[This Transcript is Unedited]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
SUBCOMMITTEE ON STANDARDS
September 15, 2010
Embassy Suites Crystal City Hotel
1300 Jefferson Davis Highway
Arlington, VA 22202
CASET Associates, Ltd.
Fairfax, Virginia 22030
P R O C E E D I N G S
DR. WARREN: So Walter I would like to convene the Standard Subcommittee meeting. We have just been putting our heads together for how to accomplish our task. So what I would like to do is Lorraine is going to bring up the Operating Rules Letter because we have the clearest direction from the Full Committee on how to phrase the letter. Because Bill wasn’t here for that discussion, then I will tell you what we talked about in fixing the letter and why, and then get that letter out. Then I would like because we are really time limited go right on to the health plan ID letter. Personally I am going to need help from the rest of the members who are here because I didn’t get all the things that we were to fix in that letter. Then at the end of that, we will try to save some time for any public comment from people that are against the wall. So we will do that.
With the Operating Rules Letter we basically had one clarification from CAQH CORE in that we had made recommendations about adopting Phase II and it needs to state Phase I and Phase II, in order to be incredibly clear. Yes?
MS. TRUDEL: This is Karen Trudel. My suggestion would be to simply make a onetime notation that Phase II includes Phase I.
DR. WARREN: Okay. That just makes it easier I think to flow through the letter. Okay. Anything from any of the other subcommittee members about that clarification?
DR. SUAREZ: I guess in the actual recommendation of the language in the recommendation, we should take out the part that talks about December 31st because that is a second aspect of the recommendation, as I recall. So in that particular one we say you prefer recommendations so we now have to say probably adopt the Phase II operating rules, including Phase I, the CAQH CORE Phase II operating rules including Phase I for all transactions, and then put a period.
DR. WARREN: Right after the word transactions.
DR. SUAREZ: Exactly and delete the rest and then create a new recommendation, 2.2, right that would cover the idea that –
DR. WARREN: Okay, and then for Bill’s benefit the summary of our discussion was we talked about three options for adoption here was; one do nothing of which no one was in favor of. One was adopting the Phase I, Phase II as they were with no changes and there was some concern about that. The other one was making a separate recommendation that we encourage CAQH CORE to work with the states to come up with recommendations by December 31st, and then our subcommittee would look at those operating rules and make a recommendation at that time, to forward to the Secretary.
The belief behind that was that if we had a window of opportunity to really make these operating sound and robust where you wouldn’t have to wait for a cycle of revision to go through. So we were trying to take advantage of that option. We did want to build in that we would review those like we had with the first go around. So is that kind of?
DR. SCANLON: I think that is somewhat consistent with where I was. I guess I am still sort of hung up on 2.1, which is let’s say no progress is made. 2.1 to me, still reads as if to a department, go ahead. But you know I guess I don’t know whether I, I like to keep people’s feet to fire to make the changes that make this more robust, and to keep our recommendation contingent upon they have made progress and we have reviewed it and we are satisfied with it. 2.1, is a little bit too much of a blank check because you could go ahead with, you can decide okay we will just ignore the rest of this. We will just let the department go ahead with 2.1 and we will be happy and I don’t think that is where we want to be.
DR. WARREN: Karen and then Walter.
MS. TRUDEL: Okay, a couple things that probably happened in the discussion that weren’t communicated: one was that CAQH did indicate that they would be happy to move forward with this. Another thing was that the consensus of the group was that the ROI for Phase II as is was better than nothing, and that if we went any further past December we wouldn’t be able to hit our deadline. We probably need to get this into the recommendations somehow. What we were hoping to get CORE to focus on was things that actually like the top ten or whatever, things that actually provide benefit and additional ROI so that it would be Phase II with value, instead of looking at every, as I said, distinction that isn’t really a difference. I don’t know whether that helps.
DR. SCANLON: Yes, I guess my question would be sort of what is the latest point that we can weigh in for a December 31st adoption?
MS. TRUDEL: December 31st. That is the date that where we need to know what –
DR. SCANLON: We, meaning NCHS, because we have another meeting between now and December 31st.
