disney, Intel, Bechtel, Chevron, Wells Fargo, and Safeway, as well as public sector employers such as CalPERS and the City and County of San Francisco.
My comments today will focus on the key features of a Health Plan Identifier to drive administrative simplification, and meet purchaser business needs in transparency and value-based payment initiatives.
First, I will discuss the Health Plan Identifier, itself.
PBGH does not take a position on the specific enumeration typology of the Health Plan Identifier, but instead advocates for an approach that meets the following five criteria, aligned with purchaser business needs. The Health Plan Identifier should be national, standard with a single source of truth, unique, embedded with information on the major payer, the subsidiary, and type of plan, and consistently enforced in all transactions involving an entity performing a health plan function across the public and private sectors.
The committee should identify specific enumeration typologies for the Health Plan Identifier that meet these criteria, as the existing array of Employer Identification Numbers, Tax Identification Numbers, National Association of Insurance Commissioners Identification numbers, health care clearinghouse and health plan assigned proprietary numbers do not meet these criteria. We recommend reviewing enumeration typologies from the National Association of Health Data Organizations and others in this field of public health.
Next, I would like to discuss how a Health Plan Identifier meeting, the aforementioned criteria will advance administrative simplification and reduce waste.
Quality and affordability improvements across the U.S. healthcare system require a clear, standard, and reliably automated system of healthcare transactions as a baseline condition. Progress has been made, but as we have discussed, the Health Plan Identifier lags behind, failing to properly represent the true complexity of administrative and payment processing functions.
It is critical to recognize, as others have, that the term “health plan” is not sufficiently specific to have a clear meaning. There are many different entities that provide, arrange, reimburse, contract, or pay for the cost of health services, or administer these services on behalf of a payer. These entities can include health insurance companies, self insured employers, government payers, third party administrators, health maintenance organizations, pharmacy benefit managers, dental benefits administrators, and others. Each of these different entities create a constellation of provider networks, benefits features, prior authorizations, fee schedules, and contract requirements that comprise a patient specific benefit plan.
Comments as to the cost of software modification to implement the Health Plan Identifier fail to recognize the cost of the status quo. The lack of a Health Plan Identifier adds a layer of manual work into the payment transactions that is very costly. Each day, providers and payment entities engage in unnecessary administrative activities to reconcile these issues. The Institute of Medicine has estimated that this type of excess administrative cost is worth a staggering $190 billion per year. We, as purchasers, no longer find it justifiable to pay for this waste.
Now, I would also next like to discuss how the Health Plan Identifier will meet purchaser business needs in transparency and value based payment initiatives.
PBGH members believe that transparency and value based payments are the keys to making improvements in the quality and affordability of health care. One of the few robust sources of objective, reliable data for purchaser transparency and value based payment initiatives are state based all payer claims databases, and private multi-sector multi payer claims databases. However, these databases need the ability to triangulate among different third party payment intermediaries back to a major health plan and member to create a complete record of care for analyses. The All Payer Claims Database Council Common Data Layout has included the Health Plan Identifier since 2011 for this very purpose, but it currently lays empty due to the lack of enforcement.
Proper health plan identity management is essential to claims based activities to support network and benefit design, provider improvement, alternative payment models, and consumer engagement. Consider, finally, these last three critical examples. Total cost of care – assessing the total cost of care on a per member per year basis requires a standard method for linking patients across all settings of care and across all payment intermediaries. Value based insurance design – aligning patient’s out of pocket cost, such as copayments and deductibles, with the value of healthcare services requires a more granular way of identifying sophisticated health benefit packages, across a wide variety of contracts and benefits administrators in a standardized manner.
Finally, transparency – health plan enrollees, especially those in high deductible health plans and exchanges, need useful price calculator tools that can include plan and provider specific total costs and expected out of pocket costs for common procedures and conditions. This, again, made possible by a unique, standard health plan enumeration system.
Simply stated, identity management is core to accountable care.
In closing, many of our purchasers operate in a business environment that has been “data-enabled” for some time, and they wonder why health care does not operate in the same way. At this point in the evolution of technology, the key barrier to progress in health care information is now the agreement of stakeholders and the commitment. We urge this committee to help modernize health care business practices, and enforce the use of a unique, national, standardized Health Plan Identifier with embedded information on the major payer, the subsidiary, and type of plan.
Thank you again for the opportunity to provide this input. I am happy to answer any questions the committee may have.
MR. COUSSOULE: Thank you, Kristy, and all of the panelists. We appreciate your time and insight here. Do we have questions from the committee members?
MS. KLOSS: Thank you. Again, thanks to everyone for their very clear testimony. Kristie, do we have your comments in writing?
MS. THORNTON: Yes. My apologies. I did submit those yesterday.
MS. KLOSS: Could you just, for my purposes in thinking this through, repeat the set of criteria that you gave us? I was able to jot I think three of the five. I would like to hear those one more time.
MS. THORNTON: Sure. Those were that the health plan identifier is, first, national, standard with a single source of proof, unique – again, unique on a national level – embedded with information on the major – the payer, the subsidiary, and the type of plan, and then the fifth one was, you know, consistently enforced in all transactions.
MS. KLOSS: I had a question I think for all of the panelists, setting the discussion of the proposed health plan ID enumeration – setting that topic aside, and focusing, instead, on the current state using the variety of ways to assign payer IDs, how is that working, in terms of administrative simplification, validation for fraud and abuse, transparency, some of the purposes that Kristie had enumerated?
I think it is very clear what has happened. There wasn’t a standard early enough early on in our chronology. Everyone had to work something out. What they worked out is working for their own business purposes. How is it working from sort of a broader health system standpoint, to use really a patchwork of approaches?
MS. KOCHER: I think it goes back to the difference between identifying a health plan and identifying a payer. The transactions identify payers. That is the business that is going back and forth in claims and claims payment. Health plan identification, when that occurs today, it is generally only in data reporting. However, that enumeration is done is based on who is being reported to. Does that kind of get – I mean, these numbers don’t change. It is not like the health plans are changing. The payers aren’t changing on a day to day basis.
Providers know what identifier they need to use based on the destination payer they are working with for that particular member. In some cases, the clearinghouses actually handle those conversions for them. The provider just knows it is Blue Cross Blue Shield of X or United whatever. Their clearinghouse figures out what the numbers are to send. Again, those are payers. Those aren’t in the transactions. We are not identifying them as a health plan. It is the destination payer or the payer that is providing eligibility, et cetera.
MS. GOSS: Can I clarify what you are asking? Are you really wondering about what happens in like utilization review and appeals? Are you focused on the operations of the health plans, themselves? Is it also of the providers? I am trying to figure out.
MS. KLOSS: I think I am trying to look at this more on a system level. We have worked out solutions that get – that allow transactions to work. It is a hodgepodge. How do we look at that from a system standpoint in light of the criteria that Kristy has laid out, transparency, some of the uses that really reflect healthcare reform. I know we have said that no one can identify any uses. The use case isn’t there. But we heard some use cases that are pretty compelling. Not having any sort of uniform health plan ID that is a national standard, will this – is this impairing those system improvement uses or accountability and transparency uses?
MS. GOSS: Before I go, does Denise have any question, since we can’t see your tent card?
MS. LOVE: Yes. Thank you, Alix. I really enjoyed the presentation. I do have a question and maybe one comment. This one is to Kelley. In her testimony, she brought up concern about the current health plan ID. One of them was a privacy concern. Kelley, could you enumerate that concern for me? I am trying to understand the privacy aspect.
MS. TUREK: Sure. The concern is if you were to use HPID in transactions in addition to a payer ID, a payer ID is working fine to route transactions right now. If you were to add this additional identifier and we have talked about sort of the complexity of not having a one-to-one match, that is one additional element that has to be handled through routing. If transactions are misrouted, including a claim or including anything with PII in it, that would be the privacy concern there, if it ends up at the wrong entity.
MS. LOVE: Thank you. That helps. Just one comment. I wanted to echo Linda’s comment that it is a patchwork. When you think about nationally or you think of regional measurements and reporting aspects, my understanding is we are spending a fortune on attribution and secondary assignment of payer. That is happening more broadly as we implement and think about MACRA alternative payment options and health services research. I wanted to echo Linda’s comment.
MS. GOSS: Thank you for that question, Denise, because it was actually one of my questions. I appreciate Kelley’s clarification there.
I want to go back to Kristie for a moment. I appreciate the robust testimony. I look forward to reviewing the electronic version when we receive it. Thank you, Rebecca. I found it kind of hard to track with everything and got lost around your comment about public health. Could you elaborate a little bit more on the impact that you are seeing from an employer perspective on public health with this identifier topic?
MS. THORNTON: The comment around public health was with regard to enumeration. So, I was pointing to enumeration typologies that exist in the public health field and also with NADO, that I believe could meet these criteria. I was trying to provide an alternative to the sort of current array of identifiers that don’t. I was trying to suggest some enumeration typology work that had been done that would meet the criteria that I laid out.
MS. GOSS: That kind of went along with Denise’s comment on the health services research. Or am I inappropriately linking these, Linda – Denise?
MS. THORNTON: I don’t think it is – as I said, not just about health services research. I think research is one piece, but there is also, as I mentioned, transparency and alternative payment model work that particularly, our private purchasers are engaged in that is challenged by this.
MS. GOSS: I do have a secondary question. Do we still have time? From a – we have heard a perspective that there is a need, I believe, is how I interpreted Kristie’s commentary, and that there is a lot of attribution and additional work challenges. I would be curious from a – from Gail and Kelley’s perspective, from your side of the fence, are you not having that issue, cost and amount of time and energy around attribution and connecting the dots? I am hearing coordination of benefit challenges.
MS. TUREK: So, I think Gail touched on this earlier and what we heard from our members as we were working on this is, you know, there is sort of an infrastructure that is existing. There is sort of an infrastructure that has been built around payer identifiers. Once that is sort of set up, it is set up. A clearinghouse working with payer providers, they kind of know how to map those people, once they have the initial setup there. I don’t think that there is like an ongoing confusion because this person has a different formatted identifier from this person. Once that infrastructure is there, it works. Is that consistent with what you heard, Gail?
