[This Transcript is Unedited]
Department of Health and Human Services
National committee on Vital and Health Statistics (NCVHS)
November 29, 2017
Virtual WebEx Meeting
TABLE OF CONTENTS
- Welcome, Roll Call, Agenda Review
- Alix Goss and Nick Coussoule
- Predictability Roadmap Update
- Alix Goss
- New Medicare Card Project
- Monica Kay
- CIO Forum Project Scoping
- Alix Goss and Nick Coussou
- Patient Matching Project Scoping
- Alix Goss and Nick Coussoule
- Prior Authorization Project Scoping
- Alix Goss and Nick Coussoule
- Public Comment
P R O C E E D I N G S (1:00 p.m.)
HINES: This is Rebecca Hines. Welcome to the National Committee on Vital and Health Statistics meeting of the Standards Subcommittee. We are going to start off with roll call, starting with members.
COUSSOULE: This is Nick Coussoule from BlueCross BlueShield of Tennessee. I am co-chair of the Standards Subcommittee, member of the Full Committee, member of the Privacy, Security and Confidentiality Subcommittee and I have no conflicts.
HINES: Alix Goss.
GOSS: This is Alix Goss with Imprado. I am a member of the Full Committee, co-chair of the Standards Subcommittee and I have no conflicts.
HINES: Rich Landen.
LANDEN: Rich Landen. Member of the Full Committee, the Standards Subcommittee and I have no conflicts.
HINES: Linda Kloss. Linda, your phone might be muted. Check your email for instruction to unmute.
MONSON: Good afternoon, Jacki Monson, Sutter Health, member of the Full Committee and member of the Subcommittee Privacy, Confidentiality and Security and no conflicts.
HINES: Bill Stead.
PHILLIPS: Bob Phillips. I am with the American Board of Family Medicine. I am the co-chair of Subcommittee on Population Health. I am a member of the Full Committee. Don’t know if they are conflicts, but I lead a national primary care registry, which touches on some of the issues that we deal with as well. Thank you.
HINES: Deb Strickland.
HINES: I see three members on the WebEx who have not spoken. You need to check your email on instruction on how to unmute. Linda Kloss you have an open line. Bill Stead, is your line open? Deb Strickland, is your line open?
KLOSS: Hi Rebecca, it is Linda.
HINES: Hey, Linda. You can go ahead and introduce yourself.
KLOSS: Linda Kloss, member of the Full Committee, chair of the Privacy, Confidentiality and Security Subcommittee, member of the Standards Subcommittee, no conflicts.
HINES: Debra or Bill.
STRICKLAND: Debra Strickland, member of the Standards Subcommittee and no conflicts.
HINES: Bill Stead. Any other members who have dialed in and I don’t see your name?
Staff, Lorraine Doo.
DOO: Lorraine Doo, policy advisor with the Division of National Standards at CMS. Lead staff for the Standards Subcommittee.
HINES: Wonderful. Is Geanelle Herring joining us?
DOO: No, she is sick today.
HINES: We also have some other staff on the line. We have Debbie Jackson and Katherine Jones and Marietta Squire. Any other members, are you on the line now? Denise Love, I see you have dialed in. Please check your emails for instructions to open your line to unmute your line.
LOVE: Hello Rebecca. This is Denise Love. National Association of Health Data Organizations. Member of the Full Committee, member of the Standards Subcommittee, and member of the Population Health Subcommittee. No conflicts.
HINES: Great. I just sent instructions to one more member on how to open the line. Let us see if they go through. Operator, please bring up – Nick, are we going to move to the ONC – or should we leave the agenda up for right now?
COUSSOULE: Why don’t you leave the agenda. I can walk through that quickly with everybody here. Ready to roll?
HINES: I think so. In another few minutes, we can see who else has an open line.
STEAD: I’m on. Bill Stead, Vanderbilt University, Chair of the Full Committee. No conflicts.
HINES: I think the gang is all here, Nick.
COUSSOULE: Perfect. Welcome everybody to our Standards Subcommittee virtual meeting. We have a few hours that we will be spending together this afternoon, going through a number of different topics. We have a rather busy afternoon.
First, we will hear from Alix Goss, my co-chair and partner in crime, about an update to our Predictability Roadmap. We will then hear an update from the Medicare Card Project. We will then go through three different scoping exercises. These are geared towards framing up our work for next year – the balance of this year and into next year, and try and scope out those topics and get some agreement from the subcommittee members and the Full Committee members that weigh in on the specific scope of activities that we would undertake.
We will take public comments at the end and adjourn you on time at 5 o’clock. With that said, I also want to turn it over to my co-chair Alix, who has another announcement that she would like to make.
GOSS: Thanks very much Nick. Welcome to everyone. We are really excited that you are here today and will be able to provide public comments, giving us further feedback on today’s topics, including our project scoping documents, which will help set focus for workload balancing within the Full Committee.
Before we dive into our topics today, I would like to take a moment to recognize the passing of an amazing colleague, Bob Poiesz. His long battle with ALS came to an end on November 2nd. His passing ended his suffering and has provided the opportunity to celebrate his many contributions.
Many in the health care standards world, know and have worked with Bob over the years. For those that do not, I will briefly share that Bob was a cornerstone of our nation’s health care standards community. Most recently he worked at the American Medical Association as a principal policy analyst. From 1999 to 2017, spanning his paying jobs, Bob was active and influential member as ASCX12.
Throughout his 26 years as a standards developer, he volunteered his time to develop health care standards, including some that became nationally adopted under HIPAA’s Administrative Simplification Provision, and to mentor others on the development and use of X12 syntax in standards development processes.
Bob’s work at X12 spans many roles. He was one of the authors of the Health Care Admittance and Communication Guide. Bob was elected into numerous leadership positions. He applied his talent and diligence in reviewing and responding to requests for implementation to the Implementation Guides and X12 ballots.
Along with Bob’s professional contributions, he brought a personal touch through his corny jokes, sweet treats such as chocolate things on your brain, and serving his signature cheese omelet to those who visited for home based meetings.
He adored his family. His wife Cathy and their three children. I, for one, had my career notably influenced by Bob, and was most appreciate for his time, passion, analytical brain and big heart.
He will be missed by many and I think you for taking a moment to recognize the contributions and the loss of Bob Poiesz. May he rest in peace.
On a lighter note, I would like to turn it over to Lorraine Doo, who will talk about the exciting news of the interoperability standards advisory.
HINE: Let us pause and ask the WebEx host to bring up document A-2, please.
DOO: While they are doing that, I also wanted to echo Alix’s thoughts about Bob Poiesz. It does demonstrate that it is a very small world that we all work in. Bob had an influence on me, as well. I admired him greatly. Got a chance to work with him. Sadly, my father also died of ALS, so it just shows that we are all connected in a lot of ways. So he will be missed for all of his contributions. I think that was really nice that what you said, Alix. Thank you for doing that and thank you for sharing the story of your knowledge of him too.
As we move on, in part to Bob’s contribution and many others, we wanted to share with you some exciting news from the standpoint of administrative standards. The Office of the National Coordinator put out – a couple of years ago they began something called the Interoperability Standards Advisory. Which means that ONC has been coordinating the assessment, identification, and awareness of standards that are being used by health care for interoperability.
This came about as they began to identify standards for the electronic health care records, also for public health and research. Frankly, I had been looking at it a little bit enviously, thinking that if it is being used for EHRs and for other clinical settings, wouldn’t it be a great way for getting some promotion for the administrative standards.
We began talking with the Office of the National Coordinator about having it as a way of getting the standards, the administrative standards and the operating rules in there. So for the first time this year, ONC has included the transaction standards and operating rules adopted under HIPAA, in the ISA for review. So that is the X12 and NCPDP and CAQH CORE Operating Rules.
Anyone can link to them and review them, and evaluate them for standards and implementation specifications, and comment on them and give us feedback. You can see here that they have been organized under Coordination of Benefits for the Claims, Non-Claims, the Financial Transaction, this would be the EFT and the ERA, and then clinical care. This is where you will see the pending attachments, also prior authorization would be under this section. Then we have the Operating Rules. So when you go to the ISA and you click on each of these, then the standards come down and you can actually link to them on the various websites.
We had sent this out. We did a distribution to ensure that there would be comments coming back in. ONC will combine all of those and give us the feedback.
If you have not already seen this for any reason, you would go to the ONC website at healthIT.gov/ISA. These are evaluated based on – if you have seen the evaluation that ONC has done looking at the standards process maturity, implementation maturity, adoption level, whether they are federally required, the cost and testing availability. So it falls perfectly in line with what NCVHS is doing, as they evaluate the standards and operating rules for adoptability under HIPAA.
We just wanted to bring that to your attention. The comment period ended on the 20th of November, but that doesn’t mean that they cannot be reviewed and comments considered when they get posted again next year.
We are very proud of this. It is part of the step towards convergence of administrative and clinical interoperability. If anybody has any commentary now, or you can wait till later on in the day.
GOSS: Thank you very much, Lorraine. I think our next agenda item is to move into the Predictability Roadmap Update, which I will be giving.
HINES: Our WebEx host, can you please bring up file B-1.
GOSS: While that is coming up I thought I could offer you a little bit of background. My goal here today is to just give you a quick update on where we are at with this very important project.
As you know, administrative transactions have been a cornerstone of opportunity for cost savings and efficiency in the health care system for more than 20 years. The secretary has the authority to adopt new or updated administrative standards annually. This supports the tenets of HIPAA, which will be reiterated in section 1104 of this Patient Protection Affordable Care Act of 2010, in which certain standards were called out to be adopted; attachments and electronic funds transfers, in particular.
ACA acquired the adoption of operating rules to support each of the adopted transactions. Where are we? Two versions of the Administrative Standards, the pharmacy and the non-pharmacy transactions have been adopted in 20 years. Operating Rules have been adopted for four of the 12 transactions. Stakeholders would like to use updated versions of the electronic transactions and operating rules, to take advantage of greater efficiency, lower burdens, improved workloads, and reduce expenditures for the greater purpose of improving patient care and outcomes.
Technology can improve outcomes through accurate information that meets the needs of the practitioners.
Standards development organizations are responsible for the maintenance and the upkeep of the tools the industry uses and are dependent on industry input to make the transaction content relevant and accurate.
HHS is responsible for ensuring that the standards can be available for use on a timely basis including a voluntary basis, between training partners until adoption can take place.
Feedback that we received in 2003, 2006, 2009, 2012, and even further reiterated in our review committee, carrying out to 2015, there is a call for having greater predictability and how the process of developing, adopting, and implementing standards can occur.
To this end, we took on a project over the last year, that started with information gathering, moved into individual discussions, and then culminated this summer in a workshop that is going to support future work to advance the committees’ effort on how to promote more predictability for all the participants that use the standards adoption process or standards process.
Our information gathering efforts created a baseline for featured standard organizations and operating entity on the processes, in garnering general perspectives for barriers for updates and their strengths.
We also held individual discussions with each of the organizations involved, enabling us to dive deeper into the issues and opportunities. That informed our work on having a visioning session with participants in August, and we have produced a summary report, The Appreciative Inquiry session, that was held in Washington, D.C. We have posted that report, and you can see the cover page on the WebEx. You can take a look at the details of that report via our website.
Plus, we have identified from the workshop, a set of themes that we are evolving. The first one is streamlining of processes, the second is changes to federal processes, the third s related to standards development organizations and operating rule offering entities, development of content rules that are agnostic of format.
The fourth theme is the improvement of data cohesion that is needed. The fifth one is the inclusion of non-covered entities, such as vendors and practice management vendors.
HINES: Alix, would you like these displayed on the WebEx?
GOSS: No, thank you. If you have the five themes, you can go ahead, if that is what you are asking.
DOO: We do have them.