DR. WARREN: That is when we would do it.
DR. SCANLON: If we are asking CORE to sort of make progress we have another meeting to review their progress, and then to potentially amend something that we say. I am thinking that we – again this is the issue of trying to create this incentive, not giving so much of a blank check as 2.1 is but saying we are.
DR. WARREN: 2.1 is not a blind check. It is saying these are the existing operating rules. We accept them as is.
DR. SCANLON: It is saying adopt.
DR. WARREN: Yes, accept as is, adopt those. There isn’t anything else.
DR. SUAREZ: Bill, just to emphasize what I think Karen mentioned, we have three options; saying nothing in other words not adopt any which is out; adopt the current rules as they are today without any changes. That is what 2.1 is saying. At least we gained the ROI from that adoption. That is saying that. Then the third option is in addition to adopting today the Phase II as they are, have any amendments or any updates to it incorporating the elements, the priority elements I guess, into Phase II between now and December, and then on the December timeline, we would evaluate whether they are sufficiently better in terms of ROI then Phase II. to then recommend to the Secretary to adopt Phase II plus, if you will: Phase II plus thereof.
DR. SCANLON: I can live with this because we have already given away the ball game. If was said that as is these things need to be adopted and we are on the record for that. If they don’t come through before December we are still stuck. So I am going to stop through slowing you down. This is I think we haven’t been as forceful as I would have liked to have been but again, I am not sure what our options are.
DR. WARREN: So on the other hand, Bill, what I can assure you is that we had since the hearings in July, lots of interaction with various stakeholders, the states and CORE, talking about how they can move towards achieving our new 2.2.
To me I claim that as a win. We got the stakeholders in a room in July. They all agreed you know here is what we need to do. They want to do this. They have shown their intent. They have shown good face, so that something is going to happen here.
Now I am concerned for them because we are talking about them doing a lot of work in three months and putting together a consensus process is not always easy in three months. But, you know if they can pull off some it, we are still better off than where we are with just 2.1.
I think that is what we are going for is that we have an opportunity to do good work here and let’s take advantage of that. It may not be the best but this isn’t going to be last of it either. There are going to be evolutions and burgeoning of this process and now we have got at least the players talking to each other and working together. I think that should be something that we see as a goal for happening here.
I do understand that you are concerned that CAQH could say, oh, we have done 2.1; we don’t have to do anything else. 2.2 is a request for us. We could either follow through or ignore it. I would hope that would not happen.
Now, let me just say something and I don’t know if you are going to stroke out and maybe this is very inappropriate on my part, but there are other operating rules coming up. If they want to be in line to be designated, they are going to work on this. I mean if I were in their shoes I would just be you know chomping at the bit to do 2.2.
DR. SCANLON: I understand that and my issue here, this is strange to be doing it at a public meeting, is sort of how do we maintain our leverage because these people, CAQH CORE in some respects, are volunteers. We are not signing them up for a contract where they have agreed for a certain sum of money to do what we tell them to do. All right? But I think we need for them to get this done and there is this question now sort of maintaining some accountability.
DR. WARREN: But we have faced that with -
DR. SCANLON: I know you faced it before but I mean I think this is an issue and I think the other thing I guess I mean obviously being new to standards I do think though at this point in time the stakes are higher than they have been in the past. That is what is worrying me.
DR. SUAREZ: I think one way to strengthen the recommendation number 2.2 is to change the word encourage to require CAQH to make a good faith effort. I mean in other words –
MS. DOO: These are your recommendations to HHS.
DR. SUAREZ: Exactly, we are recommending HHS to require.
DR. WARREN: We can’t really require.
DR. SUAREZ: You couldn’t require I suppose, huh?
DR. WARREN: That is legal leverage, those legal terms.
DR. SUAREZ: Yes, back to those single terms.
DR. WARREN: The only one I could come up with is encourage, strongly urge. I am getting quotes over here.
DR. SUARZE: Exactly, I guess that is a good.
DR. WARREN: Strongly urge. That is better than encourage.