MS. KOCHER: Yes. We are not hearing from the plans in their role as payers. I want to emphasize everything we are talking about is really payer. It is not the health plan. That attribution is back to the payer, who is handling those processes. I am not hearing from the plans that the current methods and methodologies and identifications are not working as they attribute members back to the applicable payer.
MS. GOSS: And my sense is that between your communities, there is a substantial amount of third-party administration going on, which would tie back to Kristie’s aspect. I am feeling like there is something I am not getting the disconnect. Hopefully, we will figure it out.
MS. LOVE: Alix, do you think the disconnect could be the – I am just putting it out there. This is Denise, again – is the payer to payer, payer to provider seems to be working for their purposes, which is good. Where we are maybe having the disconnect is when it is cross-payer analysis. I am just putting that –
MS. GOSS: Maybe Kristy can add some commentary on that.
MS. THORNTON: Yes, I think the issue is when it is across payers. Like I mentioned, if we take some of the examples that I provided, so, the total cost of care measurement would be across payers, as well as imagine that a national employer wanted to roll out a value-based insurance design across several payers. So, and then, again, in the transparency area, that is, again, across payers.
MS. TUREK: I would be happy to sort of take this back, chat a little bit more with our members and our AHIP experts in the line of sort of value-based care and get back to you if that would be helpful, follow up in the next week or two.
MS. GOSS: That would be lovely. Thank you.
MS. KOCHER: We can do the same.
MR. COUSSOULE: Any other questions?
MS. MOOREHEAD: Hi. This is Melissa Moorehead, again, from NMEH. Just to chime in here, I am reminded that the bulk of our conversation in our NMEH support group when we were working on implementation kind of revolved around the difference in definition between health plan and payer. I am glad to hear that we are trying to be a little bit more distinct there.
While there does seem to be some really intriguing and valuable use cases to be gained from a health plan identifier, I don’t know – one of the issues that we had is that there isn’t a granular enough definition of health plan, itself, to understand how to enumerate, particularly in the Medicaid arena, where you might have a state Medicaid agency that contracts with private insurers on a plan level to offer managed care benefits. Again, there is some background conceptual work, I think, to do there, in order to make that really come to life. It does, in my mind, beg the question as well, whether the national health plan enumeration system is the necessary factor. Is that the necessary requirement to go ahead and achieve some of those use cases or are there other ways to work with existing identifiers and relationships?
MR. COUSSOULE: Thank you for that input. We are going to wrap up this panel. We are going to call an audible, a little bit. We are going to take a short break now. We need a few minutes to set up for the next panel. Let’s take a ten-minute break now and try to come back at ten of 11. Thank you.
Agenda Item: Session B — Providers Will Offer Their Perspectives about Use, Need, and Purpose of Plan Identifiers and Impact of the Current HPID Rule
MR. COUSSOULE: We are ready to get rolling in Session B. We will get a provider perspective on this. We will start with Robert.
Agenda Item: Private Sector Providers, Represented by Robert Tennant, MGMA
MR. TENNANT: Thank you so much. It is a pleasure to be here with you this morning. I am privileged to provide testimony on behalf of four organizations. I am Rob Tennant, director of HIT policy for the Medical Group Management Association. I am representing the ADA, the AHA, and AMA. I want to recognize Jean Narcisi from the ADA, George Arges from AHA, and Heather McComas from the AMA in development of the testimony.
You have heard from Madhu and others about the background of this. I think the theory behind the HPID was wonderful, the idea of increasing transparency, allowing claims and other transactions to route effectively and quickly. But I think we have seen that subsequent to HIPAA we have come up with solutions. Certainly, I know you will hear from Debbie, the clearinghouses, the health plans, the providers have come up with solutions to basically eliminate the problem of misrouting.
Clearly, the final rule provided an enormous amount of flexibility for health plans. Any time you have flexibility within a standard, you really do not have a standard. I think one thing that we found is there is so much flexibility that we are not able to get to the level of granularity that would actually produce the transparency that some envisioned.
You heard certainly from the payers earlier that you could have a range in terms of the number of enumerations from a single up to 50 or even more HPIDs. That just adds more complications to the process.
When you look at the use of HPID and transactions, we would argue that frankly it is mostly cost with very few offsetting benefits. Certainly, we are going to be replacing one number with another. Whether that is going to bring any improvements is of course very questionable, but it is certainly going to require changes in provider software. That is both the billing side, the practice management side. That is always a challenge and always expensive. We have been through that with 4010, with the change to 5010 and most recently with ICD-10. To go back to providers and say we do not really see a value in this new number; however, it will be expensive to make the change. It is a very challenging proposition for providers.
As you heard from Kelley, there is a potential of misrouting because the numbers are changing. There could be privacy issues and certainly we are concerned about the implications about payment interruptions.
Again, the theory of transparency is wonderful. But we are not hearing from the agency that they are going to provide a look-up database. It is not like a provider can look up this number and get the full information about the health plan.
Use of the HPID in transaction we would argue will break our industry’s currently mostly well-functioning routing system.
There has been some talk about the use of this number in the ACA requirement for health plan certification. Certainly, the certification proposed rule discussed this. We obviously are very supportive of increased health plan accountability in implementation and use of both the EDI standard transactions and the supporting operating rules.
We feel that if CMS deems that the only way they can move ahead with health plan certification is by issuing the HPID. Then we feel it is justified. Just do not require that number in the transactions.
We also need a lot of clarification from the agency regarding the use for non-transactional purposes.
We also encourage CMS to look at some alternative methods for health plan compliance. If the certification process and compliance enforcement in general is held up simply because there is not an HPID, we say do not worry about it. Just go out and do random audits of health plans. Certainly, we would offer up the use of the recovery audit contractors that currently go after providers. We would certainly volunteer their services to go after health plans.
In terms of our overall position, again, we are strongly aligned with the other stakeholders certainly on the plan side by saying we do not need this number in the transactions. By requiring it, we would be forcing providers to incur potentially very expensive upgrade costs for software. We could see a system that is disrupted for, again, very little if any benefit at all.
When you are looking at the revenue cycle management in a practice or a hospital, the low level of granularity that is currently assigned through HPID is really going to add little to no value to the process. Again, down to the fee schedule level, which some of us ask for way back in the day, that would provide you a lot more transparency, but that is not what we are looking at with the current law.
Again, we are urging the NCVHS to recommend to the secretary to eliminate the use of HPID in electronic transactions. We would support the use for compliance-related activities.
We also strongly support really trying to go after health plan compliance. We have heard that there are some challenges with supporting some of the transactions currently. There have been no enforcement fines levied against any health plan since the transactions went live. We think a shot across the bow much like for those in the privacy world when Signet Health, a local health plan, health clinic here in the local DC area, was issued a privacy fine. The fact that that fine forced a lot of folks to revisit their privacy activity. I think at least one fine might be a good start.
But I did want to take the opportunity to the provider community to say we appreciate you holding this hearing. If you are concerned about how to fill the agenda for future meetings, we have some suggestions. We feel that the Social Security Number Removal Initiative is still an important topic that must be discussed.
New, coming out of MACRA, of course the patient relationship codes and how they will impact claims I think is a good topic to discuss.
Appropriate use criteria, which again, comes out of MACRA.
We sort of passed by the X12 transactions, but as we saw from the CAQH index, usage of some of the transactions is not nearly as high as it should be. Revisiting to see what can be done to increase the use of these transactions.
We are obviously concerned about ePayments and the prevailing use of virtual credit cards and some providers being charged excessive fees to engage with EFT.
I would be remiss if I did not mention our friend the electronic attachments. It has only been 20 years. There is no great rush for it, but certainly it is one area because it impacts claims, but it also impacts prior authorization. It is one of those rare transactions that if implemented can save money on both a provider and the health plan side. And of course, patient ID cards and patient matching issues. Very important. Credentialing issues and reporting of quality data, very important in this value-based care environment, and software certification, which some independent groups have moved forward with, but we need a little more effort there.
I have put up here – we are available for questions. I believe some of my colleagues are on the phone. I look forward to any questions you might have. Thanks so much.
MR. COUSSOULE: Thank you. Next up is Katherine.
Agenda Item: Government, Katherine Knapp, Veterans Administration
MS. KNAPP: Good morning. I am Katie Knapp and I will be presenting comments regarding the Department of Veterans Affairs as a health care provider.
Given the lack of a tangible benefit to the industry and the increase in cost and risk, the recommendation is that the HPID regulation, including enumeration and transaction usage, should be rescinded.
As the largest integrated health care system in the US, VA sent and received over 80 million health care transactions in 2016, and is committed to implementing HIPAA mandated electronic transactions to ensure the benefits of administrative simplification are met across the health care industry.
The questions posed by NCVHS are addressed in the two following categories. First, challenges faced for development and implementation of HPID, and future HPID usage and recommendation.
Challenges faced for development and implementation of HPID. In one of the first industry meetings regarding HPID, a question was asked to a representative from a well-known company if they were a health care plan or not. The representative’s response was “it depends.” This answer highlights the confusion surrounding the HPID enumeration structure outlined in the final rule. HPID enumeration is left to the discretion of the enumerating entity.
While flexibility is appreciated, in this instance a consistent and detailed rule may have been more effective. This flexibility is of particular concern to VA if the HPID will be utilized in place of payer IDs in electronic transactions. As a national health care system, VA submits transactions to over 1,100 payers. Transactions to payers flow through various touch points, clearinghouses, and other intermediaries, which is an intricate and multi-step process.
Given the various enumeration options for the HPID and the current use of payer IDs, it is inevitable that for most payers, the HPID will not relate to the current payer ID on a one-to-one basis.
Providers need to rely on clear, open, and consistent communication with payers and clearinghouses to ensure every touch point has the correct HPID mapped to patient plans. This severely limits the ability to perform any automatic payer mapping, adding complexity, introducing potential risk and manual processes to ensure transactions are correctly handed off to the proper entities instead of providing administration simplification.