GOSS: The next step for us and this very iterative process, is to meet with the Standards Development Organizations and Operating Rule Authoring Entities on December 14th, to further discuss and hone in on the possible next steps. We have been converting these themes into a set of thoughts and will have the opportunity to start talking about those thoughts with the SDOs and Operating Rules Authoring Entities on the 14th, which will then further inform some of our detailed work.
We also plan to engage end users in the discussion. I am going to hold off on diving into that discussion as Nick will be discussing that as part of the CIO Forum Project Scoping document that we will be covering later in the agenda. Nick or Lorraine, do you want to add anything?
DOO: I am just wondering; can everyone see all of the items on the WebEx?
GOSS: They just have to scroll.
COUSSOULE: This is Nick. I just reiterate one point, our information gathering to date, has been mostly with the folks involved in the actual creation promulgation, etcetera, of the Standards and Operating Rules. Part of what we are doing with the CIO Forum, which you will hear in a little bit, is a couple of different aspects. One is also to gather feedback of the folks that actually implement those rules in their business operations on a daily basis. That will just help us close the loop to be able to then get to recommendations and changes. We are trying to be very deliberate in that process and not jump to any conclusions, even though I think a lot of us in the earlier discussions, have a tendency to do that. But we want to make sure that we close the loop with all the involved parties first.
GOSS: Great point, Nick.
LOVE: This is Denise and I should probably know the answer to this, but I am going to ask what may be a dumb question, on number 5, includes non-covered entities as covered entities. Could you explain that a little bit for me so I can understand what that means.
GOSS: One set of feedback that we have received pretty consistently, through testimony on a variety of topics, whether it’s the review committee or looking at opportunities for adopting future standards. There’s been a pretty consistent point made by testifiers that the ecosystem is not aided in achieving administrative simplification, if not all the players have to participate in using the Standards and Operating Rules. There is consideration with number 5, about listing non-covered entities as just – how do you really make sure that there is a level playing field and everybody is using the same tools and standards to help us get that administrative simplification.
LOVE: So that would be like state agencies who are not covered entities but use the administrative data?
GOSS: Potentially. I think it is more the fact the vendors are providing the products and they do not have to comply. We will also look at the non-direct provider payer covered entity relationship, like the ERISA plan still has to follow the rules. So what you have is pockets in the process that are obligated to use the national standards and that erodes our, not only predictability, but also our efficiency.
LOVE: Thank you.
GOSS: Nick, I think we are ready to move onto our New Medicare Card Project.
HINES: File C. If our WebEx host can bring that up.
KAY: Good afternoon everyone. My name is Monica Kay, and I am the Deputy Director for the Division of Program Management. Our area is serving as the Program Management Office for the New Medicare Card Project. I, along with some of my colleagues in the room with me, will be presenting the New Medicare Card Project and address some of the questions that came up in the letter that Dr. Stead sent to us.
Hopefully, this will provide you with a lot of information regarding what is happening with implementation, as well as address some of the chief, key concerns that you may have for your constituents or organization. With that, we will jump right into the presentation. Hopefully by now you have heard of the New Medicare Card Project, but for those of you who have not, I just want to present you with a little bit of background regarding it. The Health Insurance Claim Number is the Medicare beneficiary’s identification number. We use it for claims processing, determining eligibility for services, we use it in multiple entities, such as the Social Security Administration, Railroad Retirement Board, with our states, and of course, with our providers, health plans, and other organizations. The Medicare Access and CHIP Reauthorization Act of 2015, mandated that CMS must remove that Social Security number-based HICN from those Medicare cards to address beneficiary risk of identity theft.
So from that legislation, CMS is responsible for mailing out new Medicare cards with a new Medicare Beneficiary Identifier or MBI, by April 2019.
A couple of our operational goals, and I won’t read them all to you, but the main thing is that we wanted to make sure that we minimized our burden for beneficiaries, minimize the burden for providers, and disruption to our Medicare operations. And just ensure that we had a way to exchange that HICN or new MBI, for our business critical data exchanges. Of course, we needed to manage the cost, scope, and schedule for the project.
With that CMS has undertaken a large effort in order to update our 75 systems, a legacy system, also understanding what it means to take an order for outreach activities, and analyze the many changes that need to happen to ensure that we remove that SSN based HICN off of there, and replace it with our new Medicare card.
What this means is it affects a majority of our stakeholders. That includes our federal partners, our states, our beneficiaries, providers and plans. Billing agencies, advocacy groups, data warehouses, clearinghouses, vendors, and partners. We have been working with them very closely since 2015, to help implement this Medicare card Initiative.
So let us talk a little more about the brass tacks in doing this. We must be able to do three key things. We must first generate Medicare Beneficiary Identifiers or MBI’s, for all of our beneficiaries. This includes our existing (currently active, deceased, or archived) and new beneficiaries.
We must also issue new redesigned Medicare cards. Those new cards that contain the MBI for our existing and new beneficiaries.
Lastly, we must modify our systems and business processes that require the updates to be able to receive, transmit, display or process that new MBI.
CMS plans to use our new MBI generator to assign over 150 million MBI’s in our initial enumeration, that includes 60 million active and 90 million deceased and archived, as well as generate a new MBI for each new Medicare beneficiary. We also have to generate a new MBI for any Medicare beneficiary whose identity has been compromised.
So just a couple of different characteristics between the old HICN and the new MBI number.
The Health Insurance Claim Number, the HICN, is a primary beneficiary account holder social security number plus BIC, or Beneficiary Identification Code. It is a 9-byte SSN plus a 1 or 2-byte BIC. Key positions 1-9 are numeric.
The new Medicare Beneficiary Identifier or MBI, is a new non-intelligent number. It is also 11 bytes, and key positions 2, 5, 8, and 9 will always be alphabetic. If you are looking at the Webinar, you will see examples of the Health Insurance Claim Number and the MBI number that will be used in the future. Please note that that MBI is fictitious on the page.
So the New Medicare Beneficiary Identifier (MBI) will have the following characteristics. It will be the same number of characters as the current Health Insurance Claim Number, or HINC, which is 11, but will be visibly distinguishable from the HICN. It will contain alphabetic and numeric characters throughout the 11-digit identifier. It will occupy the same field as the HICN on transactions.
It will be unique to each beneficiary. So the husband or wife, or dependent, will have their own MBI. It will be easy to read and limit the possibility of letters being interpreted as numbers. And will be upper case only and will exclude S, L, O, I, B, Z. It will not contain any embedded intelligence or special characters. Nor will it contain any inappropriate combinations of numbers or strings that may be offensive. We don’t anticipate changing that MBI unless it has been compromised and we have been notified as such.
Next slide, please. If you are on the Webinar, you are seeing a picture of our MBI Generation and Transition Period. April 1, 2018 is when our transition period begins. December 31 of 2019 is when it ends. During that timeframe, April 1, 2018 through December 31, 2019, we will both accept and process both the HICN and the MBI in transactions.
If you are looking at the bottom of that graphic, you will see that from April 1, 2018 through April of 2019, is when we plan to conduct that phased card issuance to our beneficiaries.
Next slide, please.
So what that means is that we will have a 21-month transition period from April of 2018 through December 31, 2019. CMS will complete its system and process updates to be ready to accept and return the MBI on April 1st, because we will start receiving a new beneficiary into our program.
All stakeholders who submit or receive transactions containing the Health Insurance Claim Number, must modify their processes and systems to be ready to submit or exchange the MBI by April 1. Again, that is what the expectations are for new beneficiaries coming into the program.
Stakeholders may submit either the HICN or the MBI during that transition period. CMS in turn, will accept and use for processing, and return to stakeholders either the MBI or the HICN, whichever is submitted on that claim during the transition period.
CMS plans to monitor that use of the HICNs and MBIs during the transition period to ensure that everyone is ready to use MBIs only by January 1, 2020.
Next slide, please.
CMS is making system changes so that when a provider checks a beneficiary’s eligibility, the CMS HIPAA Eligibility Transaction System or HETS, will return a message on the response indicating that CMS mailed that particular beneficiary their new card.
Beginning in October 2018 through the end of the transition period, when a valid and active HICN is submitted on a Medicare fee-for-service claim, both the HICN and the MBI will returned on the remittance advice.
Just a few details around that. You will get that MBI in the same place that you currently get the changed HICN, which is 835 Loop 2100, and Segment NM1, which is the Corrected Patient/Insured Name, Field NM109, which is the Identification Code.
A couple of points to note around that, use of the HICN and MBI for the same person with Medicare on the same batch of claims during that transition period, will process all claims with either the HICN or MBI, even when they are both in the same batch.
Next slide, please.
Other points of note, for our Medicaid and supplemental insurers, we will give our State Medicaid Agencies and supplemental insurers the MBIs for Medicaid-eligible people who also have Medicare before we mail the new Medicare cards. During that transition period we will process and transmit Medicare crossover claims with either the HICN or MBI.
Our Railroad Retirement beneficiaries. The Railroad Retirement Board will continue to send cards with the RRB logo. You can actually access what the new Railroad Retirement Board card will look like from our Medicare site: Newcard.gov site. I will provide that link to you.
You won’t be able to tell from it whether or not it is RRB other than looking at the logo and the line at the bottom of the card that indicates it as a Railroad Retirement beneficiary.
Another point to note, beginning in April 2018, we will return a message on the eligibility transaction response for a RRB patient. In that message it will say, Railroad Retirement Medicare Beneficiary. This will also be found on a 271 Loop 2110C, in the message segment.
Medicare providers must program their systems to be able to identify the Railroad Retirement beneficiary so that they know to send those claims to the Specialty Medicare Administrative Contractor or SMAC.
Next slide, please.
Private payers, for non-Medicare business, will not have to use the MBI. We’ll continue to use their supplemental insurer’s unique numbers to identify those customers, but after the transition period, supplemental insurers must use the MBI for any Medicare transactions where they would have used the Health Insurers Claim number.
Then in addition, CMS is working to develop capabilities where providers will be able to access a beneficiary’s MBI through a secure look up tool at the point of services.
These are for instances in which a beneficiary does not present their new Medicare card at the point of care. We believe this look up tool will give providers a mechanism to access that beneficiary’s MBI without disrupting their workflow.
Next slide, please.
So let us talk about some exceptions after the transition period. For beneficiaries, providers, and plans, they will no longer use the Health Insurance Claim number for internal and most external purposes. But we do have a few exceptions. For our Medicare Plan exceptions you will be able to use the Health Insurance Claim number or HICN, for appeals, and that includes our claim appeals and related forms.
You will be able to use it (the HCIN) for adjustments. You can use the Health Insurance Claim number indefinitely for some of our systems. That includes our Drug Data Processing, Risk Adjustment Processing, and Encounter Data. You will also be able to use it for reports. You can use it for incoming reports for us, for quality reporting, and Disproportionate Share Hospital requests, as well as outgoing from us. That includes our Provider Statistical and Reimbursement Report and our ACO reports.
Additional fee-for-service claim exceptions again include our appeals. You can use either the HICN or the MBI for claims appeals and related forms. You can also use the HICN for our span claims and that includes our 11X-Inpatient Hospital, 32X-Home Health, and 41X-Religious Non-Medical claims if the claims “From Date” is before the end of the transition period, which is 12/31/2019.
Other exceptions include our incoming premium payments. People with Medicare who do not get Social Security or Railroad Retirement benefits and submit those premium payments, they should be able to use the MBI. But if they do not have that, we will still accept their health insurance claim number on incoming premium remittances after the transition period. This includes our Part A, B, and D premiums and our income-related monthly adjustment amounts.
As you can see from our timeframe, we have accomplished a lot since the law was passed. In our position now, we are asking that providers prepare and test their systems and processes to use the Medicare Beneficiary Identifier by April 2018 and if they use vendors to contact them to find out about their practice management system changes.