DR. SUARZE: I think that is as much as can be expected really. As I think it was mentioned Bill, you weren’t here but it was mentioned during the committee, there is already work being done by the industry including states and CAQH, to identify those elements all ready. I mean it is all ready happening even before any of this as you have seen because during the hearings there was that sense of you know need to begin to work, to incorporate those changes. So I am strongly encouraged, where is that.
DR. SCANLON: Well, and as Judy said we have leverage in the future.
DR. WARREN: Occasionally I am politically incorrect but at least it is my honest thought.
DR. SCANLON: That’s okay. What better place than an open meeting with a transcript.
DR. WARREN: Marc, you have been incredibly quiet. Any comments?
DR. OVERHAGE: No.
DR. WARREN: Okay.
DR. SUAREZ: I’m sorry, in your first one Lorraine had said, adopt Phase II operating rules to say, including Phase I or that includes.
MS. DOO: Do you want me to say which includes Phase I?
DR. SUAREZ: Which includes; that is a better way.
DR. WARREN: Rather than in parens. Just take it out of parenthesis.
MS. DOO: Okay.
MS. THOMAS: These two haven’t actually included in Phase I so you couldn’t. This isn’t like two through Phase I. Phase I is not a part of Phase II.
DR. WARREN: So we have our “which includes” in the wrong place. I think what it should probably read as CAQH CORE Phase I and Phase II operating rules. Yes.
DR. SUAREZ: Oh yes, that is better. That is the right way.
MS. DOO: Do you want me to say Phase I and Phase II?
DR. WARREN: I would prefer it that way that they be in order but that is.
MS. DOO: You are a very demanding customer. I can do it.
Do you want to say something about how we then give you an opportunity to look at the – I don’t know what you would call it, Phase II plus.
DR. WARREN: Yes, because I feel strongly NCVHS needs to do that but other members also felt that way, since we have been tasked with that. Oh yes, so we have to remember that we are telling HHS should do this but now what we are doing is saying that –
MS. DOO: Right, you are telling us to submit to you what we have received from them.
MS. TRUDEL: Maybe it could be that HHS should look to NCVHS to –
DR. WARREN: Review this update?
MS. TRUDEL: Yes.
DR. SCANLON: Well but the first part is, 2.2 is strongly encourage, okay, and it doesn’t say deliver to HHS. So you could bring this up by making 2.3 part of 2.2 and say, and submit to RIO elements or upgrade its Phase II to HHS or review in time for its December meeting.
DR. WARREN: Good. I just want to clarify with CORE. We have made up our own labeling for you of Phase II plus. Is that going to be okay in the letter or should we call it something else? The enhanced Phase II? Okay so instead of Phase II plus I would say, the enhanced Phase II. I think I like that wording better. Thank you.
MS. THOMAS: Just want to clarify it is actually only two months that we have for December 1st; not three months.
DR. WARREN: Right because of holidays, yes.
MS. THOMAS: Well it is also because three months it would have been through December but we don’t have December so we have October and November essentially. Also that in terms of the return on some of this work that the states have done, the states have not done any ROI work on this. So I just wanted to raise that because the evaluation that will get done by the open process and the stakeholders will have to rely on the assessment of the participants because there isn’t any ROIs specifically that any of the states have done in the work that they have done. So I just wanted to make point as well.
DR. WARREN: I think the intent is to use the process and engage with them and what you can produce is what you produce. I mean both Walter and I have engaged in standards development work and so we are well aware of the timing and the effort that it takes to produce those.
DR. SUAREZ: I think the priority items will, if they haven’t already, will come up very quickly in terms of these are the top five things. I mean the rest are minor things that don’t really elevate to we need to immediately address them but the top five or ten or whatever number will come up very quickly.
MS. THOMAS: I would agree I just didn’t want there to be an expectation that there was going to be a detailed ROI on the items.
DR. SUAREZ: No, is no.
MS. THOMAS: That was all.
DR. WARREN: Then in looking to the Committee, these are the only two changes that I noted from our discussion that we made in the letter. Does anybody know of any others? I think that is it. Okay, we are going to declare a semi victory on this one. Victory will be declared tomorrow, hopefully, and let’s move on to the health plan identifier, and just remind everybody we need to end a little bit before four because there is another group coming in here at four.