Additionally, the lack of a reference database that would be used to identify and confirm HPID further complicates this issue. VA utilizes the National Plan and Provider Enumeration System (NPPES), the NPI data repository frequently and sees the lack of something similar a major void.
The current process of routing transactions to and receiving transactions from payers utilizing payer IDs has been working well with trading partners. It is our expectation that the introduction of HPID in electronic transactions will negatively impact this process and, ultimately, influence the resulting revenue stream used to benefit our nation’s veterans.
Future HPID usage and recommendation. VA has already invested taxpayer dollars developing capability to prepare for requirements as outlined in the CMS Final Rule. There is considerable reluctant to invest further in something that has no discernable value added.
Twenty years ago, when transaction processing was in its infancy without clearly defined payer IDs, HPID was a viable concept. But circumstances have overcome the need and usefulness. As mentioned at the beginning of these comments, the recommendation is that the HPID regulation should be rescinded and no further regulation should be published. The proposed rule does not meet current business needed, and will complicate streamlined business processes and increase cost.
I hope these remarks have been helpful, and I thank you for the opportunity to submit these comments.
MR. COUSSOULE: Thank you very much. Questions from the committee members?
MR. LANDEN: A question for Rob and the providers. You mentioned health plan auditing. How do you envision that an HPID would work in that scenario? What is the value of the HPID would bring to the certification to health plans or the auditing that you mentioned? And relate that to transactions if you would please.
MR. TENNANT: That is a good question, Rich. I think one of the arguments is how can you certify a health plan until you know what is a health plan. I think that has been a challenge. I will not speak for CMS, but it appears to be a challenge for why they have not been able to move ahead.
From our perspective, you do not really need a number. You just need to do an audit. You pick an entity that is perceived to be at least to be a payer of medical services. And maybe you start with the ones that have had complaints launched against them already. You go out and say, let’s take a look at what you are doing in terms of compliance with the EDI standards and the operating rules. It is at that point where they can say no. We are not a health so we are not – we do not need to be compliant. That is fine if they can establish that.
We argue that if that is the only way that you can audit a health plan then move ahead with the HPID. But we do not really believe you need that in order to achieve compliance. It is really just sending a signal to the health plan community that the enforcement actions are coming. I think that alone will encourage health plans to adopt the standards and support the operating rules. Again, you do not need the HPID in the transactions. I think that has been established and I am sure Deb is going to talk about it. The clearinghouse. Right now, we are not seeing a lot of problems when it comes to mismatching with claims. It is a good question.
MS. GOSS: Thank you. I am curious as providers, Kati and Rob, how you view the commentary from Pacific Business Group on Health related to the value-based purchasing and payment methodologies and alternate payment models. Let’s not focus on – let’s use it in the transaction. Let’s think about some of the other use cases. I know we will receive some follow up from some of the payer communities. Don’t feel like this is your one shot. You can certainly think further about it and come back and provide us with clarifying text if you would like, but I would like your initial reaction to the value proposition of there is some benefit to having a health plan identifier especially from the larger system perspective.
MS. KNAPP: I do not have a ton to say right now just because it is out of scope of the transactions, which is what my office focuses on. I do appreciate –- we are so focused on how it can help in transactions. To hear something different almost – we were not expecting it today at all. Most everyone is just saying not to be used.
I would like to take some time and really think about that a little bit and get back to you.
MR. ARGES: This is George Arges from American Hospital Association. I would like to touch a little bit on what Kristy Thornton may have said regarding payer typology. It is a little bit different than the Health Plan ID. I think the Health Plan ID – pretty clear about how we view this.
In terms of having a payer typology might be beneficial. Number one, hospitals have to report to many state health agencies about the services that were provided within their facilities. And the payer typology code is something that they try and abstract. But it would be nice to have the payer self-identify using one of these payer typology codes to be embedded in their name either in the enrollment card that is issued to the subscriber just so that there is some standardization that can be derived from that typology.
And the typology is just a better more refined category than just simply saying Medicare. You could say Medicare Traditional, Medicare Advantage Plan or if there are all inclusive payment models to indicate that this is a Medicare all-inclusive model.
From that perspective, I think not only is it good for health researchers, but it is also good in the sense of being able to get a market assessment of what is actually taking place geographically within our nation’s health care system.
From that perspective, it is a little bit different than the Health Plan ID, but it is something to consider down the road.
MR. TENNANT: Just to add to that and I agree with George, but I do not think George is saying use the number in the transactions, but there are other use cases for a number.
But I will say when it comes to alternative payment models whether it is ACOs, patient-centered medical homes, bundled payments, they are occurring now. We are managing now with the identifiers we are using. By adding a new layer of complexity, again, you would have to get down to the level of the fee schedule because when a health plan contracts with an ACO, it is not at a general level. They get into the specifics of the contract. That is what you would need to be transparent. I do not think we are ever going to get to that level.
I do not think you need to link the HPID with the movement towards value-based care and alternative payment models. That is happening regardless of an HPID.
MS. GOSS: I think that is a really interesting point and I would do a shout out for anybody who is in that world and if they have a commentary on the HPID because it was – like you said, Kati, I was surprised by that commentary. I just want to make sure we do not gloss over it too fast. What I am hearing is great consistency. We do not need it in the transactions, but there is a larger dynamic going on as we look forward for the next 20 years. Currently where we are at is not what we need when we designed HPID 20 years ago.
MR. COUSSOULE: It raises a question. I am not sure it is applicable for just the panelists here, but the previous ones. And probably what is to come is – I do not think many of those were even envisioned, those challenges when this was first started. I would have a question. Are we trying to use this to solve a different problem because it may be a piece of a solution to a different problem, or potentially? I guess it is not so much a question, but a comment. If in fact there is a different problem to be solved other than what the HPID was originally envisioned for, is it appropriate? Is it helpful in that regard or not?
MR. TENNANT: I would say that there is an example of it might be helpful to bring in folks like NAACOS, the National Association of ACOs. Is there a current problem with attribution and would an individual identifiable number help with that? I do not know the answer. But better to get it from those folks that are dealing with this on a daily basis.
MS. DARST: Can I make a comment? I hear all of this and I have listened to it for many years from the provider sector. I think one of the problems that I see by putting a number against a health plan is that health plan changes. It is not going to be stagnant. Every time they come from a $25 copay to a $35 copay, for example, would they need to go get another number? But it is the same health plan. What does the number tell you as a provider? If you are receiving this, does the number tell you anything or are you better off with the attributes of the health plan that the patient has for coverage?
I struggle with that because I think our eligibility transaction and that with my X12 hat on – the eligibility transaction has a capable of providing a lot of the detail that the providers are looking for at the time of eligibility that should be accurate for that moment in time versus I have a number that says this is the health plan. Last year, that one was a $25 deductible and this year it is a $35 deductible or it was $1000 copay and this year it is $1500 copay. I did not see that if there is a change in the attributes of the health plan you now need to go get another number. I do not see that a number solves the problems of letting providers know what the plan has for attributes. Does that make sense?
MR. TENNANT: And it is not just if it is a change in the copay, but perhaps it is every year when you renegotiate the contract. And a large group practice may have hundreds of contracts on a rolling basis. It would make it almost impossible to submit claims.
MR. COUSSOULE: Any other questions? Denise, any questions on the phone?
MS. LOVE: No. I appreciate you asking and I am listening. I like the discussion. No questions.
MR. COUSSOULE: We will wrap up this. Thank you all for your participation and great input and start setting ourselves up for our next session.
Agenda Item: Part 2: States, Clearinghouses, Vendors, and Standards Development Organizations
Agenda Item: Session C – Other Organizations Will Give Their Perspectives on Use, Need, and Purpose of Plan Identifiers, and Impact of the Current HPID Rule
Agenda Item: Clearinghouses, Debbie Meisner, ChangeforHealth, Sherry Wilson, Jopari Solutions for the CooprativeExchange (by phone)
MS. MEISSNER: Thank you. I would like to thank the committee for asking me to provide testimony today. My name is Debbie Meisner. I am with Change Healthcare, formerly Emdeon. I will not go through the whole list.
As you may know, Emdeon did rebrand last year to Change Healthcare and then subsequently on March 2, we merged with McKesson Technology Solutions to form a new company. And the new company’s name is Change Healthcare.
This slide is really just to give you an idea of the breadth of the experience that Change Healthcare has a company. The new company is well positioned to be a leader in the health care industry, connecting providers and payers for 12 billion health care transactions a year. We connect over 5,500 hospitals, 117,000 dentists, 800,000 physicians, and 600 labs, to over 2,100 payers, representing over $2 trillion in health care claims.
Today, I am here to provide some insight about the health plan identifier from a clearinghouse perspective. When we look back to 1983 WEDI Report, there was a need for a national payer identifier. As the industry worked through the issues of losing transactions, mis-routing and not knowing how to get from point A to point B. However, after 24 years, the industry has worked collaboratively the clearinghouses together along with providers and payers to fix the problem. Today, billions of transactions are exchanged with minimal disruption to the flow in those transactions.
I believe that much of the resistance to move forward with the current HPID regulation has to do with the way we, as an industry, perceive health plan versus payer. You have heard that mentioned over and over today. Although we tend to use these terms interchangeably, their functionality is very different.
I am not going to go in depth on these because you have heard this certainly over and over today, but this is the actual regulation. I highlighted to me the functionality of what the health plan does in the regulation. In this HIPAA transaction code set regulation, the term health plan is defined as the entity that provides or pays for the cost of the medical insurance. It does not say that they actually administer it.
In the X12 transactions in 5010 just as an example, the claim defines the payer as a third-party entity that pays the claims or administers the insurance product or the benefit so they are the payers, the administrators where the health plan is actually the one who funds the benefits themselves.
Because Loraine and you all asked for pictures, I complied with a picture. I just wanted to go over a few examples of the relationship between health plans and payers where it can be very straightforward or it can be very complex. To help better understand this, let’s take a look at a few of the use cases. There are many. But to give you an idea, I will just cover a few.