As I have said previously, April 1, 2018, all systems and process must be able to accept the new MBI and this is because we will have new beneficiaries coming into our program.
Also in April of 2018, we will begin mailing the new Medicare card with the MBI to approximately 60 million beneficiaries. In June of 2019, that is our expected launch of our provider lookup tool where their provider will be able to look up that beneficiary’s MBI if they do not present it on site.
In October of 2018 is when we will get the return of the MBIs on our remittance advices. And of course, January 1, 2020 is the end of our transition period where we will be using MBI exclusively on data exchanges.
What we are asking that providers do to get ready for the MBI is that they subscribe to the weekly MLN Connects newsletter. We send out a lot of information related to that via our provider letters from the Medicare administrative contractors.
We are also asking that they verify their patient’s addresses. And if that address is different on file than they have from their transaction responses, we encourage those providers to have their address corrected with SSA, which is our source of records for all of our Medicare beneficiary addresses.
We also hope that they remind people with Medicare that we will never contact them to request personal information and that they should protect their new Medicare number like a credit card and only share it with those trusted providers.
We definitely want providers to get ready to use the MBI format. Ask the billing and office staff if their system can accept that 11-digit alpha-numeric MBI. And if they are using vendors to bill Medicare, ask them about their MBI practice management system to make sure that they are ready for the change.
And of course, you can visit our website where we post information and update it frequently at www.cms.gov/newcard.
Additionally, we want to make sure that you can access that new provider portal to obtain that patient’s MBI. You will be able to look up that Medicare patient’s new Medicare number through your Medicare Administrative Contractor or MAC to secure web portal starting in June 2018.
Let’s talk a little bit about outreach and education. CMS plans to give outreach and education to our 60 million beneficiaries, their families, advocacy groups, and caregivers, of course, health plans, the provider community through our provider letter and fact sheet that already went out, and our Quarterly Open Door Forum, which we have had several since we started. We have also been communicating with our states and territories and our other business partners, including vendors and organizations and forums such as this.
We will involve all of our business partners in our outreach and education efforts through our existing vehicles for communication. Again, this includes Open Door Forums, our HPMS notices and MLN Connects letters.
Just to give you an example of what the new card will look like. On the left, you will see the new CMS Medicare card and then on the right, you will see the new Railroad Retirement Board card. If you will just notice the difference between the logos that are on the far left as well as the Railroad Retirement Board indicator at the bottom.
And times of that new card issuance, CMS will begin mailing those cards in April 2018 to meet our congressional deadline for replacing all Medicare cards by April 2019. Please note that the gender and signature line will be removed from the new Medicare cards and that the Railroad Retirement Board will issue their own cards to their RRB beneficiaries. We are working with those states that currently include the Health Insurance Claim Number on the Medicaid card to remove that ID and replace it with some other Medicare Identification Number.
For beneficiary outreach and education, CMS plans to conduct that outreach and education to all of our beneficiaries on a timely basis to help them prepare for that change. It started in September 2017 with the mailing of our Medicare and You Handbook, which advised them and encouraged them to get their addresses updated with SSA. That will also continue through April of 2019.
Once they receive their new cards, beneficiaries will be instructed to safely and securely destroy their old Medicare cards and keep that new number confidential.
And then we are also working towards developing a secure way that beneficiaries will also be able to access their new Medicare number when needed.
As you can see from the tutorial, a lot of this information has been shared with you and it provides our timeline for when we are doing certain outreach activities.
Education and outreach resources are available on our website again at www.cms.gov/newcard where you can print and order them for your offices. We have a flyer that you can hand out, tear-offs for patients, a poster at the providers’ offices, as well as conference cards for beneficiaries.
A couple of key points to reinforce with patients. As I said before, help them to understand that mailing everyone a new card will take some time and that a card might arrive at a different time than a friend’s or neighbors. Definitely make sure that their mailing address is up to date by contacting Social Security. And you will have the information on that – and just making sure that they are aware of giving out that new Medicare card number and to guard it just as they do today.
A few key points that we want everyone to know are that providers, stakeholders, and everyone else needs to be ready by April 1, 2018. This includes their systems and their business processes. This is when new cards will begin to be mailed out as well as new people coming into our program who will never know that they have a health insurance claim number.
We also want you to note that there is a 21-month transition period from April 1, 2018 through December 31, 2019 where you will be able to use the HICN or MBI in your data exchanges.
We also want to make sure that providers know that they will have three ways in which to get that new Medicare Beneficiary Identifier: when the patients present the card at time of service, when the provider receives it through the remittance advice, or if the provider obtains it through the secure web portal with the MAC. And then of course, we are providing educational information via our website on our employers and partners page.
Thank you all for participating today. I know it was a lot of information in a short amount of time. But I just wanted to make sure that you had some resources that you could use. Please go to our website. That is where we update the most frequently asked questions and that is where you get your up-to-date information on the New Medicare Card Project. That is also the place where you will receive your resources. If you have any questions, comments or concerns, you can send them to NewMedicareCardSSNRemoval@cms.hhs.gov.
With that, I will ask if there are any questions.
LOVE: This is Denise. Alix, can I go ahead and ask? This is great. Thank you for this presentation and all the great work you are doing there to make this transition.
I have been asked by a group of states, a question that you may or may not have the answer to. But we have quite a few states that are getting research extracts for Medicare administrative eligibility and claims files for their claims database and state research. I think they are coming through RASDAQ. But there is a real concern about bridging. When there are two-year quality measures and two-year measures, how will that happen on those files that do not have the historical HCIN after they convert to the MBI?
KAY: The first thing is I would like you to please send that to our mailbox because I know I need to do additional research on that one. But just to give you some initial information, if you are using Medicare data for research purposes, there should be a DUA in place with that organization. If they need to request certain pieces of information whether historical or the new MBI, that needs to be contained within that DUA. That request has to be updated. But please – send it back. If the state is exchanging data for research purposes, it should be covered under their DUA agreement with CMS.
LOVE: I think it is. I will follow up on that, but thank you.
KAY: Please send it because I want to get the details of what is being exchanged and the particular system in question.
LOVE: Yes. I will do so. This just came up on a state call I think last week. There were quite a few states who were asking the question. We will follow up.
KAY: If you can let us know what states were affected, that would be really helpful.
GOSS: But I think that there is some content on RASDAQ’s website about that.
LOVE: There is.
KAY: Any other questions?
COUSSOULE: If we can ask the committee members to please select the “raise hand icon” then we can make sure we get to people in a rational way and know who is going, similar to the way we use tent cards on site meetings.
LANDEN: Monica, nice presentation. Thank you very much. Good update. One thing you did not mention. I saw a news release several weeks ago about the creation of an ombudsman person for the card removal initiative. Can you talk a little bit more about that? Who is it and what is the role and purpose and who does he or she serve?
KAY: Yes, we do have a provider ombudsman. His name is Dr. Eugene Freund. He is assisting us in addition to his duties that he already as at CMS. It is just another resource that stakeholders can use that they can reach out to him as well with questions on the new Medicare Card Project. We work in close concert with addressing some of the things that come up in some of his engagements with stakeholders that he frequently goes and talks to.
To make sure that I answered your question, he is just another resource that we can use for obtaining information about questions, concerns, or issues that the stakeholder communities may have regarding the new Medicare Card Project in addition to his existing duties.
LANDEN: Just to be clear, he is primarily for provider stakeholders?
KAY: He is for provider stakeholders. But I am quite sure if you came up to him with a question, he would get it back to us regardless who the stakeholder was.
LANDEN: And contact with him is through the mailbox that is up on the screen now, the new Medicare SSN removal?
KAY: Yes. You can definitely send it though that vehicle.
COUSSOULE: Thank you, Rich. This is Nick Coussoule. One question I have. Will there be any kind of a crosswalk created?
KAY: This is Monica. What is going to happen during that 21-month transition period is that you will receive the MBIs on the remittance advice through the claims. To give you a simple answer to that, the answer is no. But to expound on how you would get that MBI is that you would get it through either the patient presenting it or getting it on the remittance claims advice once they come in.
SERIO: This is Lois Serio. From the state’s perspective, we are including the MBI on many if not all of the exchanges that occur between the state and CMS. That is how they will be receiving the MBI.
PARTICIPANT: (off mic) – can patients look up for their new number —
PARTICIPANT: Just to be clear, the remittance advice piece of it starts in October of 2018. They will not start immediately.
COUSSOULE: Great. Thank you. I do not see any hands raised.
GOSS: At this point, are we ready to move on?
We are going to switch to the CIO Forum.
HINES: File D. Thank you.
GOSS: I am going to help facilitate the Project Scoping discussion related to the CIO Forum. And then when I cover the next one, Nick and I will flip around. Thank you for those members who took their – that was awesome – needing to do that for each of our Q&A round.
Nick, take it away.
DOO: For editing purposes, I may need to have the proverbial editing ability. Is that possible?
HINES: It is. Michael, if you could give Lorraine Doo access to editing this while they get started, that would be great.
GOSS: And we will be doing that approach for all three of the project scoping.
COUSSOULE: What I am going to do here is to walk you relatively quickly through the entirety of the document, covering the sections and structure of the documents. And then we will back up and walk through the individual pieces and take comments at that point in time so that I can hopefully give you all a good overview of what we are trying to accomplish and then we can start talking through feedback and updates that we need to make.
The purpose of this project as Alix hinted at a little bit during the predictability roadmap is to solicit input from senior IT leads and implementers of the standards and operating rules, both from the perspective of how they are implementing today as well as the changes that they believe are coming in the future, and how that might be impacted. We will drive into ideally a program that will do a one or two-day session. We will have various and sundry individuals come in to provide information in regards to those topics.
One thing I want to make sure I stress a little bit is what is out of scope if you look at C down under Section 2. What is out of scope is we are not really intending to review the specifics of the standards or operating rules. We are really more interested in the process and the challenges and opportunities and the limitations based on what is coming.
From that perspective, outlining the major components and elements of work to be done, part of it is setting up all the logistics for what would be to happen as far as the dates, the specific coordination of panels as well as individuals and companies and types of organizations that need to be represented.
Specifics to individuals beyond just what kinds of group and kinds of entities we need. We would put together the usual summary for the participants about the questions that we would like them to respond to and then the other usual logistics about setting up federal meetings that we need to set up.
We would look for key inputs, dropping down into segment 4, from a number of different sources where some of this or individual or government agencies and federal sources and HHS, et cetera that we would get that feedback from more specifically in ONC and others about what other initiatives would be going or are underway that would be on the radar.
And then from the timeframe perspective, we would ideally like to start in the first quarter to put the information together to conduct a forum in the second quarter and then following on after the second quarter would be getting the feedback and informing the visioning work both with the predictability roadmap as well as the potential other initiatives going to NCVHS at the same time.
The CIO Forum Project Summary at the end of this page, which is now showing on your screen, gets into a little bit more detail at a high level, a little more summary of what the intent is. I will give the participants here a chance to read through, that because I think that is actually pretty useful and then we will go back down to the beginning. I will give you just a couple of minutes and then we will go back down through the beginning of the document.
(Pause to read the document)
COUSSOULE: Okay. Hopefully you have had a chance to at least read through that. I guess what I will do now is go back to the beginning of the forum documents. In regards to the description and purpose of the forum, are there questions or comments from committee members in regards to the purpose? Please click your “raise hand” icon and I can try to make sure we get to everybody in a reasonable fashion.