This is the one, Walter I need more help with because my notes are really skimpy on this one. Lorraine, can you get rid of all of our edits from before so that we have a clean letter to look at? There.
MS. DOO: Do you want me just to go to one or to the top?
DR. SUAREZ: I think the main issue was – well there were two issues. There were no questions about some of the recommendations with respect to identify yourself and the actual number. There were questions number one, about the definition of health plan. I think Larry suggested it would even include the language that we used and documented in the background document that says CMS considers the health plan based on that as a way to referencing the definition of a health plan. But I think the big debate or the big question was do we have enumeration at the legal entity level plus the product level, only the product level? My sense I guess from the outcome of the discussion was that we need it at both levels.
The reality, the challenges, we don’t have today. Well we have a good way of at least pointing to who is a health plan based on definitions like HIPAA definition of health plan plus, other. We don’t have a good sense of who is a or what is a health plan product and that is why the second recommendation was to ask HHS to work with industry to determine that and use input from the industry to define what is a product and what is the right level of enumeration for those products. That was basically the main discussion of that point.
DR. SCANLON: I am a little confused because looking at sort of the letter that we have been circulated in the briefing room, to me we first of all, in the introduction where it starts at the top of the second page, we say they come in a variety of types and forms and arrangements through which they perform and deliver services and these include health plan components and it goes on. There is not a taxonomy in there. There are multiple taxonomies in there.
DR. WARREN: Yes, that is the problem.
DR. SCANLON: Well, but see then we kind of, we don’t say forget that. We have got to come up with a taxonomy to have a reasonable set of health plan IDs or we are in trouble because we when we get down to what was, I don’t know whether it is still observation one okay, there is three to me it seems like we are saying three different plans of health plan IDs. There is one at the entity level or the corporate level so to speak. There is a second one at the product level and then we raise the possibility that there is an intermediary ID. There is an intermediary ID.
DR. WARREN: That is not a health plan.
DR. SUAREZ: That is not a health plan.
DR. SCANLON: Well, but why don’t we say, yes work with the industry to reach a consensus and name the definitions for intermediary entities. Consider whether these should be eligible –
DR. SUAREZ: Intermediary entities are entities that are not currently included in the definition of health plan that potentially need to be identified because they need to be identified in the transaction. An examples of those are re-pricers, for example, or rental networks or others. There are other entities that are not health plans.
DR. SCANLON: We had this discussion to some extent. There is this question of whether the health plan should identify an insurance product, and there is another issue about this ID as to whether or not it should represent an address to which people submit something. There are two very distinct things and if I am dealing with one of these intermediaries and I am using that health plan ID and I am not using the insurance product ID, then we have lost that connection and that is the health product.
DR. SUAREZ: That is not how the transactions work.
DR. SCANLON: Are you telling me that both IDs would be on the transaction?
DR. SUAREZ: Yes, yes.
DR. SCANLON: Okay then that is different. I am sorry. All right.
DR. SUAREZ: The transactions have IDs for.
DR. SCANLON: Are they calling them both health plan ID?
DR. SUAREZ: They are called both the health plan ID and the transaction itself, in the actual transaction. You said put the identifier of this and then it says if the health ID has been adopted then use the health plan ID.
DR. SCANLON: I operate on a principle that ignorant readers should know what we are talking about and I will put myself in that category. I didn’t know we were talking about it that way.
DR. OVERHAGE: I am struggling here to come up with a positive suggestion. I am still having a lot of heartburn. The plan is okay however we define those, and we can be very liberal everything under the sun. Particular benefit design I am still having heartburn over thinking of those having IDs.
DR. SUAREZ: Like which? Give an example.
DR. OVERHAGE: You know the blue gold plan in Blue Cross Blue Shield of North Carolina that is offered in Charleston.
DR. SUAREZ: I don’t know that we are recommending it.