The administrative transactions mandated under HIPAA are exchanged between health care providers and the administrators of the benefit plans. Let’s take a look at a large health plan. It is self-funded and in this case, there are multiple administrators of the health benefits. For example, you might have a commercial insurance company for the medical benefits as well as a dental group insurance company to take care of your dental benefits, a vision health plan to take care of your vision benefits and a PBM to take care of your pharmacy.
As a large self-funded health plan, you never see those transactions. You outsource that to a large health insurance company or dental provider, whoever you are using for your health benefits. The health plan never sees a transaction.
The transactions are routed to the payer or the administrator, using a legacy payer ID and each administrator would have their own payer identifier.
Another example would be a large commercial payer. The large commercial payer identified by the legacy ID is the administrator for many large self-funded plans, partially-funded plans and sometimes wholly insured plans. As in the previous diagram, the health plan itself never sees the transactions. The transactions are rooted to the payer, the administrator, using that legacy payer ID.
There are times when a payer so the administrator of the transactions may request or use multiple payer identifiers to identify themselves. There are reasons for this and in this case, the payer acts as the administrator for multiple product lines of business. Perhaps they are doing Medicare, commercial business, other different types of workers’ compensation. They may have very different business lines where they want that claim to get routed differently once it hits their system. I know we have some payers that ask for a payer ID for their encounters versus their claims because they also do not want to hit those into the adjudication system.
And then there is the situation where the payers acquire another payer. For a time, they may have two payer IDs, one for the mother company, one for the one that they acquired. And there may be a business need to continue to do that until they can consolidate systems and make sure that they can be recognized as one payer.
As a clearinghouse, we typically work with those payers to transition either over to a single payer ID and sunset the old payer ID, working with the providers and software vendors to educate them. There are situations when a payer will have a multiple payer ID.
I want to hit a little bit on the questions that you asked. What health plan identifiers are used today and for what purposes? There is the visual request by the way. In today’s environment, health plan identifiers are not used to identify a payer. In some transactions, you will find the group plan number or the group number is exchanged and is associated not with the payer, but is associated with the patient or the subscriber to the insurance.
The payer ID is used for many administrative functions and is commonly based off of the National Association of Insurance Commissioners or the NAIC number, not to be confused with the NEIC number of the large commercial clearinghouse from years ago. They adopted the NAIC number as their proprietary number assigned by the payer or the receiving entity. It is typically a five-bit number. You are talking about systems that have been set up for five-bit proprietary NAIC number or proprietary assigned number and changing it into a 10-bit number, which could cause some real disruption to the providers.
Some examples of the use for the payer ID just to give you an idea of why as clearinghouses this was a huge effort for us is that today a payer ID is used to establish the vast network of the data exchange that goes on throughout the whole industry.
We used the payer ID to do payer-specific requirements for such things as the appropriate formatting of the patient identifier. Throughout our code, throughout our editing validation systems, there might be a code in there that says, for example, if this is going to Medicare, the HICN number has to be nine numerics followed by one alpha. If it is not then we reject it saying no, this does not belong to this payer or you have the wrong number. Fix it.
Payer look up is a big part of the software that is residing at the provider site. They do not know and I will Aetna because I happen to know that number. They do not know Aetna is 60054. They know it as Aetna. There are look up tables that will give any aliases for a payer and they can put that payer name in there and it will pop up and say here is the number or it will populate itself.
In the case of OCR scanning, there is no payer ID per se on the paper claims. The payer name that gets put into the payer box is used to look up the payer ID. These payer look-up tables are throughout and they use aliases for the different ways that you can spell different insurance companies.
Clearinghouses have what they call payer lists. All of us publish them on our website with a large payer list so you can go out and say can I send this payer to change health care. Can I send this payer to ABC clearinghouse? All of those payer lists are out there to help the providers, the software vendors know what the payer IDs are for each of the clearinghouses.
Provider enrollment is very important. We have a verification throughout our systems and software vendors to say is this provider enrolled to exchange electronic transactions with this payer. That is another important part.
We also use that payer ID to determine what format the payer wants, how to aggregate the claims, what schedule to send the claims. Some payers want it hourly, some want it daily. This is all based on scripts that are out there. If the payer ID is ABCDEF, they send it every four hours. We send it at the end of the day.
In some instances, re-pricers are set up as payers so that the claims will go to the PPO provider network to get re-priced before it goes to the payer for benefit determination. We also use that payer ID to parse provider reports and distribute them as well as billing of transactions. Lots of information.
You also asked what business needs do you have that are not adequately met with the current scheme in use today. None from a clearinghouse purpose. Everything is working fine.
What benefits do you see the current HPID model established by HHS regulation as currently established? We see no benefit, but we do see a lot of cost.
You asked about the challenges. Today a health identifier is not used for exchanging administrative transactions. Instead we use the payer ID, as I have mentioned. We use it for many different functions, as I just went over.
Given the complex environment and the proliferation of partner-specific non-standard legacy payer IDs, it is clear that if any given stakeholder were to move to the HPID in the place of payer IDs, it would certainly have a ripple effect throughout the system.
The biggest concern with us in replacing a payer ID stems from the misrouting of these transactions. If you looked at the huge network for routing transactions, it is much like our national interstate highway today.
The network can be simple from a provider to a payer or the network can involve one clearinghouse from provider to clearinghouse to payer. Or it can have multiple clearinghouses in the hop.
When you have a clear direction, it is pretty simple once you establish the route, as other people have said. We have established that route. We have them into our software vendor’s products. We have them in our clearinghouse. We know how to get from Point A to Point B.
The wrong number would certainly cause significant misrouting. This is really just a simple picture that shows how we connect today and that routing number is the payer ID. There will be provider clearinghouses that go into a national clearinghouse that go to the payer. There are provider clearinghouses that go to payer clearinghouses that then go to the payer. It is very – you can see like a spider web. And the next picture really gives you – the more providers and payers you add to that network, the more complex that network becomes.
If you go back and you look at the analogy for the national highway, the payer ID is that route number that we use to effectively exchange health care transactions. If you go back to the highway analogy and all of a sudden the route numbers changed across this vast country that we have, think of what would be impacted. All your GPS systems would break. Your navigation systems in your cars would need to be updated. All your written instructions – you might as well rip those up and throw them away. And the directions on the websites would all have to be updated and changed to account for the new numbers. The same is true in our EDI network if the payer ID were to change. PHI is at risk once you start having misrouting. Cash flows are impacted and we start losing transactions.
In closing, the cost, risk, and overall impact of our industry stakeholders is significant when proposing changes to the established payer ID and would result in no additional functionality or return on investment. If the regulation is not revised to remove the requirement for use in transactions, the cost and impact to the industry will be significant.
We strongly recommend that a full cost benefit analysis be completed as an aspect of any kind of justification. The estimated cost to change health care alone, just change health care, was over $11 million. There would be no return on that investment for us at all.
We support the enumeration of health plans at the appropriate level deemed necessary if and when there is a business case to support this. However, we strongly recommend removing the use of the HPID/OEID within the health care standard transactions.
I want to take one step back for a second and talk about the certification. Remember the diagrams that I showed. Certifying Change Healthcare’s health and welfare fund or whatever we call it these days – when we see no transactions, brings no value, it is the payer level where certification needs to happen to make sure that the payers, the people exchanging the transactions are being compliant. All we could do as a health plan and we did go and get as Change Healthcare, an OEID or HPID. I am not sure which one we did. Probably HPID. The only thing we could do is each year we would have to go to whoever is administering our health plans and ask them are you HIPAA compliant and then take their word for it. We do not see any transactions as a health plan. As a self-funded health plan, we do not. There are very few self-funded, self-administered health plans today.
In closing, I appreciate the opportunity to provide comments on behalf of Change Healthcare. I would be happy to answer any questions.
MR. COUSSOULE: Thank you. We appreciate that. I believe we have Sherry Wilson on the phone.
MS. WILSON: Good morning. Thank you. Members of the Subcommittee, I am Sherry Wilson, Chair of the Board of Directors for the Cooperative Exchange, representing the National Clearinghouse Association and the Executive Vice President and Chief Compliance Officer for Jopari Solutions. I would like to thank you for the opportunity to present testimony today on behalf of the Cooperative Exchange membership concerning the National Health Plan Identifier.
Before we get started, this a brief overview of the Cooperative Exchange. We are the National Clearinghouse Association. We are 25 clearinghouse member companies, represent over 90 percent of the industry to process over 4 billion plus claims annually, representing $1.1 trillion. We support over 750,000 provider organizations, 7000 plus payer connections and over 1000 HIT vendors. We represent the vast EDI network infrastructure of the health care industry.
In terms of recommendations for HPID, we surveyed our members to determine the current use of and the need to move forward with the National Health Plan Identifier. We had 100 percent survey – among membership that agreed, one, there is not a business need for the use of HPID in the administrative transaction. Two, that the regulation should be rescinded.
The following responses to your questions are based on our survey findings. The first question. What health plan identifiers are used today and for what purpose? Based on our survey findings, the Health Plan Identifiers as defined in the regulation are not used today and as Debbie stated, our national EDI Network uses the payer identifier instead to exchange transactions in just using it for payer specific edits, payer lookup tables, provider enrollment with payers, payer formatting, distribution and routing. Payer identifiers are also published on our payer lists for providers, payers and vendor use.
In terms of what business needed are not adequately being met, today, as an industry, we have worked diligently over the 25 years to establish a national EDI Network. Based on our industry survey results, we have not identified any other business needs at this time.
In addition, we work closely with the standards development organizations and across stakeholders when new business needs do arise. This has proven to be a very effective strategy in addressing our stakeholder business needs.
In response to the next question regarding the benefits of the HPID, our survey response once again reflected 100 percent consensus that there is no benefit to the HPID model established by the HHS regulation and as written, it does not meet our needs for routing, editing, and reporting.
In terms of the next question, our survey response identified three specific challenges with the current HPID model. One, it does not take into account the relationship between health plans and payers. Debbie just reiterated. The functionality of these two entities has very different roles.