The one additional comment I would make, and I will ask Alix to weigh in on this as well. The one additional comment is that we are really trying to or intending to, double dip a little bit in regards to the forum that we would put together. As we proceed down the predictability roadmap, evaluation, data gathering exercise and up to recommendations, we knew we needed input from the practitioners and implementers of the standards. But we also know based on other work, the National Committee is doing in some areas that we would love to solicit their feedback into some of the future challenges that are coming, both in relation to standards and operating rules as well as to help inform some work on those initiatives that we may undertake such as the Beyond HIPAA or even the – that is probably the most relevant one.
GOSS: Well said, Nick. This is really about not only understanding how to predictability of what we are already doing, but to make sure that we are doing that thinking to the lens of the longer-term innovative view, so we are looking forward to the forum and hearing the feedback. I noticed that Linda Kloss has raised her hand.
KLOSS: Thank you. It occurs to me as I am looking at the purpose and the description and program that we may want to specifically include the chief financial officer of health care organizations because a lot of this does have to do with revenue cycle issues. I think in some ways in that regard the CFO or revenue cycle or financial technology folks may end up being the subject matter experts at the table. I would think that we may want to do some outreach to HFMA and we may want to make sure we have the CFO represented as well as the CIO.
GOSS: It looks like Lorraine captured that. Are there other questions, comments?
COUSSOULE: Let me walk down then to the specific layout of the program. Our intent was to schedule it either one or two days and some of that would depend specifically as we get into how many different groups and how much time we would actually need based on those groups and the different feedback in individuals and then also how we would – the question I would ask for the other committee members is there are some questions about how we separate out the feedback from and specifically relating to standards both current challenges and future challenges as well as the more visioning kinds of issues and items that would go a little bit beyond standards and potentially other aspects of what the committee would undertake.
GOSS: Nick, I see Denise’s hand is up.
LOVE: I just had a question and maybe this has been addressed. How will the CIOs be selected? I am thinking of smaller organizations that may have not a CIO or a CIO that is stretched among other jobs. I guess I am asking about the selection process.
GOSS: I know that we have started some discussions with CHIME and they are willing to help us identify candidates. Plus, I think we would identify potential CIOs or maybe even CFOs based upon – suggestion from within the known universe of testifiers, but also look to make sure we are balanced in the organization type. I am giving you some of my personal preliminary thoughts about how we would go about doing that. I do not know that we have thought at that level of detail quite yet and we want to solidify what it is that we want to talk about in a general approach. But I think your point is that CIOs of different organization sizes have different challenges and we want to make sure that is reflected in our panel.
LOVE: Yes, and especially some rural components. Just my opinion.
COUSSOULE: We are not really caught up in the titles, if you will, more about the general goals. We thought that this would be one of the easier ways to communicate the kind of role that we were looking at. This is not about somebody who is necessarily in the weeds of the day-to-day transactions, but somebody that can understand the company challenges with the technology at that level. It needs to be somebody who can — not just technical, but can also play that understanding of the business side role.
GOSS: — conversation off of Linda’s comment that when we send out an invitation to participate to an organization, we put a description along with what you just described and try to let them – who they think —
KLOSS: It would be great to have a team, but that may not be realistic. We have had representatives from HFMA in the past and they have been helpful.
GOSS: I also think that the way we are approaching our work today at NCVHS and creating project scoping documents and I know I have been suggesting that once we finalize a project scope document that we make that available on our website. It starts to give the opportunity for the word to get out enough in advance. If people are interested, they have a way to raise their hand to us so that we would – they can broaden the ability to hear testimony from a diverse set of participants.
I see Rich Landen has raised his hand.
LANDEN: I think another way of phrasing what we are looking – are those who are operationally impacted by the standards and we are looking for what they are seeing with the standards. We are also looking for the – how the standards have to be involved to meet their future business needs. I like Linda’s suggestion that you cannot always differentiate between members of the C Suite because there are different memberships and organizations of different sizes. But we are looking for the people who can talk at a strategic level rather than down in – I think we are looking for multi-year roadmaps. The purpose of that is the C Suite —
GOSS: I think to your point, Rich, it is about a person coming to represent their organization’s perspectives from day-to-day business operations, information technology systems and financial aspects. I would hope that even if we would target a particular organization that they would send a representative that could reflect their overall organizational view of what predictability would look like for them. What do they need in a predictable standard and operating rule development and promulgation process, but also – where do we meet today with their innovative needs of tomorrow?
LANDEN: Well stated. Are there any other questions or – comments —
COUSSOULE: The only comment I would make is I do want to be sensitive to Denise’s point, which I think was a really good one is that we need to make sure we are encompassing different scale organizations because they have different sets of challenges. We do not want to only focus on large companies with big organizational structures and big technology organizations, but make sure we understand the challenges all across the spectrum.
GOSS: They may not have the ability to come in person. We do support the ability for people to submit written testimony because it is often quite difficult for small organizations to have the financial resources or the time to actually come to DC and do that kind of testifying.
COUSSOULE: I think if I walk down through the document a little bit, I guess the next topic I would like to cover is a little bit of the types of organizations that we need make sure are included. Drop down to 3E. What kinds of organizations do we need to make sure we are covering? If you look at the list here, it talks about health care technology companies, hospitals, developers, EHR vendors, associations. Are we missing anything that we need to make sure we have covered from just different business area perspectives or different types of organizations?
GOSS: I think for this kind of discussion, Rich and other subcommittee members, I think we do brainstorming. Feel free to chime in. We will start with Rich.
LANDEN: I assume the EHR vendors, but I think that should be broadened more to software vendors if we do want to include as we have discussed earlier the revenue cycle and practice management vendors as well, especially as we talk about smaller organizations. There are many of them who either rely – much shall we say under vendors or to actually outsource operations to a vendor or a service contract. You will want to include those as well.
GOSS: I agree with that comment and thinking that we have payer systems. We have clearinghouses. We have more than just the EHR folks.
DOO: Are there any name examples – the practice management. There were some other types that you had just mentioned. Alice, I think you had said something or Rich.
GOSS: I said specifically payer systems and clearinghouses.
LANDEN: And the category that I mentioned — the other one is outsourcing vendors.
DOO: Thank you. These examples might actually not be so as appropriate?
GOSS: Correct. I know you had a nice catch-all and others to be named in that.
COUSSOULE: I know payers were not specifically listed in that, but we can be sure that they will be included.
I guess I will skip down. The one I will come back to at the end is the suggestions for appropriate questions to ask. Let me get to the other parts of it first. I will skip down to the key inputs. Our thinking process was that we needed to make sure we got good input in regards to what else is happening in the industry, and specifically also through the federal sources that we need to be aware of to make sure we are including them in our exercise. There are a number of agencies listed there: internal CMS, et cetera. What might we be missing or not including there if we are trying to make sure we get a good scan of what is happening concurrently that we need to be cognizant of?
LANDEN: Two concepts I would like to call out a little bit more explicitly. I think they are in here conceptually. Number one is product design. This is primarily under health plan or the employer side. How does the technology support innovative product design? What does the – new technology enable innovation? Can it simplify things? Can it help achieve our efficiency objectives?
And then the second concept is both on the health plan side and on the provider side and that would be the contract and compliance management. I know there are a number of software products out there, but how standards can – or maybe they cannot, but how can – again, back to innovation and efficiency. How can we automate a moderate contract or how can standards help automate or make it more efficiently contracting and contracting management, contracting clients –
DOO: Contract provider, provider plan contracting? Is that what you mean?
LANDEN: Yes, the contracts between the health plans and the providers are what I am focusing on.
GOSS: Nick, while she finishes typing that, I raised my hand because we have two comments. I think they were related to the prior discussions. I also noticed that when Linda Kloss raised her hand. I am not sure if she is in this section. I have the comments that – come back to.
KLOSS: It is. I wondered if we wanted – I know one of the next innovation challenges is important input. I wonder if we also want to know what their current key priorities are. I think that is slightly different than Nick’s innovative challenges. But it would be useful to know what marching orders they have based on organizational goals.
DOO: Can you say that again?
KLOSS: Other inputs for the projects.
COUSSOULE: I think that is a good point, Linda. That is clearly our intent to both understand the existing challenges and whether the current processes in place and results from the development, implementation, promulgation of the standards and operating rules serve the existing need. It is both existing challenges as well as the future of visioning. We want to make sure that this is not solely a visioning exercise, but also an – exercise. If we are not clear on that, we need to make sure we are. That is great feedback.
LOVE: Yes, and this may have been addressed. I am coming always at it not from the front end of the transaction, but the back end. This may be subsumed in Rich’s comments, but beyond transactions, we have alternate payment models. Reporting and capturing data as we bridge fee-for-service world to other kinds of worlds that we are only imagining now, is that subsumed in the contracting compliance management or how reporting happens as a transaction changes or the payment models change? Is that too in the weeds?
GOSS: No. I think we had captured a bit of the ACO aspect. She has updated that to reflect alternate payment models.
DOO: Is that okay up there or do you want it somewhere else?
COUSSOULE: I think if we capture it now, we will be fine.
LOVE: That is fine. I just wanted to be sure it was there.
GOSS: I am going to suggest that we back up to the prior section please. We received two suggestions. One was to make sure that we included pharmacy because we have appeared to have not included them as far as organizations to be engaged in this.
DOO: That was not intentional at all.
GOSS: I know it was not, but Margaret keeps us honest. NADP, as an association, is suggested to be included. They are very active and likely to be very interested.
DOO: That is a terrible oversight.
COUSSOULE: One of the challenges that we will have frankly, is trying to make this a manageable session while still getting input from all relevant and interested parties. We will likely by necessity be excluding some people, not by design, but I think by necessity from the actual live hearing. But we will try as best we can not to do that and make sure we are comprehensive. Clearly, if somebody is not presenting, they can still provide written feedback as Alice indicated earlier.
We do not want to try to start off on a negative note, if you will, but I do want to be realistic when we start looking at all the potential involved parties to make sure we are getting a good representation across the spectrum around the table for that feedback, but also making sure we take in the other feedback that is warranted.
GOSS: Good commentary. I think in your editing, Lorraine, my perception, although watching you like a hawk, we deleted NCPDP from the list.
DOO: In part because they would go on to the SDOs. The pharmacy professional. You think they go both?
GOSS: I think that NCPDP is the standards – that would testify – but also that they have some pharmacy-specific entities that they wish to present – if I got that wrong.
DOO: No, that is totally fine. I think it will be iterative, so it is helpful.
GOSS: I think the point she would like to have included is the National Committee of Independent Pharmacies, which is NCPA, Association for Independent Pharmacies.
DOO: Okay. And NADP.
GOSS: NADP came in from Matthew Albright. I am not seeing any other hands raised and I am sure how far you are through the sections you wanted to go next.
COUSSOULE: Let me cover one more thing, which is the timeframe. And the reason I get into that a little bit is to ask the other committee members even thinking about other items that are on the docket that would potentially be undertaken.
Again, our intention would be to frame this all up in the first quarter to be able to conduct a forum in the second quarter, summarize that feedback to tie in the predictability roadmap and then take the other path of that and use that to inform other efforts that we might undertake or be undertaking the committee.
I do not know if anybody sees that as a conflict or a challenge or opportunity within that timeframe they would like to comment on. I see Linda’s hand up.
KLOSS: I think we are considering some Privacy Subcommittee activity in April. That would be two kinds of major invitational events in the second quarter. I am just raising that as an issue that may have to be resolved by the executive subcommittee.
GOSS: Linda, you bring up a really great point, which is actually why I had just raised my hand and put it back down. After the subcommittees complete their virtual meetings this week, we will have an executive committee next meeting next week where we will work to reconcile the various desires of the subcommittee into a reasonable work plan for the whole committee and that most effectively leverages the available financial and bandwidth resources that we have.
Although we are discussing all of these projects scoping documents for 2018, do not walk away with the belief that this is a done deal and the time table is written in stone because there are likely to be changes after this call when we meet next week. And then I would anticipate that a cohesive plan will be presented at our January 9 and 10 Full Committee meeting and invite Bill Stead or Rebecca Hines to chime in on this aspect.
HINES: You are right. We are hoping to come to the January meeting with most of these puzzle pieces worked out.
STEAD: I would say we are hoping to come out of the December 7 call with a plan that is workable and that would have the most impact across the subcommittees. And then we will flex that plan as we have to as we learn more as we always do. Is that fair, Rebecca?
COUSSOULE: Okay. Other questions? I do not see a hand up at the moment. Let me go to one other question where I would like to get the rest of the committee’s input and feedback right now and that would be dropping back into Section 3K specifically, which what kinds – we talked about a number of different topics, but what kinds of questions do we want to make sure we include in the framing of the hearing so that we can guide the participants? Some of them are included a little bit throughout this document. We talked about a few of them, but just anything in particular that the committee members feel that we might not cover or want to make sure we stress as far as questions we ask the hearing participants to weigh in. I assume we have been really good at capturing that so far.
GOSS: I think Rich and Linda started – a little bit earlier on the discussion. I am not sure if there are other comments people have.
KLOSS: I would be interested in having some time spent on understanding how organizations monitor the standards environment and determine how best to take advantage of standards development. There may be some very interesting learnings about how to support organizations to do this well.
GOSS: Yes, because we really touch upon one of the most challenging things in the standards world is that there are volunteers that pay to be members and travel the meetings and to do work. In this economy, it is very clear that organizations have to make hard choices about where they are going to spend their resources financial or human and supporting a standards development or operating entities sort of development work is a time and resource commitment. From my own leadership time within X12, it was really hard to get people to support it and to understand the value of it and the positioning of being in the know and influencing the process.
KLOSS: I just want to clarify what I was meaning because I totally agree with what Alix said. We know that organizations that can commit to being part of the process, gain a lot in their understanding and ability to use the standards. But even if you are not at the table, how are you aware of the full breadth of what is going on? My hypothesis is you are not aware. You are not monitoring. These things catch you off guard or you do or do not have a good process then for evaluating and integrating standards development opportunities into what you are doing.
I think there are two levels of monitoring. There is roll your sleeves up and participate and then there is know what is going on and be incorporating it into your planning.
COUSSOULE: That is exactly where I was going, Linda. I think that is great feedback. We have a few other hands up.
STRICKLAND: One of the things I think would be interesting to explore with these folks is the funding cycle for their organizations. What is the timing for funding specific efforts? If we came and said X was due in two years, is it a one-year cycle for them to get the funding and to prepare that or is it based on small, medium, and large projects? Does the timeframes vary? I think that would be important for us to understand the variances there.
DOO: Debbie, is it appropriate to include updates for operating rules as well or is your question strictly related to standards?
STRICKLAND: Yes, it would include operating rules as well and basically any other changes that we would be proposing.
COUSSOULE: I see Rich’s hand up.
LANDEN: Three comments here and I do not have these in terms of specific questions. I guess my first one would be get reaction to the goodness – between the HIPAA transaction standards and operating rules and the business process requirements of the organization, how well does or does not the transaction standard which for the most HIPAA transactions are processed for these claims, eligibility, enrollment? How well or how well do they not meet the current needs?
Second would be the same question, but at our other two-time points: five years down the road, ten years down the road. That is number two.
DOO: So you mean how well do the two meet the business needs of industry – is that right?
LANDEN: Goodness of fit. How well are the business needs met by the standards?
GOSS: And that you would like to do that in a time span of currently and then your anticipated view —
LANDEN: I think earlier we said we are looking at three years out, five years out, ten years out.
GOSS: Yes, we did.
LANDEN: The other point is testing. What would the organizations – as far as testing requirements before industry gives them a revised set of standards.
DOO: Some of the words are blocking out. That is why I am missing some. Is it what do they want the testing requirements to be before the industry gives them a new version?
LANDEN: Yes, how thoroughly should the proposed standards be tested before final adoption?
GOSS: Rich, can you clarify something? When you say the word testing, there is testing where I can just check to see if it works within my own systems and maybe a training partner or two and then there is a difference between more of a robust pilot. Are you missing a distinction between testing and piloting or you think it is all part of the same trajectory.
LANDEN: I would put that question on the presenters. What do they need?
DOO: So define testing from a standards perspective?
LANDEN: Yes. For an end user, what is the expectation or what is the ideal stage that the transactions have gone through before they arrive at the door step of the end user?
DOO: The end user or NCVHS?
LANDEN: I am thinking the end user.
COUSSOULE: That becomes particularly relevant for the point Linda raised earlier for the folks that are not involved in the actual development process of the standards. What would the expectations be? I think that is a great question.
LANDEN: That would apply to anybody who develops software on behalf of the end user.
COUSSOULE: I see that Denise’s hand is up as well.
LOVE: I think Rich kind of stole some of my thoughts, which is good. But I just want to be sure that my thoughts are captured in that goodness of fit because what I hear in working with some vendors – RFP right now is how to balance the standardizations with the nimbleness and flexibility needed in this rapid change environment. Rich, does that goodness of fit get at that with the business requirements? Because the push is to move faster than standards.
LANDEN: Denise, thank you for the compliment, by the way, but I think there is probably a distinction between nimbleness and flexibility in terms of what I was describing as good fit – how well does it work – does it exceed the business requirements.
But I think where you are going is more what I would categorize is the ability to innovate – we have a set of regulations on the books that are not going to change quickly. That to me would be – as we have seen in the past, we cannot have it too loose because it becomes the Wild West and every trading partner does its own thing. Is that where you are going on this?
LOVE: It is. What is that balance and how can we bridge it? I think you need a little of both. I agree. What is the optimal balance then? Because the standards process does move quite slow.
It also bridges another little – I do not know if this is appropriate for this discussion, but what is the common good? The standard, open source versus proprietary competitive. That probably gets something that is beyond the standards. I do think flexibility, nimbleness versus standards, what is the optimal balance.
COUSSOULE: Denise, you raise an interesting question. If we think about the standards process and where it may be lacking, where have some of the testifiers gone around that to develop proprietary things because the standards could not meet the needs? I think it would be useful to also to understand that.
LOVE: Exactly. And some of those innovations end up being standards down the row.
GOSS: How does the more predictable development and commendation and implementation process help avoid or – more efficiency and the lack of people going off and doing something outside – come back eventually. We have only had two major versions adopted in 20 years.
LOVE: And how to capture those innovations and rapid cycle them back into a standard.
GOSS: And that can go along with some of the things that we even heard about — floor not a ceiling, but that is a separate comment.
DOO: Who was that that just spoke about rapid cycle something?
LOVE: That was me. Just kind of free associating here. As we see these innovations happening outside of the standards, I think what I struggle with is how do you capture that back into a standard in a more timely way.
GOSS: We are using the term standard here to refer to both standards and operating —
DOO: Right. We did have it in our write-up below where we said when we use standards —
STRICKLAND: I want to zoom all the way back to when we were talking about testing. Alix, you brought up pilots. I think that it would be an interesting dialogue to have with these folks if they think that their organization would be able to participate in pilot programs without regulations.
DOO: Can you say that in a question?
STRICKLAND: If they feel that their organizations would be able to participate in a pilot of the standards without regulations.
GOSS: It is not just piloting but actually working towards implementation without – there are two – there is one where are you willing to pilot it before it gets promulgated – but then there is also that you may be willing – if you were not limited – let me rephrase that. If you were not forced to upgrade to a new version, would you be willing to voluntarily do a pilot for a newer version – in the absence of any federal —
STRICKLAND: Right and maybe we want to say without regulations or funding.
COUSSOULE: — in a production system, not just a testing system.
STRICKLAND: Yes. I think it would be a testing system initially, but they would have to really build it out. It would be like a production system because there are so many components to these standard transactions that you would really have to build a side-by-side copy. You have member databases. You have provider databases. You have benefits. You have all these other systems that they need to integrate with. You would have to have copies of many of those in order for you to actually do a full end-to-end test with the transactions completely.
DOO: Because you would need every type of entity. Because you need the plan vendor, the provider.
STRICKLAND: Correct. It would be quite an orchestration.
COUSSOULE: We are about at our time limit here. Any final questions from committee members?
KLOSS: Do we want – I am sure we are going to have some discussion about what a roadmap – what are the characteristics of a useful roadmap. We are talking about how does it fit into it and so forth. We would probably need to take a step back.
GOSS: This is a lot of really good input and I have seen more hands up.
LANDEN: The last page of this section, the CIO Forum Project Summary. That second paragraph that begins “how do CIOs keep up with emerging technologies?” As I reread that again – is kind of reactive. I would like to slightly re-focus that and to also incorporate not just reaction, but to identify opportunities for innovation that are enabled by the next generation of standards and operating —
DOO: Do you want to send me something?
LANDEN: Sure, I can do that.
DOO: That would be great. I would love it.
GOSS: I want to make sure we get everyone’s great input. This has been a really productive discussion. Nick, I think you were going to bring us into break.
COUSSOULE: I was. Thank you for all of that feedback. We hope we have captured it all. I have taken lots of notes as well to make sure that – we hopefully will capture it all.
We are at about 2:48. Why don’t take 15 minutes and come back online at 3 o’clock. We will plan on five past three if that sounds reasonable to everybody.
GOSS: This is Alix Goss. I am going to go ahead and start talking about the patient matching assessment, our project document. First, I would like to start with a little bit of background information.
First, to describe patient matching and using the Office of the National Coordinator, this shorthand description of techniques used to match the data about an individual housed by one healthcare provider with the data about that person housed by another or many others. In practice, patient matching is the process of comparing different demographic elements from different health information technology systems to determine if they refer to the same patient.
Many recommendations have been made over the years to tackle different aspects of patient matching. Experts advise the entire healthcare system and can impact its performance from data capture, patient registration to technology and algorithms along the way.
There has been no industry-accepted baseline benchmark or testing approach. In 2017, ONC launched the Patient Matching Algorithm Challenge done in part to promote the need for better transparency about the performance of patient-matching algorithms. We have also seen another industry effort with CHIME support of the patient matching through their challenge with their $1 million Healthcare Innovation Trust National Patient ID Challenge in 2016.
I want to kind of set up what patient matching was and a little bit about what we know is going on in the industry. The project description here is to conduct an analysis of industry initiatives and opportunities that are underway to improve the accuracy rate of patient identity reconciliation. So we really want to analyze the current state of work that’s happening in the public and private sectors, and patient safety is at the core of these discussions.
We want to identify these industry initiatives to understand their successes, barriers and risks and lessons learned that can be leveraged on a broader scale. And then we can summarize the findings and create an environmental scan, white paper or other work product to allow the committee to determine if there are any next steps for the workgroup.
The goal for the project is to produce a summary report to share with the full committee and then have it available on our website. It will then help the committee determine if there are recommendations that we should be making to our federal colleagues, other workgroups or organizations working on the issue. We also believe that by engaging in this initiative we may find opportunities to collaborate with ONC’s federal advisory committee, as patient matching spans clinical and administrative efforts.
That is the purpose and description of the project. The scope — It is within the scope to assess the current state of work on patient matching. However, given the extent of the work already underway at ONC and that it will likely be taken on by their federal advisory committee, we understand the importance of collaborating with ONC and contributing where it’s appropriate. This is to avoid redundancy between our two efforts.
It is important to address what is out of scope, which is the evaluation and assessment activities related to patient matching, and not about creating or adopting an individual identifier. We are not trying to go the individual identifier route.