The second challenge is the current transactions have not been properly designed to support the HPID.
And third, the payer ID we feel must be kept as is to continue efficient routing of transactions experienced today. Again, as much, throughout the testimony, avoid risk of data breach due to misrouting.
In terms of recommendations moving forward with the Health Plan ID, our survey once again findings of 100 percent consensus recommends that you do not require the use of the HPID in the administrative transactions.
And second, there must be a clear – unless we establish for all stakeholders prior to going forward with any regulation.
In conclusion, today billions of transactions are exchanged with minimal disruption in the workflow. As Debbie said, if we take a step back and the need for a national payer identifier was introduced in the 1993 WEDI Report, this was not the case. Many transactions were getting lost and there definitely was a need for a solution.
However, in the last 25 years, the clearinghouse industries worked collaboratively to fix these routing issues seen earlier in the development cycle of electronic transactions. To that point in summary, we have three recommendations. One, the payer ID must be kept as is to continue the efficient routing of transactions and mitigate the potential breach risk due to misrouting.
Two, we recommend you rescind the current regulations.
And three, that a clearer one must be established for all stakeholders prior to going forward with any regulations.
In closing, we would like to thank the members of the Subcommittee for their time and attention. The changes being discussed today represent a major transformation for our industry. We sincerely appreciate all of your efforts to bring clarity and consensus to the process. If you have any questions, please don’t hesitate to contact us and use as a resource. Thank you.
MR. COUSSOULE: Thank you very much. Next up is Dave Nicholson.
Agenda Item: Billers, Dave Nicholson, CHBME
MR. NICHOLSON: My name is Dave Nicholson and I am the owner of a Maryland-based medical billing company, PMI. I am here today representing the Healthcare Business Management Association, HBMA.
Our members process medical, physician, insurance billing, and other claims integral to the health care delivery system. We are a recognized revenue and cycle management authority by both the commercial industry and the government agencies that regulate it.
Per your request, I will address each of the questions you have raised in order. Number one, what health identifiers are used today? Health plan identifiers are used today, despite the fact that they are optional rather than mandatory, for most plans. However, most HPIDs are at the macro or health plan level and are not necessarily specific to the product that the patient is covered by at the time of the visit.
In order to begin meeting the needs of our physician clients, the HPID must be used in conjunction with a policy identification number.
HPID is generally sufficient to get you to the ballpark, but the policy identification number is what you need to get to the right section, row and seat.
HPIDs are insufficient to get to the level of granular information that providers need in order to make patient-specific determinations.
Question Number 2. What business needs do you have that are not adequately met with the current scheme? In theory, the Health Plan ID should allow the provider or billing company to ascertain basic information about the patient eligibility, the amount, including the patient deductible, and where a claim should be sent.
Question 3. What benefits do you see the current regulations provide? Our member and their clients are frustrated by errors arising because the claim was routed to the wrong location, a claim was rejected due to incorrect health plan information given by the patient or the provider has difficulty verifying that a patient was truly enrolled in a particular plan and the benefit of that plan in which the patient was enrolled. The HPID is important, but must be linked to the beneficiary ID in order to ensure that the provider gets accurate and timely information.
Number 4. What challenges do you see in the current model? Although not specific to the model, the ongoing challenge is the reliability of the information you receive from the health plan. For example, the provider’s staff is doing an inquiry the day before a visit. They verify the enrollment and the beneficiary’s deductible.
For example, in this case, $150 and the deductible have not been satisfied. The bill for the visit is $200, meaning that the patient pays $150. The health plan is obligated for the remaining $50. The office collects the $150 from the patient and bills the plan for the balance of $50. However, between the inquiry and the visit, the health plan received a claim from another provider for the same patient. In reality, the patient’s deductible had been met. The practice will now have to refund the patient for the over payment.
Question Number 5. What recommendations do you have going forward? HBMA encourages the NCVHS and the Secretary to mandate health plan ID cards contain relevant beneficiary information that will allow the provider to easily access the particular product in which the beneficiary is enrolled.
The HPID must direct the provider electronically to the appropriate site the first time to figure out just what the patient is enrolled in.
The health plan needs to do a better job communicating their ID numbers both online and when contacted by phone. Many payers do not handle their EDI transactions directly and they sometimes outsource to other companies to process their EFTs and ERAs.
With all the different connections and intermediaries, it is not uncommon to be transferred numerous times before you speak with someone who can help. Because of this, providers are required to manage several different websites for their providers. One company reported that they have between 75 and 100 log-ins to manage the ERA and EFT setup for their providers.
In conclusion, on behalf of the HBMA, I appreciate the opportunity to make these comments and observations and I would be happy to answer any questions that you may have. Thank you.
MR. COUSSOULE: Thank you, Dave. Questions from the panel or from the members of the committee?
MS. KLOSS: I think this is both to Debbie and Dave. Do you have any estimate or do you track the number of times that there are problems encountered in using the provider ID to get a claims paid? Payer ID. I think all of our testimony has been it is all working fine. You are raising some other issues. I am just curious.
MS. MEISNER: There certainly are instances where the patient presents an old card. It gets directed to the wrong payer. But that usually gets caught up front pretty quickly and it rejects back to the provider to say this patient is not eligible with this payer. But typically, if they do eligibility verification to begin with whether they do it using the transaction or the phone, from our perspective as clearinghouse, we do not see very many rejections from misrouting.
MR. NICHOLSON: We do track it. I could not give you the exact number right off of the top of my head. It is something that I am sure we can forward to the committee if you are interested.
MS. STRICKLAND: This question is to Dave. I am just wondering how you think that the HPID could resolve the issue of that deductible dilemma that you presented to us. That these are claims that are crossing in the night. I am just wondering how the HPID would help with this situation.
MR. NICHOLSON: Obviously, there are sometimes in cases where claims come in and match almost instantaneous. In other words, I do not know how you would ever get to the perfect answer. But the overnight issue – you should be able to get pretty close. But to me, you have to have that beneficiary information linked to the card or linked to the ID because if you do not have them linked, you may know what the plan is, but you do not know what the patient’s beneficiary information is.
MS. STRICKLAND: Deductible information should be communicated in the eligibility transaction as mandated by the operating rules of HIPAA. By that, you should be able to get the information at a point in time that that patient is – at least that you are doing the eligibility and then the overnight thing. These things happen. We do not know that the payer may be running a batch at night or they may be running real time. It is very difficult. But I am not sure I can see where the plan ID would help resolve that particular issue.
MR. NICHOLSON: You are right in that sense because we view the whole problem as being the linkage of the two.
MR. COUSSOULE: One question. You indicated that you are seeing a lot of HPIDs flowing through today. Do you have any idea of the volume of that? You said – of transactions – you have not actually contained that today.
DR. NICHOLSON: Our company is actually linked to Emdeon. She would probably be a better one to ask. I am really not sure.
MS. MEISNER: We are not seeing any through our clearinghouse. I am not quite sure where you are – we may see a smithereen. I should not say we are not seeing any.
MR. NICHOLSON: We link to a table essentially.
MS. MEISNER: And that is a payer ID that you are using today.
MR. COUSSOULE: Denise, any questions on the phone?
MS. SNOW: No. Thank you.
MR. COUSSOULE: Anything else? Thank you very much. I appreciate the time and great information. We are now going to take a lunch break. We will reconvene in an hour so 55 minutes I should say at 12:50. Thank you.
A F T E R N O O N S E S S I O N
MR. COUSSOULE: We are ready to start our Session D with our standards organizations. We will start with Laurie Burckhardt. I think we have a presentation. Please introduce yourself and then help us learn.
Agenda Item: Session D – Standards Organizations
Agenda Item: SDOS, Laurie Burckhardy, X12, Chuck Jaffe Rep, HL7, Margaret Weiker, NCPDP, Gwen Lohse, CAQH, and Nancy Spector, NUCC
MS. BURCKHARDT: Thank you. I appreciate it. Member of the subcommittee, I am Laurie Burckhardt. Today I am representing X12. As an individual, I was the one that spearheaded along with Margaret the Health Plan ID discussions that we had in X12 several years ago now. I come back with some of that background too, not just from an organization’s perspective.
Before I started, one of the things I got to looking at when I was hearing the presentations today and talking about the routing, I am like how did we solve the routing. Routing was an issue, but how did we solve it? We just know we solved it. When I looked back, what was prior to X12? I am tossing the blame elsewhere. It was not an X12 issue. I thought it sounded good anyway.
Definition of a payer. X12 along with WEDI developed an issues brief, specifically the WEDI’s issue brief. What is the difference between a health plan and a payer? In the two organizations, what we have done is we identified the definition of payer because legislation identified the definition of a health plan, but we needed to identify the payer. This is a very important term. Keep this in mind as we move forward.
The term payer as used in the transactions is defined as the intended entity that is responsible for one or more of the following: final processing of a claim in order to return the remittance advice, final processing of an inquiry in order to return a response, and final processing of an enrollment or premium payment. Keeping that in mind as I go over these next few slides. This issues brief should be attached to the WEDI testimony as well. If you do need another copy, just let us know and we will be happy to get that to you.
The question one was what health plan identifiers are used today and for what purpose. Again, as a standards-designated organization from an X12, I cannot speak to whether it is being used or not and I think you heard the answer was not today. But how is it represented into the X12 transactions? What I did is I just took the claim transaction as an example.
Entities receiving the transactions published identifiers to use in transactions. This identifier may be a tax ID, an NAIC number, or even a proprietary number. It is just a number that is just chosen. It is an identifier chosen randomly that is published out in websites.
The role of the payer is distinct from the role of the health plan even though a health plan can be in both roles. Not all health plans are payers and not all payers are health plans. Transactions rely on identification of the role and the entity being identified that it is paying. A health plan can be a payer in the transaction. The entity that is being identified for its role as a payer, not as a health plan.