In regards to the major components or elements of work to be done, which is Section 3, we anticipate first engaging the Office of the National Coordinator and the federal advisory committee, or as we refer to it as FACA. We want to assess what we have learned and we typically take a very iterative approach, wading into the water and determining what is the next appropriate move forward. This will also consider stakeholder engagement, identifying and engaging with established industry stakeholders such as CHIME, AHIMA, WEDI, SDOs, operating rule authoring entities, analytical organizations, and organizations involved in replacing master patient indexes.
We also think we need to identify new stakeholders such as NATE, the National Association of Trust and Exchange, Blockchain entities, Health Information Exchanges and other innovators who may have commentary on this important topic.
Once we have narrowed down our thoughts about how to proceed and who to engage, we are going to plan for and act upon our selected activities, which we are sort of envisioning as being a one-day forum for bringing all the various pieces together that would enable us to produce the environmental scan; of course, hold the selected activity and then prepare the summary report.
Key input would be to start with HHS and other federal sources, look at industry group efforts and investigate other federal and private sector industry activities as identity reconciliation is not unique to healthcare.
From the proposed timeline perspective, we anticipate in calendar year 2018 being able to proceed with an approved charter and scope, as it gets reconciled with the Full Committee’s work, and, in the first quarter of 2018 calendar year, anticipate that we would meet with ONC and identify all the parties engaged in work on Patient Matching. We would then conduct follow-up conversations with CHIME. We have actually had one already with CHIME. They are very supportive of this initiative and actually submitted a letter to the committee for our consideration that led to its prioritization as a potential 2018 work product.
In the second quarter of 2018, determine what activities should be conducted for the remainder of the year based upon what we have learned in this entire quarter; evaluate the options for stakeholder engagement, monitor the progress of the CHIME Innovation Finalists, and determine —
MS DOO: I guess we can eliminate that.
GOSS: That’s right. They are taking a pause and reaffirming their next step.
We will then determine the role of NCVHS in collaboration with ONC’s federal advisory committee. Moving into the third quarter, planning official activities, finalizing and pursuing national engagement strategy and outlining the appropriate event logistics.
In the fourth quarter, we would likely hold a hearing or a workshop based upon our current thinking. Of course, this is all, again, in consideration that on December 7th we will have to balance the workload better.
I will give you now an overview of the document that was presented and the background about the patient matching. I extracted a few pieces that I used in my opening remarks. I would really like to go back to the beginning of the document and walk through each of the steps and have committee members raise their hands for comments as we go. We will go ahead and start with the description section.
With our goal of really doing an industry analysis and elevating our current take on patient matching, that will be our focus in this event. Are there any comments on the purpose?
Okay. Scope and out of scope. Any comments on those two parts, C and D?
COUSSOULE: One question that comes to me is how much do we want to ask the question about not only what the state of patient matching is but to get to more of a clearer elucidation of what the issues are because of the challenges with Patient matching? Is that something that we want to try to discern at the same time in a little more — just to ground the potential for any kind of future either recommendations or feedback based on the environmental scan?
GOSS: How I’m hearing that, Nick, is do we need to be much more succinct in the scoping document about not just getting a state of the efforts but, really, what are all those issues that they are tackling that come from the patient matching reality. Did I get that right?
GOSS: I think you are spot on. I want to know what are — we would want to highlight what are the current modern day issues that we are encountering because we don’t have a consensus on the best way to achieve 100 percent patient matching. So I agree with you.
I am thinking that we want to make sure about that distinction, not just what’s currently happening in the industry on this topic but really the nuggets of goodness, as to what challenges, barriers or issues are trying to resolve to get a 100 percent matching rate.
LANDEN: I just want to piggyback on Nick’s. I would like to see what you were just saying portrayed quantitatively. What are our error rates now? What are our success rates in doing patient matching? My assumption there — and I want to test it out — is that we have improved in the last five or ten years, but I suspect it is far from satisfactory.
I would just like to emphasize the quantitative so that we can focus the discussion and actually have a metric to observe as we move toward implementation of various solutions.
GOSS: Good addition.
DOO: Where would that go?
GOSS: I don’t think we have a section for that, Lorraine, specifically because we didn’t get down to the point of identifying possible questions and scope. Part of the aspect would be I think to address it within the scope section specifically that we want to not only get an assessment of the current state but also of the issues with patient matching, and to have those points be quantified.
DOO: I am just sort of writing.
GOSS: We will go back and update this. I think I saw Linda’s hand go up and Denise’s hand.
KLOSS: Do we want to try to understand the kind of best practices? I think Rich touched on this, that we know there’s a range, that there has been progress, but there is still quite a range. In some of my discussions with organizations on information and data governance, some are striving to almost get to six sigma levels on patient matching and others don’t really have a handle on what their rate is.
It seems to me that this might be an interesting theme to tie into whatever report, that this is an area of critical importance. It is one without any standards or agreed-upon best practice metrics. I think we could try to be seeking out a better understanding of whether a best practice standard could come out of this.
GOSS: Thank you, Linda. We have captured that.
LOVE: I was a little late, so I may have missed this. Is patient matching — is this very global, or is this specific to industry? You know, the states are doing so much patient matching and it varies by use case as to the precision and the methodology that a particular entity may undertake depending on the use case. We are seeing a lot of probabilistic and deterministic matching in public health.
But I guess I’m confused on this discussion on patient matching and in what context.
GOSS: I think it’s a pretty global context, in my perspective. This is about ensuring that we have — If you look at it from an industry perspective, there have been goals of getting to 100 percent matching accuracy rates, and it’s specific to healthcare although we want to learn from others. But I think it is a global healthcare challenge that needs to have the current state elevated and the best practices as well as the challenges.
LOVE: Okay. It is a very broad topic. That’s just what I want to underscore. We have many use cases, and again, methods do vary and the precision that you are achieving and the cost that you are willing to undertake. Because you can get a good probabilistic, say, at 75-80 percent in some cases, but how much do you want to spend on that 20 percent to manually forensically put together that 20 percent?
Anyway, I am probably digressing, but you answered my question.
GOSS: We have captured that addition. Linda, did I see your hand?
KLOSS: I think that Denise’s comment raises a really good point that we will need to clarify and scope that best practice, and the standard does or may differ for analytic uses versus patient care uses. So, use cases are an important part.
GOSS: Yes. So we may need to be thinking about use cases as we design this to make sure that we are hitting the basic covered entity exchanges or the internal organization, to a public health registry to a research organization. Right. That could get pretty broad. We are going to have to be creative about that.
KLOSS: We have to be careful about what we are addressing.
GOSS: Nick and Rich, I see your hands are up.
LANDEN: To Denise’s point, I think Linda covered most of where I was going. It is certainly an important point and I think we need to spell out that, depending on the use, we don’t necessarily need to achieve 100 percent. So, what are the categories of use cases, and then practices and costs would be varied by those categories. Obviously, the closer we have to get to 100 percent the more effort, the more complex, the more certainty we need, thus, more expensive.
But just to lay that out. As Denise pointed out, it is not a single, one-size-fits-all description of a problem nor solution.
GOSS: I am starting to wonder. I think a 100 percent goal is spot on, but when we think about that, if you’re at 80 percent, what is it going to take and the cost to get to 100 percent? There is a cost-benefit aspect there and I’m wondering what kind of questions we have about that. Is the goal to get to 100 percent and is the cost and effort justified?
LOVE: This is not a raised hand but a comment. You can get to 100 percent different ways depending on the certainty score that you want. You are going to have to make some judgments, so your 80 percent could be a good hit, good match, likely within a probability of 97 percent that those match.
Then you get into another terrain where the match is a pretty good match, not precision. Then you get to that last percent. You can get to 100 percent if you relax your risk assessment there or your precision. And again, it probably depends on the need. For clinical decisions you want 100 percent, but for statistical purposes, no, you don’t need 100 percent.
COUSSOULE: I am exactly with Denise on that one. I think the challenge is both a use case challenge and then what I will call an expectation of automation. If you’re doing a kind of one-off for an individual and the match rate needs to be 100 percent, whether you can automate that or whether you have to have a human that does judgment and does different things are two different things. When we talk about it we tend to talk about it as far as an automated fashion.
LOVE: Right. And that human judgement — and I have been involved in some of these projects. Then you have to decide how far you go with the human judgment, how many supplemental documentations do you go after to verify that small percent. Even with human you have to make some decisions about how precise.
GOSS: I see Bill Stead’s hand is up.
STEAD: I was actually trying to put it back down because Nick raised my point.
GOSS: Linda, do you have a question?
KLOSS: I certainly don’t want to leave the impression that I was advocating for 100 percent. I actually think that the approach of use case clarifies this, and we need not try to work out that answer because that will be one of the things we learn in the scope of exploring the current state.
GOSS: Other member comments or questions? We really talked a lot about in scope. Any questions on out of scope? I don’t see any member hands raised.
Let’s go to the outline of the nature of component elements of the work to be done.
COUSSOULE: Sorry, Alex. In regards to the out-of-scope, are there any efforts at all — Do we want to see if there are any efforts at all kind of winding around in regards to an individual identifier? I know we are not interested in pursuing it. Do we want to know if there are any efforts going on with it?
GOSS: I think because of the federal mandate of not funding it, at least on a federal level, I am not sure if anybody would be undertaking that in the face of that block. How do others feel about this?
KLOSS: You mean outside of the master patient index activities going on?
GOSS: Are you referring to the fact that organizations have a master patient index and at an annotated level they will be able to do the identity reconciliation and accidentally create their own identifiers?
KLOSS: Yes, under scope we have HIEs, health information exchanges, and some regional efforts to create master patient indexes to facilitate patient matching.
GOSS: Oh, you are talking about what’s out of scope as being we are not going to look at the health information exchanges NPI?
KLOSS: I don’t know. That is just the question I can’t answer. The second, out of scope, we are not, I’m assuming, going to get into the proprietary algorithms that are being promulgated.
GOSS: I think we don’t want to analyze algorithms, but I think there could be commentary that might come out around best practices and use cases and stuff like that which might trip us into some algorithm discussions. I am curious to hear from others.
COUSSOULE: I think as we ask people these questions we will likely get some information in regards to success rates with certain approaches, but our objective of this meeting is not to seek out the best approach, kind of like what CHIME was doing or what the other efforts to try to find what the good answer was. We are not really interested in that level of detail, but it would be good to understand what kind of results people are getting so that would inform kind of the use cases that Denise raised earlier.
GOSS: I am tracking with you but I am not tracking with the comment that Lorraine just typed that some research may be necessary to inform the environmental scan.
DOO: I don’t mean research, formal. Just like is there other stuff happening, perhaps. I don’t mean environmental scans officially. I just meant everything informal.
GOSS: And you are thinking that’s out of scope?
DOO: No. I’m just making notes so I don’t lose it as you guys are talking.
GOSS: Okay. I get the point that we are going to have to do some informal searching to determine what’s really going on out there in the industry.
DOO: Just because as Nick was saying, if there is something else that’s out of scope.
GOSS: Are there other member comments on the out-of-scope section?
Let’s talk about the outline of major components and elements of the work to be done. This is feedback on our intent to look through a variety of steps starting with engaging ONC, seeing what stakeholders are doing. Plans for and holding the events is sort of straightforward. Any additions or comments on that section?
LANDEN: A question. One of the stakeholders I don’t see listed is individual patients and specifically represented by patient organizations of some sort. While patients are at the center of this, I always struggle with to what extent does a patient perspective add value to the process.
My guess is we should include patients here somehow, but I struggle to be able to get a rational value statement to what they would add. Since all of us potentially are patients.
GOSS: You triggered for me the perspective of going from patient safety as an aspect to identity protection as an issue. There is one aspect. If I’m the wrong patient and you’re going to do surgery on my left leg, that’s one thing. There’s a patient safety aspect there. But I also hear that, from a patient perspective, their privacy concerns are related to the identification process and what can happen to their identities, and things get conflated. Two Robert E. Lees and one is Ernest and one is Evelyn, and you’ve suddenly got the same person with now two records that are conflated in misinformation, and how does that then riffle through the system.
LANDEN: How does that contribute to the attainment of achievement of our objectives for this program?
GOSS: I think that we do want to include the patients, caregivers and providers or their associations to speak on their behalf. Like AARP or something like that.
DOO: Start having a whole new list.
GOSS: We could. Denise?
LOVE: Maybe I am, as usual, missing something, but it seems very industry-centric and maybe that is where it should be. But in my world, I deal with the public health and public databases that are doing massive linkages. Right now we are working with Census on six public health databases with tax and homeless and VA and disability — it’s huge.
I just wondered if the public focus is part of the discussion.
GOSS: One of the areas I wanted us to focus on was under key inputs and looking at what other federal and private industry is doing, and I think that maybe in that section of A, B and C under Item 4, we need to more clearly elevate the public sector, the states and the research entities. And I wonder to what degree academic entities may want to have some kind of dynamic. So it may be that we add some of that here but also build it into the key inputs section.
LOVE: Yes. From a legal standpoint, some of the states are serving as some of the linkage services because they have legal authority and the databases, whereas, the private sector linkage to linkage is a little more complex with different health systems because of the data ownership and privacy. So, in the public domain I am seeing a lot of the partnerships and community partnerships come together under that legal framework to do data-sharing exchange and then give back the appropriate data.
GOSS: You really, for me, also triggered the idea that you see states trying to bring in services for their citizens into a much more effective interface with those citizens, so that you could do almost one-stop shopping where you say I am in need of some support, and you go to a state website and that then actually helps you understand what services are available from different agencies within the four departments within a state. And that is being driven by an annotated master patient index that would span everything from education to healthcare —
LOVE: That is one use case, and then we have others where you have transparency and cross-sector measures that need to be pulled together centrally and then pushed back out, matched a little bit. Again, we are back to use cases. But I do think there is a public component here that should be integrated somehow.
GOSS: I think we just incorporated that into two aspects, and I do think your point about it tying into a use case is a good point.
DOO: I was just wondering, it seems like the development of use cases almost needs to be like an activity.
GOSS: It does. It would not be in here yet because we haven’t added it, but I think we would want to likely talk to ONC and then maybe reflect on some of the industry work and then do some investigation.
But I think we definitely — also in key inputs are actually proposed timelines, and we definitely want to develop use cases. I’m not sure if we want to try and develop the use cases first and then go talk to folks, or try to engage folks and get their thoughts on use cases and then develop some. Does anybody have any thoughts on that?
I think the next step is for us to move into Section 5, if no one has any further comments or questions on Sections 3 or 4.
On the timeline, we talked about getting our bearings in the first quarter of 2018, narrowing down what it is that we want to do in the second quarter, and that would probably include defining the use cases that we need to add in there. And then plan for the selected activities in the third quarter which would not only address the engagement strategy but probably finalize the use cases there. And in the fourth quarter, hold an event.
DOO: Should I just put “hold event” or determine, just leave it at that?
GOSS: I think we are not sure. Carrying a workshop will occur I think is fine because we don’t know where it’s going to fall.
I am not seeing any hands raised on this process flow and timeline. I am perceiving silence as you are feeling pretty good about this, knowing that we need to do a little bit of tweaking to the document and make sure that we have cascaded some of the scope and out-of-scope section appropriately down to our inputs and activities.
LANDEN: Yes. That works for me, too.
GOSS: All right. We are ahead of schedule and we can move, with Rebecca’s document reference in hand, to the prior authorization standard transaction and business process scoping documents.
HINES: Before that happens, we will make sure this document gets saved and then we will move on to Document G.
GOSS: I’m going to get started with background information on prior authorization. The healthcare industry continues to report that one of the core transactions under HIPAA standards is too complex and has so many business process issues that it has not met the intent of administrative simplification. This applies to both their X12N 278 prior authorization transactions for non-pharmacy exchanges, and the NCPDP standard for prior authorizations has not been adopted, but has been recommended to be adopted, and the industry strongly wishes to use it.
Stakeholder workgroups have been meeting to discuss the challenges with the X12N prior authorizations for 278 transactions in the related business flow. Some of the issues identified to date include variation in medical and pharmacy benefits, which result in different prior authorization rules that are cumbersome, inconsistent workflow processes, and requests for additional information that require manual efforts rather than automation.
Can somebody please turn off their buzzers?
Additionally, health plan web portals have become predominant venues for information exchange, and while they offer a certain level of functionality and information exchange for prior authorizations, they are unique to every health plan. Thus, a provider must have a separate portal, access code and password for every health plan with which it conducts business, and this subverts the principles of administration simplification.
Since 2014, NCVHS has held three hearings on prior authorizations, one in February 2014, a Review Committee hearing in 2015, and then a subcommittee hearing again in February 2016. During those hearings, testifiers indicated that there is little use of the prior authorization transaction except the electronic prior auth transaction is predominantly used in the exchange of prior auth information between prescribers and processors for the pharmacy benefit.
There were a number of ideas generated from our prior recommendations in three separate letters sent to the Secretary, and our understanding is that there are several stakeholder workgroups addressing the barriers to the use of prior authorization, and that the purpose of these workgroups was to evaluate the challenges and identify the business cases, current workforce and ROI for these transactions. The goal is to find out how to increase usage and lower the cost.
That background sets us up to talk about the purpose of this project, which is to get a comprehensive view of the current industry efforts to address shortcomings in the use of the adopted standard transaction referrals and authorization, the X12N 278, which is exchanged between health plans and providers. Many issues with the use of those transactions were revealed in the review committee hearing, and we are interested in getting an update on the industry’s progress in addressing them.
This will be a fact-finding project and will involve informal information-gathering to determine what industry has done and is doing to collaborate and address the business process issues that impact the use of the standards. An analysis of current efforts and available data will help the committee determine next steps for its efforts on the topic.
Out of scope is that we are not going to do a use case analysis and development.
From the major component and elements of work perspective, we want to conduct the background information, identify the prior authorization activities underway within the industry and federal agencies, use the information gathered to understand the issues and barriers that still persist, and decide what actions are warranted for the committee and, as appropriate, develop a summary report that could be eventually posted to the website.
Currently, we are anticipating our current key inputs as WEDI Prior Authorization Workgroup, NCPDP SCRIPT Workgroup, CAQH CORE’s Workgroup, HL7, ONC, CMS, other federal initiatives like VA or DOD may have underway, HIMSS, AHIMA and provider associations, are all potential sources of work on the prior authorizations.
We are anticipating our time frame being the first quarter of 2018 to evaluate the HHS strategic plan and implications for NCVHS apropos of reducing burdens in prior authorization scope, increasing prior authorization usage, identify existing workgroups focused on prior authorization issues, and determine if and how stakeholder workgroups will be monitored and tracked.
The second quarter we are looking at monitoring the progress of DSMO, new Standards and Operating Rule and ORAE progress on change requests and updates related to the 278. Determine if the hearing will be held during calendar year 2018, and pursue where necessary, notification aspects if we choose to do so and, also, monitor what’s happening in the industry.
In the third quarter, there is potential for the Designated Standards Maintenance Organization, DSMO, to bring forward new versions of the standards and operating rules for prior authorization. The industry efforts we need to monitor, and then we consider transaction utilization data and cost savings that can be obtained outside the CAQH efficiency index to understand the cost-benefit analysis of HIPAA and determine if there is any action necessary.
This is very much a process where we want to figure out where we are at in the industry right now, and I use that term broadly for public and private, and then inform what we really need to do to help advance this issue.
It has really been felt, from my own personal perspective, that the feedback that we produced in the 2015 Review Committee Report issued in 2016, was taken seriously by the industry and they have really been actively engaging in this, so we want to elevate their work and figure out where we can bring extra value.
Thank you for everybody’s patience as I walked you through the background on prior authorization and the scoping documents. I would like to suggest that we return to the top and ask the committee members if they have questions on the purpose of this project.
LANDEN: Thanks, Alix. One question that runs throughout the documents is we seem in some cases to exclude the NCPDP SCRIPT ePA transaction and in other references to it we include that. I would suggest we need to figure out if we are just talking about the X12 278, as we state very clearly in the opening sentence, or are we talking about both the X12 and the NCPDP. I would suggest as we go forward, for discussion purposes, let’s put the NCPDP SCRIPT ePA in the out-of-scope area because we are on record with a recommendation, and to the best of my knowledge, CMS will be moving forward with that sometime in the future.
There are six places in the paper where we have references to NCPDP.
GOSS: Yes. I had read this document before, but as I was going through my overview, that point really jumped out of me. I found myself confused about it and would encourage anybody from NCPDP to send a comment in if they disagree with us proposing this as being out of scope, while we also solicit input from the other members.
Are there other comments on the purpose?
HINES: Alix, you have got your comment in the Q&A box from Margaret Weiker.
GOSS: I did. Margaret Weiker has confirmed that she agrees with it being out of scope. Thank you, Margaret, for confirming your perspective.
Other comments on the purpose section? See no hands raising.
Let’s go to the out-of-scope. We just made the ePA NCPDP electronic prior authorization out of scope. Are there any other comments on this section?
KLOSS: I am back on the purpose statement and I’m just wondering about the last sentence under sub-point (1), “An analysis of current efforts and available data will help the committee determine next steps for this effort.” I guess that just seems so vague and I just wondered if we couldn’t be a little more specific to determine what recommendations it could make to further this effort, or something at the end here. We really don’t know what we would do with it? I just would be more comfortable if we could be more specific on what we will do with the current efforts.
PARTICIPANT: Maybe it’s what NCVHS’s role would need to be.
GOSS: For instance, we may do a review of what’s happening on the issue and determine that people are making really good progress, and it may be that that means let them go, or it might be time for some recommendations to come forward and to elevate that for industry.
So it may be more than just an environmental scan aspect. It could be that we need to actually hold a hearing that would support us making recommendations based upon the industry work.
KLOSS: I would be more comfortable with being a little more specific as you just stated. Current efforts, and what steps NCVHS might take to advance progress or something, rather than talk about our role.
LANDEN: Just in the same section or preceding the section. Since we are now putting the NCPDP out of scope, I think we need to change the title. That would be Prior Authorization Standard Transaction and Business Process – Barriers to Non-Pharmacy.
DOO: I was just going to say exactly.
GOSS: We will have to make sure we do a lot of clean up. I like it there at the beginning. It makes it really clear. The only other way to do it, to my mind, would be 278s.
Any other things on purpose or out-of-scope?
Going to Section 3, this is the outline of the major components and elements of the work to be done. Any comments on this section?
COUSSOULE: The question, part of it, is how are we going to do this, right? The information-gathering, absent a formal hearing of sorts — it does raise questions of how we would, in a more structured way, gather that.
DOO: I will say that it’s going to be very important to get an update from the WEDI Council, WEDI Prior Authorization Council, which seems to be the de facto gathering place for all of these industry efforts.
GOSS: It might be that we want to do a survey tool or we could create a standard set of questions or things that we want to answer and then garner that information in some kind of an overview grid or document. It sounds like we should start with WEDI, from what I just heard. It sounds like they are the PA hub at this point.
I also think that X12 is the owner of the 278 transaction, and knowing the prior history, they are likely participating in the WIDI Prior Authorization Coordinating Council quite extensively.
DOO: Right. Everybody is convening under that umbrella, I guess.
GOSS: Including CORE?
GOSS: Great. It really makes it easier if they are all together in one place.
GOSS: It sounds like we can go to them as the starting point, but we want to make sure we are not missing any other activities that might be out there.
DOO: Right. So maybe the first question is to obtain a list of all the participating entities.