In the claim transaction, we have submitters and receivers. They are identified with using a qualifier called an ETIN, which is established by trading partner agreement. Payers are identified with the qualifier PI. This is a qualifier. And then there is also a qualifier of XV that is available for use.
What business needs do we have that are not adequately met? As this point in time, X12 has not been proposed with any business need to use health plan IDs in transactions.
I should say I cannot speak for today, I might have gotten one today, but as of the time that this presentation was written and submitted on Friday, we had not yet received any business need to utilize health plan identifiers.
The future of X12 transactions. Currently, X12 is in the development of the version 7030 of our TR3s. The future version – in today’s HIPAA version, version 5010, what we have is that the XV qualifier is required if mandated for use. What we have done in the future versions of X12 based off previous hearings is that we have made the qualifier just a qualifier. Legislation will dictate whether it is used or not used or if willing training partners want to use it. The Health Plan ID has become just another number.
What are our next steps? I think this slide is very important because as I mentioned 7030 were just in the development of some of our guides. Some have already been through public comment period. The claim transactions are currently out for public comment period and we have established dates for the next transactions ready to go out. We are really in a position that if it is recommended and adopted that health plan ID not be used in transactions, this is the perfect time for that decision to be made so that we can make the necessary steps to remove it from the transactions. If it is not, it is going to go back to what I previously said. The XV will be there. It is just going to be an identifier that if you are reporting a Health Plan ID or an OEID, you use this XV qualifier.
Again, it bears to be said. If it is determined HP is not needed in electronic transaction, we are in a perfect position to remove it. And by removing it from the transactions, this would eliminate any ambiguity that can happen because people will see that number and thinking that it still needs to be used.
That is actually all my slides. I do want to plug in though for attachments. I am going to jump on Rob’s. I really would like to see attachments, but again that is version 6020. So 6020 – we are all good on.
MR. COUSSOULE: Next up is Chuck Jaffe. Are you on the phone? We will pen him if he comes back and joins us.
MS. WEIKER: I am Margaret Weiker with NCPDP, which is the National Council for Prescription Drug Programs. We are a not-for-profit ANSI-accredited standards developing organization that focuses on the pharmacy services sector in the health care arena. My comments relate to pharmacy today.
Earlier we heard a lot about the routing of claims and potential numbers that are used today in the routing of those claims in regard to an 837. You have heard NAIC numbers, tax ID numbers, and those types of things. From a pharmacy perspective, we route totally different. Our claim transactions, which by the way, over a billion of those are done in a real time and when I say real time, I mean real time. We are talking three seconds or less. We use what was formally called the BIN or the bank identification number. In some instances, we use that combination with what is called a process or control number or a PCN.
The BIN is no longer – that terminology was retired by ISO. The actual what is called now an IIN or the issuer identification number. This number is actually an ISO standard. The number in the US is – the registering agency is ANSI, the American National Standards Institute. This number was originally – it came about for the financial industry and the routing of your credit card information. It is an international standard.
The IIN is the primary number. It currently is a six-digit number. They are running out of numbers believe it or not. They are migrating to an eight-digit number. NCPDP with our new version will be migrating from a six-digit number to an eight-digit number. They will be converting the existing six to eight by appending 00 through 99. That standard has already been approved through the ISO process.
Our routing is done by the IIN and is necessary. Some use what is also called a processor control number, which is a second level to say I am going to send to this processor this PBM, this payer, this health plan, but they may administer multiples. They may assign a processor control number to separate out their lines of businesses. That is the pharmacy routing piece of this.
NCPDP provided testimony in 2010, 2012 and 2014 on this topic. It is now 2017 and our position has not changed. NCPDP does not have a business requirement for the use of the HPID. That has not changed since our testimony in 2010.
Just to reiterate, if the rule that exists today is not withdrawn, rescinded, removed, we ask that a new rule come out and exempt pharmacy transactions from the use of the HPID. If transactions are still to house HPID, the pharmacy industry would like to be excluded from them where there is no business requirement from a pharmacy perspective to have that number.
Yes, it is somewhat ironic that I am asking for another rule to be released, considering back in 2012, I am still waiting for that rule. Yes, I am asking for another one.
That concludes my testimony. Thank you.
MR. COUSSOULE: Next up is Gwen.
MS. LOHSE: I am Gwendolyn Lohse, managing director of CAQH CORE. Thank you for inviting us to testify today. CAQH CORE is a nonprofit, multi-stakeholder collaboration of more than 130 organizations representing health plans, clearinghouses, vendors, government agencies and organization. We are the designated HHS author. The health plans under CORE cover about 75 percent of the commercially insured.
We are reiterating two points that were communicated to CMS back in the 2015 latter that the CAQH Board wrote to CMS on HPID. We are also reiterating the need and the growing need to focus on monitoring an in-depth study on this issue. I am just going to walk through. I will try to skip over the things that are repetitive. I am going to jump through my testimony. You do have a written copy of the testimony in front of all of you and then we submitted an electronic copy.
The first thing is regarding the use of the HPID to route the transactions, again, recommending this not be done and especially not in use with the various payer identifications to payer IDs.
Two points to bring out. I am not going to repeat the definitions that have gone over. There is no federal definition of a payer in any regulation. There is no public list of the number of payers in America. There is no public list of the number of health plans in America. Being able to aggregate any data on this issue is extremely difficult because you cannot get a denominator.
With regard to supporting efforts that would allow the various types of IDs currently used for transactions for monitoring, we are highlighting that the industry use the patchwork of proprietary IDs for routing transactions. Some of the identifiers are payer IDs and they are not HIPAA-covered entities. There is no aggregated data on this and that is the understanding of the industry’s success. Challenges or the costs associated with this patchwork are not clear.
Additionally, there is no collective industry understanding on how this ID patchwork would apply to emerging or routing needs such as processing value-based contracts.
As notated in detail in our letter, the lack of the understanding of this growing concern around value based is an issue for some of the CAQH CORE participants. They are worried about it because the identification needs get a lot more granular within the value-based contracts. That is the first issue. Do not put in the transactions for routing, but we do really need to study this and figure out where we are going collectively.
Second, for other lawful purposes, the HPID is allowed for other lawful purposes and for public policy reasons or for HIPAA compliance enforcement. We do think HHS has the ability to do that. We do outline some characteristics on the top of page 2 that HHS should pursue if they do have a public policy or HIPAA compliance. A compelling business case, a clear enumeration structure, publication of notice of proposed rulemaking, ability to manage the compliance risk for the health plans, and to access the list of HPIDs, similar like you see with NPPES so the identification system that is used for providers.
Identity management and validation of certain identities become more and more important as we rely on data exchange. We need to make sure we can validate across valid sources.
In order to secure that our positions reflected today’s point of views, on April 18, CAQH CORE did hold a call with our participants. About over 40 organizations participated in that call. Forty percent of those were health plans or Medicaid agencies and the rest were a mix of vendors, clearinghouses, provider organizations, and standard settings.
Over 90 percent of them participated in the polling on the call or actually gave a comment or followed up afterwards. There was very active participation. We are going to summarize that quickly of the details in the letter.
As another thought, we do think we were not able to do the amount of study needed on this issue. You need an in-depth study with a project team, a timeline, and resources to really get at the issue and to be able to do things like Venn diagrams and denominators. You need to take the time to do that. We would be happy to collaborate on that issue.
The first question. How many identifiers are used today and for what purpose? We had a list of eight that were submitted to us. You can see those on the testimony. Four of the eight were used more frequently as noted. Of the seven of the eight, you could actually validate against a shared system. If there is a need for fraud and abuse or validation of numbers, there is a system to go against. For proprietary IDs, obviously you cannot go against it and validate in a shared way.
With that, the other issue too that came up was the definition between a payer and a health plan. That continues. I think you have heard that loud and clear. There is not a clear understanding and it continues to be a difficult topic and one that the industry needs education on.
We did ask a question about obtaining health plan identifiers. Specifically, we asked providers and provider-facing vendor systems how they obtained HPIDs. You can see on page 3 of the testimony. The most common sources reported were the health plan and clearinghouses’ list, the companion guides, and also the member identification card. That is a lot of different sources.
Recently, we have been doing site visits at provider organizations, both health plans and also small provider groups and large provider groups. They validated all of these sources. They also showed that there was significant manual work for a provider staff to actually use this process to validate the IDs and potential impact on claim routing. That may vary on transactions because a provider may be using one tool or one vendor or clearinghouse for five of the transactions and a different one for the other three. They may be doing some of them in paper. They have to use all these different sources to come together.
While it is unclear that there needs to be a single database of health plans or identifiers, we reiterate that HHS should study in-depth the need for this and any potential benefits for it.
With regard to current business uses, obviously routing is the most obvious for fee for service. We also heard and this is in detail in the testimony paper claims, putting the identifiers into health plan and vendor web portals and then also using them on the phone. If you do not actually do electronic transactions, you need the ID. And differentiating between plan and products, which I think we heard a little bit this morning, that granular level that you need. And then proprietary claim remittance reports and payer-to-payer providers.
We also did hear about the compliance need. There were several providers that brought up HIPAA compliance and the transactions so that not the routing purpose, but the use of the HPID for these other purposes.
What needs are not being adequately addressed? Many did not provide a response. Some reiterated that there were no needs. Others did highlight patient-specific coverage that is not being addressed by this HPID. Again, that granular level. Part of that is clinical and administrative information, the integration of that. And actually accessing a standard source to validate the identifiers.
One thing I do want to point out. We did hear from an expert about value-based contracts. Right now, it is not reported as being the biggest need, but as this grows, there is an indication that there needs to be an understanding and an access to individual health plan contract terms. This individual shared that value-based payment volumes are currently low for most providers. They are using spreadsheets and customized health plan identifier systems to track these specific contracts. If you go above and beyond the 15 to 20 percent that some providers may have for value-based contracts, it will be very hard to do this manually. CAQH CORE is actually doing work on value based and we are seeing the same thing.
What benefits do you see? Really no one was seeing it for today’s fee-for-service routing. Again, the need for the compliance was brought up. We then listed at the very end of our testimony what challenges do you currently see. One is actually the definition of the health plan versus the payer and defining what is the target for whether it is a policy purpose or a routing purpose to bring that up.
CAQH CORE has studied all its certified entities and we do not have a denominator because we do not have a list. It becomes a challenge for us. There is no publicly available searchable database. For some entrance into the market like new vendors, they cannot get a list to start out their businesses.
We also heard validations and understanding enumeration strategies. And then more detail on the actual enumeration process and requirements that health plans would be using. If there was a public list, there would be an availability for the industry to better understand the strategies for identification. I think we have talked about identity management this morning so making more access to that.
I just want to wrap up that we would be happy to study this more in depth. We would also be happy to share some of the value-based work that we are doing or the challenge we have had in tracking the impact of the core certification if there is no denominator. Thank you very much.
MR. COUSSOULE: Thank you, Gwen. Just for the committee members, I think we have now received information of the written response from Chuck Jaffe. Is he on the line? Next is Nancy.
MS. SPECTOR: Hi. Good afternoon. Thank you. My name is Nancy Spectrum, chair of the National Uniform Claim Committee. I am also director of coding and HIT advocacy at the American Medical Association. I would like to thank you for inviting us to be here today and provide input on the HPID regulation.
I know some of you know about the NUCC, but just to give you a little background. We are a data content committee. We were named in HPAA as that. We also serve in a role to advise the secretary on issues around standards development.
As a committee, we have a broad diverse group of health care industry stakeholders, providers, health plans, designated standards maintenance organizations, public health organizations, and vendors. Our work is primarily around the paper 1500 claim form, but we also as a data content committee are working on how we can align the data content that would be required within the professional, non-institutional health care claim. That is a little background. We hope we can provide a broad perspective on data reporting and claims needs facing the industry.
I will try not to repeat a lot of what was said. I also do want to in some ways reiterate some of these points that have been made because I think you may find it helpful to just hear the number of people who are in groups who are saying similar things and the same things.
Obviously, you have heard today about the background of what was intended when HPID was identified within the HIPAA legislation that it was going to be an identifier to be used throughout the HIPAA-adopted electronic transactions. With that, its original purpose was around this idea with the electronic data interchange. With the transactions as they are today, health plans do not actually need to be identified. Only the payers need to be identified.
That gets back to the point that has been made several times about the difference between a health plan and a payer. I think Laurie made the point earlier too and we had made it as well saying that payers may pay for health care services, but they are not necessarily health plans. Health plans may function as payers, but they are not necessarily always a payer. There is that variation in terms of how you define and label. I think someone said it earlier today. Are you a health plan? They said it depends. We talked about that at the committee level as well that there is still that variation that exists within the industry as to what the differences between the health plan and a payer.
We have talked here as well today about how as EDI transactions came online, payers and industry together solved the problem of how to identify payers for the routing of transactions. These are the payer IDs that continue to be used today. The NUCC in our discussions has not identified any issues or new business needs at this time to change what is currently used with the payer ID identification system.
We are aware that health plans have the various identifiers that they do use the NAIC identifier, tax identifier. There is also the Health Insurance Oversight System, the HIOS identifier and other identifiers. These identifiers all have specific purposes and uses.
To just more directly address the questions, in terms of what health plan identifiers are used today, I just spoke about the awareness around the NAIC, tax, and HIOS identifiers and how each one has a specific need and purpose.
The NUCC is not aware of any unmet business needs with the current use of payer IDs today.
We have looked at the HPID model as it was established in the regulation. We could not find any benefits nor a business need for it within the current EDI transactions.
IN terms of challenges with the current HIPAA model, again, we have concerns that it would undue current processes that are in place and that it would also be costly to implement and maintain and ultimately bring no value to the EDI transactions as they are today.
We are recommending that the current HPID regulation be rescinded and no further regulation be developed for HPID.
I would like to thank you for the opportunity to be here today and happy to answer any questions.
MR. COUSSOULE: Great. Thank you, Nancy. One last check to see if we might have Chuck Jaffe on the line. Questions from the committee members to pose to our illustrious panel?
MS. GOSS: Laurie, you made a comment about 7030 in the public comment periods and being in the process right now. There was an aspect related to the timing. And if you are going to do it, do it now because we are under review with the standards body, public comment period for 7030 on the claim.
MS. BURCKHARDT: On all the HIPAA transactions. Currently, we are under 7030. We have submitted comments so the guides that have already gone through the comment period. There is a process we follow. Yes, we do have a process. We have received business requirements, changed requests, and applied them to the version. Guides have gone out for public comments, specifically the 834, enrollment in the 820, the premium, and then some of the other claim status and response. The 835 has gone out. Those have gone out. We have submitted comments on that to allow us even though they have gone through the public comment period. Comments have been submitted to say HPID needs to be addressed. Now the response has been you are right. We will do it. But we have not said what that response will be.
We are in a situation where we can remove it or we can leave it in like it is right now. And right now, again, it just says if you are going to use a health plan or an OEID as an identifier, use the XV. Otherwise, you would use the other qualifiers.
MS. GOSS: No harm, no foul if it stays in there. However, if there is going to be a regulatory decision as a result of this testimony and recommendations to the secretary, the timing is right. That is all I heard.
MS. BURCKHARDT: The timing is right for 7030. Now, again, there are some other steps to that though. That means 7030 has to be adopted. Correct?
MS. GOSS: That was actually going to be my next question, which is when is X12 currently forecasting that they will be done with the 7030 suite so that they can bring it to the DSMO or maybe they are having the DSMO do their review in parallel with the public comment period.
PARTICIPANT: That is not the DSMO process.
MS. GOSS: I know. Optimistic.
MS. BURCKHARDT: I do not have a date for you. In talking to Lorraine earlier, that is one of the things that I am going back to X12 with to let them know this committee – we need to get a date on. We need to get the DSMO up to speed. We do need to get a date and we do understand that.
One of the things that I want to say though too is that it kind of just came to light. No matter what, we are going to have to have some sort of legislation. Either go forward with 7030, remain quiet, or do we maybe have to look at adopting 5010 erratas that were done back in – because the current – if Health Plan ID went forward, it could not do it in the current transactions because we did not get the verbiage right.
MS. GOSS: There is regulation needed one way or the other either to upgrade to 5010 to 7030 or to do an erratum to fix if we stay with 5010, but keep Health Plan ID. Then something has to get fixed. I am with you.
MS. BURCKHARDT: Yes, we are juggling various things. Now, if you remain silent on HPID then the transaction, the 5010 version could remain as is. We have options. Right now, it is kind of like the perfect storm and we are just in a position to make a fix so that we do not have to live with something for another ten years. I guess that is my point.
MS. KLOSS: Thank you all. I think I am probably going to mangle my question, but just bear with me. It is to Gwen and anyone else who cares to weigh in on this. You are recommending that there is a need to step back and take some kind of study, do some kind of study. It is not necessarily on Health Plan ID like an enumeration strategy, but some way of cataloguing, capturing the breadth of health plan products or a range of services or identities.
MS. LOHSE: Correct. If you think about the two needs that were identified, one is for routing purposes and one is for other policy issues. First, I am going to talk to the routing issue. We have all kind of – we have heard great consistency on it. With today’s routing purposes, yes. No need. The routing purposes are changing and they are getting more granular due to the fact of these value-based contracts and also due to the fact of new entrance in the market.
As an industry, we do not have any collective viewpoint on how many IDs we are using, if there is a validation tool, which almost every data element now even provider directories are going through and we are starting to create a validation process. There is no way to validate these numbers nor is there a collective understanding of the cost it would take to take this patchwork of system and add on or change it to apply it to a more granular identification need for value-based contracts.
There was a discussion earlier today I believe from the woman from California about provider patient attribution. We have been looking at this in a little bit of detail. The level of identification and therefore the routing from the system, the provider is using, which may or may not be the systems today. Many providers may actually be using their EHR to do some of these transactions. Those routing needs are going to be very different moving forward if we actually move to a system where you need patient/provider attribution. It is not the same needs.
MS. GOSS: I am sorry. Isn’t that sort of what is also already happening in health information exchanges today?
MS. LOHSE: Do we have a collective understanding of it and how it would apply across the industry? We personally have not seen anything.
MS. GOSS: — that point. I was just trying to make an analogy. It is another aspect if it is happening and it is a substantial issue knowing who’s who in the whole ecosystem.
MS. LOHSE: Absolutely. If you think about for those providers today that don’t actually do the transactions electronically, you all heard how they are getting the IDs. It is probably not the most cost-effective methodology nor is it – it is prone to error. Do we want to invite a system that is potentially costly and prone to error into a more complex routing system? That is the first need.
The second need is obviously public policy issues. We have particularly been interested in regard to HIPAA-covered health plans and because we have a certification process that is voluntary for HIPAA-covered health plans. And then also those entities that support them in the clearinghouses. There is no way to fundamentally measure on a national level full impact because there is no denominator that has been recognized as a denominator. Linda, I hope those answered your questions.
MS. KLOSS: You are really encouraging some thinking going forward to allow more – to both think through how routing will change, but also think through how we can measure system performance.
MS. LOHSE: Absolutely and doing both of those in an aggregate manner. It is great to hear from some of the larger entities that handle the number of transactions or some of the organizations that represent a high percentage of the covered entities or the covered health plans that does not give us the full system picture.
MR. COUSSOULE: Other questions? Are there questions from the committee members? Denise, if you are still on the phone?
MS. LOVE: Yes, I am and no questions here.
MR. COUSSOULE: I thank the panel for your excellent information and insight. We will move on to the committee discussion.
Agenda Item: Committee Discussion
PARTICIPANT: Can we have a moment just to scan the HL7?
MR. COUSSOULE: Sure.
PARTICIPANT: It will just take a moment.
MR. COUSSOULE: We have had a chance to hear from lots of different parties involved in this ecosystem today. We also have written comments provided in some level of detail from a number of other players, some of which have been published and some of which are still in the flow. But we expect that we will have that to review as well.