COUSSOULE: We have defined the key inputs so we need to verify them and then figure out a way to do a data-gathering exercise for capture.
GOSS: It sounds like if WEDI is already doing a lot of that work and has their fingers on the pulse of all of this, we can collaborate with them and use that as a launch off point.
DOO: Right. To say were concerned that there would be duplication of efforts.
GOSS: Other comments on Section 3? Similar to the patient matching conversation, this is really about — We’re finding our action steps based upon what we learn in each step, and we certainly do not want to duplicate. We want to help elevate and play an appropriate role in addressing barriers to administration simplification and standardization.
Looking to move on to key inputs, if there are no objections, with a question about whether or not we should keep NCPDP workgroup on that list, since we took them out of scope. My suspicion is that they are actively engaged in the WEDI stuff, so we won’t get disconnected. They can let us know if that’s a bad assumption.
DOO: I guess if we have provider associations we should really have all payers. Should I put health plans and provider associations?
COUSSOULE: I think that makes sense.
GOSS: Thank you for confirming NCPDP is involved in the WEDI PA Council workgroup. Charles Steller sent me a message about HL7 X12, AHI, BCBSA, CAQH CORE, HATA, NCPDP, AMA, WEDI, Cooperative Exchange. I am going to take that as the list of who is actively playing. If I didn’t get that right, please send me an updated note of how I’m supposed to interpret that list. Thank you.
That’s good to have that pretty robust list of participants. I think we may actually need to narrow this list down as key inputs and make a number of those organizations reflected as participants within the prior authorization —
DOO: Right. We can insert that.
GOSS: We can move on to timeframe. Looking at calendar year 2018, first quarter, get our bearings. Second quarter, determine if we need to have an event. Third quarter, see if there is anything coming forward from the standards bodies.
LANDEN: Please spell out FRN.
GOSS: Federal Register Notice. We need to spell out FRN.
DOO: Thanks, Rich. All the abbreviations we will definitely do that at first use.
GOSS: Any other comments on our timeframe? I can see, after we do some coordination with the WEDI PA Council, this will be able to be a lot tighter set of activities. Other committee member comments?
STEAD: How do you think about sequence or interaction between this and the Predictability Roadmap? I’m not sure I understand what the best critical path might be.
GOSS: I see the Predictability Roadmap as our current priority focus, and that work needs to advance notably, and the prior authorization transaction upgrade is likely to be included in the DSMO or X12 bringing forward a recommendation for an upgraded set of standards, 7030.
Off the cuff, I’m not sure I see much more intersection although I think that — I’ll stop there and see if other committee members have comments.
COUSSOULE: I think I am with you. This came more out of the feedback from either the review committee work or other work we did for the Report to Congress as an important topic for us to undertake and, certainly, given the progress being made across the industry, would be worthwhile for us to revisit.
It certainly has some relevance to the Predictability Roadmap, but I’m not sure they, by necessity, need to be sequenced in that way.
GOSS: Actually, if we got more predictability in standards development, promulgation and implementation, it might — and that we came forward with new approaches to the prior authorization 278 transactions to related implementation specifications and that we were rapidly learning in that cycle, predictability actually may help us achieve better usage and lower costs and increase administration simplification.
STEAD: I think that is sort of where my question was coming because it seemed to me we probably want to get the Predictability Roadmap work far enough along that, as we looked at prior auth, we would be looking at it through that lens. Then we could work prior auth as we did that, and what we learned from it could feed back and maybe enhance an upgrade or iterate the thinking around the Predictability Roadmap.
GOSS: And keep in mind that from a workload perspective, this is not the only — you know, we talked about three project scoping documents but also we have the terminology and vocabulary efforts in the queue, and Linda Kloss has been amazing in advancing that effort with a lot of support from you, Bill, and getting some research.
Anyway, I think that we’re going to have some juggling that we need to do to really address how we are going to sequence things, because Roadmap is already in the queue and rolling. Terminology and vocabulary, that’s rolling, too.
My personal take is the CIO Forum is really the priority over the other two projects we discussed today because we want to use it as a way to garner more end user perspectives and inform our Predictability Roadmap conversation as well as sort of the larger what’s coming down the pike visioning kind of aspect that ties into some of our other discussions.
STEAD: Very helpful context, thank you.
GOSS: I was speaking on my behalf. I want to make sure Nick has a chance to —
COUSSOULE: I would agree. I think Bill’s point earlier is well taken. I think a better understanding of and progress on the Predictability Roadmap is likely to have more influence on the prior auths than the other way around. I think that is clearly the sequencing I would see.
GOSS: Any other comments or questions on this document?
LANDEN: At the end of the document, in the background on prior authorization we need to do cleanup there for references to NCPDP.
DOO: Yes. Majorly.
GOSS: Yes. And I think we are going to have to update these and have them available for the next Executive Committee call. I know that Lorraine and Nick and I and Geanelle are scheduled to talk next Wednesday, but I’m suddenly thinking there’s a disconnect on our availability and timing to meet, maybe what Rebecca and Bill need of us. Can you clarify?
HINES: We ideally would like your updated work plan as soon as the four of you can get it to us, but definitely before December 7th.
GOSS: We were thinking we would have that for you on December 6th in the morning.
HINES: Nothing is in blood or stone. And, of course, once we harmonize or line up each of the work plans, things are going to have to probably shift anyway.
I think some of us at least can sort of envision where the puzzle pieces might fit, and, of course, they are going to have to get shifted around depending on the other things. You know, it’s one of these lovely SAT or GRE questions. If this is here and this is there and that is there, then how do they all line up? You leave the station at this time with this train, and so forth. I wouldn’t sweat the details.
If you can get the broad outline and if something gets moved from Q3 to Q4, whatever, it’s okay. I would just say if you can sequence out what you think is one, two and three in terms of the meeting, because that’s what we have to schedule. And what can happen in a full — Is there a half day or an afternoon that can take place at a full committee meeting for some of this? Do things need a day, do things need a day and a half? Those are the kinds of things that would be helpful so we can schedule the next three to four quarters.
GOSS: We had developed a draft work plan so we can tweak that, but we have to then reconcile that plan with all the wonderful feedback that we got today.
HINES: If you could do that by Monday, that would be great. And if you can’t, do the best you can.
STEAD: Just to add a little color commentary, basically, on Monday, informed or not, Rebecca and I are going to have to assemble the draft straw person of the full committee plan that we will bring into the December 7th call because you all need to receive it in advance of that call.
We recognize all this is going to continue to move, and what we are simply trying to do is get a way that it could fit together so we can then negotiate from that platform to what’s best for everybody.
HINES: The more clarity you have for us by Monday, then the better clarity — like Bill just said, the platform for our discussion on December 7th. If you don’t have clarity, then what we come up with may need a lot more shifting around on that call. So do the best you can, but it will be our starting point.
GOSS: We will do the best we can in trying to pull this together. We will need to confer with Lorraine and Nick on availability because we will have to finalize documents and then make sure they link across all of them and they get the new version.
HINES: I don’t think we need the scoping documents by December 7th updated. Obviously, you are working on that. More just the broad brush of what goes in what quarter based on today so that we can start aligning this with the other committee work.
DOO: Quick question. Mostly what we need to know is what events would be going into what quarter. For example, the CIO Forum, we need to know whether it goes into the first quarter or the second quarter.
HINES: Exactly. And we know the dates of the three full committee meetings, so would one of these activities of this subcommittee or one of the other subcommittees plug in nicely as one day. I don’t think we want to add two days if we can help it, but one day on the beginning or end of a full committee meeting, such as the May meeting, for example, or the September meeting. And, of course, the other subcommittees might have dibs on that, in which case, it would have to be a stand-alone.
So that’s the kind of thing. We don’t need the details. We just need sort of sense for where things land so that we can start. As you know, it’s very challenging to get meeting space and hotels. May is already becoming problematic for hotel space, so just keep in mind, the sooner we can — just like Linda did for privacy, even though we are not clear exactly what we’re using it for though we have an idea, she has got two dates in April for something so that, whether it’s the Beyond HIPAA or something else, we have that at least penciled in. We want to start penning things in after next week’s call.
COUSSOULE: I think that is fair. We will do our best to try to get something together.
GOSS: One thing that would be helpful is to get the marked-up documents from today because I didn’t take detailed notes. Basically, what we have to do is validate our work plan, shifts or no shifts, based upon today —
HINES: Sure. The WebEx folks will get those to us by email and then you will have those in hand.
DOO: It seems like we are — again, just preliminarily — probably going to have the CIO Forum. There is a possibility of having some kind of a hearing at the end of the year, should the SDOs come forward with an update to X12. We probably will get a request for an update to another standard —
GOSS: I am expecting NCPDP to come forward with their change request likely before we see X12 come forward.
DOO: That’s what I am talking about. Yes. And that would be the first half of the year. So we know there are some things that we have to somehow plug in.
GOSS: I think we are close because we did a lot of that leg work in advance.
DOO: The question was are we allowed to do those standards meetings virtually. That was my question.
HINES: That is your call. As you know, the more things we do virtually the less of the budget gets chewed up on travel and such. But them it has the down side, so you just have to decide. I would think you would want to do the CIO Forum in person, for example. So think about those kinds of things.
GOSS: Yes. Nick, any thoughts or comments at this point? I think we have got some marching orders for the next couple of days and we finished the scoping documents, which is about to lead us to public comment.
MR. COUSSOULE: Yes. I think I am ready for that, too, and unfortunately, I’ve got about 10 minutes and I have to leave to catch a flight.
HINES: Michael, can you put up Slide H, please? To all of you attendees on the line, we are now ahead of our schedule. We were planning to have public comment at 10 until 5:00 but we are ready now for public comment.
If you have questions or comments, you can use the Q&A section on the WebEx platform. When the slide comes up you will also see you can send an email, and it is certainly fine to send it after the meeting. We can share it with the subcommittee. This is your opportunity to get input into the committee’s discussion. So using the Webex Q&A function or email at CDC.gov.
GOSS: We only had one comment which is that you need to include a patient matching project for NCPDP and activities underway, so we want to make sure, Lorraine, that we add NCPDP to the matching project.
DOO: Okay. I will make a note.
GOSS: You don’t have that document anymore, do you, because you gave them all back —
DOO: Yes, but I’ll make a note so that when I get it back from them I will just add that in.
HINES: Thank you, Margaret, we have got your comment. Anyone else want to forward a comment or question for the subcommittee?
GOSS: I think it’s really good that you mentioned we have the NCVHS email at CDC option so that people can submit those, like you said, even after the meeting, especially if people were planning to be here at 4:50.
HINES: My email address and this email address are on the website so people can always reach us, and they do.
I am checking my email account and there are no messages. I would say we have given people ample opportunity at this particular juncture and I have no further comment on the public comment period. Alix and Nick, the floor is yours.
COUSSOULE: Okay. I think, absent any other feedback from the committee members, we are about done for the day.
GOSS: I think we are. I think this has been a very productive session. Thank you for all the subcommittee input in advance on the project scoping framework and the commentary today. It was really great to see all the industry participants actively listening and sending us comments. We really appreciate that. I think we are setting ourselves up for a really great amount of work in 2018 that can hopefully bring a lot of help to the industry. I meant that seriously, guys
HINES: Michael, if you would put up Slide 5 and leave it up until 5:00 o’clock if possible in case someone dials in at 4:50 and wonders where the heck the public comment is that would be helpful.
STEAD: Nice work, team.
GOSS: It has actually been a really good couple of days of meetings. Even with some of the technical glitches I think it has been productive and we are all learning the way to do this virtually, so it will help us in the future to do more of these.
COUSSOULE: Thanks, all, for your participation. We really appreciate the active feedback.
HINES: The meeting is now adjourned.
(Whereupon, the meeting was adjourned at 4:25 p.m.)