Any themes the committee members believe we have heard today that we would like to discuss in regards to what we have heard or what we have read in the testimonies so far?
MR. LANDEN: Thanks Nick. I think it was pretty clear that we heard a consensus from the provider side, the payer side, the clearinghouse side, the SDO side that for routing purposes for today’s HIPAA administrative simplification, the electronic transactions that the HPID is neither needed nor wanted. I was very impressed with the degree of consensus around that. I have seldom heard all those different facets of the industry agree on much to that extent.
To me that suggests that one of the points we make in whatever we produce is that we declare victory with claims routing stating that the payer ID and the various sources of that payer ID are sufficient and that HPID at this point has no role to play in the current claims routing situation.
From the few comments that addressed issues around health plan identifier outside of claims routing, I think that suggests that we may – we, as NCVHS, may want to identify that and talk about that for our future work plans, but that would be a de novo discussion. That would not be a continuation of the routing issues that form the basis for our looking at the HPID over the last four or five or six years, however long it was in our previous recommendations. I think there is some merit to the conversations. Public health data consortium on the research. CAQH, a little bit on the research. The business management association and some of the value-based systems. There may be other opportunities that would constitute a national need.
MS. HINES: Can you repeat what the – the committee may want to identify what for our work plans?
MR. LANDEN: May want to talk about the concept of a health plan identifier specifically excluding any use for routing in the current system, but look at future uses as were either suggested or mentioned in passing by some of the testimonies today for other uses that we were describing. What do we really need to know? What does our system really need to know about a health plan as opposed to routing a transaction?
MR. COUSSOULE: Not to interrupt you, Rich, but we will need to be cognizant of – because this is a regulation, we do not necessarily need to find a use. At the same time if there is a need that this is part of a solution for it, we can explore that. That is what I am hearing you talk about.
MR. LANDEN: I think to me what I heard is that the recommendation and I am not sure the proper language, but to repeal, rescind, retract. I heard those verbs for the current final rule that is not being enforced. I think that would be part of our considerations and recommendations to the secretary.
The second part, again, would be assessing in terms of getting our hands more around the issue and then assigning that a priority among all the other things that we are thinking about addressing over the next couple of years or have been asked to address.
MS. KLOSS: I think we should keep these two parts probably pretty cleanly separate and try to really crisp up what we are going to say about the current rule making. I went back to our earlier letter of September 23, 2014. And recommendation number one was that HHS should rectify in rule making that all covered entities, current and future health plans, providers and clearinghouses and their business associates will not use HPID in administrative transaction and that the current payer ID will not be replaced with HPID. We have said that. I think that is probably pretty consistent with what the point you just made and certainly what we heard today.
And then the question is rectify and rule making. That could be clearer. Are we specifically recommending that it be rescinded or are we just extending discretion? There may be some discretion in extending the discretion particularly if we are suggesting that we need to look at how health payer ID might play in transactions in the future. I think that is up for debate.
MR. COUSSOULE: I think that is an interesting topic. Do you make or not make a recommendation because of what might or might not happen going forward? It is a tough saying. Just kick it down the road for however long you want to kick it down the road for in case it has a use later.
MS. KLOSS: Exactly. And I remember when this committee was talking about how to word that recommendation of rectify and rule making. I think we were a little bit obtuse for that same reason.
MR. LANDEN: As still a relatively newbie here, I was not part of the committee when that letter was sent. Again, with apologies if I may be losing some of the continuity of institutional memory, my focus would be that the issues that we heard today, the remaining issues outside of identification and transaction sets are so different to the core concept of what an HPID was over the last 4, 6, 8, 20 years that industry and policy would be best served if the recommendation were simpler. Just retract the rule, whatever verb is appropriate, and for any new development of the HPID concept start fresh. Start from scratch.
MR. COUSSOULE: One comment I will make is it raises an interesting question of when this was originally proposed back in 2005. Again, my history does not go back that far. Had it have been more aggressively pursued in a level of detail could have provided more value and a more holistic view of the system, which I think is a point you had brought up earlier, Linda. However, we are not in 2005. It may be worthwhile pointing that out.
MS. KLOSS: I think framing some of that useful history that we began with today would be very helpful certainly when it was written into HIPAA as – in 1996, it was very clear. We needed some way to identify health plans, people, and providers. We did two of the four.
MR. COUSSOULE: I guess the challenge is – the problem needed to be solved. It got solved. Whether it got solved in the best way possible almost does not matter now, but you have to weigh off where you are today against that potential change.
MS. GOSS: And I think that point where are we today and where are we going is really what I am struggling more so because it seems to me that this rule is not needed. It is not designed around the business functions and solving the problem it was design to do.
But what I am struggling with is being able to concretely understand and articulate the aspects of the value-based purchasing and the research and the public health needs. We had some commentary on that today. I see that we have additional written testimony, which may enlighten this further. And seeing how they also may fit with some of our beyond HIPAA privacy and security considerations, some of our vocabulary considerations, the CHINME letter that we have just received on patient identifiers.
There is some strategic thinking we need to do about the next 20 years or 10 years as we are transforming the way we pay for people’s health care and also expect the quality aspects tied to their health plans. They are going to become more innovative. I think it is going to produce a lot of criticalities.
I would like to try to give us some time to Gwen’s point. Maybe we should be doing some studying of this. But I also think that there is some time urgency about us at least giving some feedback to the secretary about what we have heard especially as it may impact some of their other opportunities for policy development.
MS. LOVE: This is Denise. I like the conversation so far. I generally agree. But I have a dumb question and maybe you can help me. I thought I heard or understood that TPAs and PBMs are excluded from Health Plan ID under the current structure or rule and that is the case and is that a problem.
PARTICIPANT: You said third-party administrators. I just want to make sure we heard you correctly.
MS. LOVE: Yes. Third-party administrators or PBMs. Are they included in – Health Plan ID under the current structure or not?
MS. WEIKER: From a PBM perspective, a PBM is a pharmacy benefit manager. They are not a health plan. They could get an OEID if they so wanted to, but they are not a health plan, but neither is a TPA because in my former life, I also did all of the certification and getting the licenses, et cetera for a third-party administrator. They are not a health plan either. They could get an OEID, but they are not a health plan.
MS. LOVE: And that is from my perspective, it may be more of a policy issue than a routing. Thank you.
MS. STRICKLAND: I just have a question and I am being new to this whole process. I am thinking based upon the testimony that we heard today that it is pretty clear. HPID, as Rich said, is not needed or wanted. It would actually cause more harm than good. That is one issue. I think that is the issue and we need to put that information forward to the secretary.
The issue about these other needs, research and the timeframe that it will take to get that done, I think that is another thing. It may not even be identified as a health plan ID. It may be something a little bit more finite or called something else so that it would not get complicated with this issue. We could potentially move this issue forward and be done with it and then pick up the other issue as time permits from this committee’s perspective and deal with that at a more granular level.
MS. GOSS: That might give industry some time to —
MR. COUSSOULE: Just add onto that a little bit. I believe that the other issues we have heard that there are some very real issues and challenges there of which something like an HPID may be part of an answer, but it would not be enough of the answer to me for that to be at least at this point in time recommended to go forth with that.
MS. KLOSS: A couple of other issues. Back to this framing a recommendation on rescind or extend, is there any unintended consequences of a rescind for those that in fact are using Health Plan ID? Does that confuse? I think we need to at least visit that. Maybe some of our experts that are still in the room can weigh in on that.
Secondly, we had quite a lot of – several discussions about the issue of health plan certification and the implications and whatever recommendation we make for that. I think we have to look around the edges of that core recommendation and the implications. I think we need to say something about those areas.
And then finally, as we have done in other letters, we have raised new things that are a little bit beyond scope. We have raised them in a way that says research is needed on X, Y, and Z. We are not saying we have all the answers. But in the course of the hearing and all of the testimony, we have identified some new needs. We are laying out those out there. I am not saying that NCVHS necessarily will do that, but sometimes we have recommended to the secretary that research is needed on X, Y, and Z. There may be other ways to do that research besides NCVHS. I do not think we should be bashful in trying to frame that larger and more future issue. We do not have to come in with a recommendation on it beyond that. This needs study. It is an issue that is now being brought to us.
MR. LANDEN: I would just like to call out one of the letters we received that was not presented today. It was from AHIMA and the Public Health Data Standards Consortium. That letter talked extensively about a typology. We heard that same reference from several of our commenters today. In line with Linda’s previous comments, yes, that is an opportunity that we need to learn about. But again, I stress that even though those ideas are out there, they are attractive, I have no – until we get farther into them, I have no real sense about what their priority might be vis-a-vie our work plan for the next couple of years. Yes, research is indicated, but whether or not we make that recommendation for further research to the secretary or not. We should think about that.
MS. GOSS: To extend Rich’s comment, I think that we need to ask the National Center for Health Statistics, specifically Michelle, who is a staff member to the subcommittee, to talk to us about that because I know she has been actively engaged and may provide some additional context to your point, Rich.
MR. COUSSOULE: Good discussion. I am going to wrap up a little, but we need to have time for public comment. Do we have individuals either on the phone or in the audience who would like to offer up any more guidance or information for us? We would love to hear from you now.
MS. LOHSE: Gwen Lohse, CAQH CORE. As you think about the recommendations, you may want to consider the scope of what NCVHS’ responsibilities are and what would you like to hear as to adoption challenges and real aggregated data and therefore what the industry needs with regard to identifiers and managers within your scope as you oversee all the HIPAA requirements and are they getting out the door, where are the gaps.
As you look at, for instance, OEIDs, when we do not have a list of the health plans and we do not have a list of the OEIDs, it is a challenge for you as a committee to collectively see how the system is doing. What tools do you need for us to have in order to report what you need for your future reports? Thank you.
MR. COUSSOULE: Thank you, Gwen. That is a good comment. Other comments from our audience? Any other questions from the panel or the committee members? I would like to thank all of our presenters today and our panelists and our staff for putting together a very good meeting. With that said, we will officially adjourn for today. Thank you.
(The meeting adjourned.)