DR. OVERHAGE: Okay, I just want to make sure because there was –
DR. SCANLON: CMS already tracks that. That is an ID that would be useful to them yet, there is a contract requirement in Medicare Advantage that when you make an offering in an area –
DR. OVERHAGE: That is in Medicare Advantage but what about all of the other stuff?
DR. SCANLON: There is all kinds of comparable stuff. The exchanges are going to operate the same way Medicare Advantage does and then they will be selling products. They are going to be wanting to monitor their products.
DR. SUAREZ; We are not recommending the letter.
DR. OVERHAGE: It is not the product. It is the plan.
DR. SUAREZ: We are recommending in the letter two things. One is that every health plan, the legal entity as defined in HIPAA be enumerated with an ID, the legal entity. Kaiser would have one ID for that.
Then we are saying in addition to that, we cannot yet offer a specific recommendation to CMS to say enumerate health plan product. Kaiser has multiple products, you know one for Medicaid in each state; one for Medicare; one for commercial; one for self insured. But we cannot yet recommend as a committee to CMS, you should require every health plan to enumerate this kind of product. We are not at that state.
So the second recommendation is CMS should work with the industry to define which are the products that need to be identified with an ID because that is really what needs to be done. It is sort of in a provider arena. The hospital gets one number and then there are parts of the hospital that could get one number.
In the health plan arena there could be that concept that a health plan gets one number for the legal entity and then numbers for products of the plan. We are not in this level of recommending this specifically to enumerate the following products. We are saying CMS should work with industry to define those. We are not ready to tell CMS in this letter that they should define this.
DR. SCANLON: I think we should tell CMS that having the health plan ID only be a distinction like Kaiser versus Humana versus something else. Unless there is some other way, could have been this record, to identify sort of the product level, then we haven’t served any purpose at all. I think that is also consistent with what we heard from the providers that testified. They need to have much more specificity than this is Aetna. This is Humana. This is Kaiser. There needs to be more information, and this is something I said, we talked about this before, if it is somewhere else in these records that is fine but it has got to be there.
DR. OVERHAGE: Where will they come from is the question. I think you can enumerate all of those but where are the people who send it going to get that plan ID?
DR. SCANLON: They potentially are going to get it from the insured because when you are issued a product you are going to be told sort of what your plan ID is.
DR. OVERHAGE: But what I am saying is the patient walks in, what plan ID do I put in the transaction?
DR. SCANLON: The one on their card.
DR. OVERHAGE: They don’t have a card 80 percent of the time. They don’t have a, I mean it doesn’t exist. It doesn’t work that way.
DR. SCANLON: It is hard to operate in a world that is so dysfunctional.
DR. WARREN: We do that every day.
DR. SCANLON: Ultimately, we are going to have to identify the plan that these people are in. How are we going to do that? If we don’t do it through an ID that the individual has, what other mechanism are you doing it in.
DR. OVERHAGE: The other mechanism and I think what I heard Walter suggesting is, if I know what the health plan is, Mr. WellPoint, I have Jim Scanlon in front of me. Here is his ID number that you have issued Mr. Healthplan. You tell me what plan he is on because you know. I don’t know.
DR. SCANLON: And what they tell you then is what you put on your plan.
DR. OVERHAGE: Sure, that would be great if they would do that but then you don’t need to enumerate it because that is totally internal to them.
DR. SUAREZ: Well but that is part of the eligibility transaction when I send eligibility inquiry that says this is, as far as I know this is a plan, Aetna, and this is the name of a person. The health plan reply, in their eligibility response, provides part of the detail about this is that program, this is their benefit level. This is all that, but now with the overhead rules we are going to be getting even more.
DR. OVERHAGE: But you have to have a plan ID to start that.
DR. SCANLON: Individual ID.
DR. SUAREZ: You don’t need to necessarily if you don’t know it because well, you need to know where to send it or which is the general plan.
DR. OVERHAGE: Why do those need to be enumerated then?
DR. SUAREZ: Well because of the eligibility transaction includes a plan ID.
DR. OVERHAGE: I didn’t need a product ID. I just need a plan ID.
DR. SUAREZ: Right, if you have a product ID it is better, but if you don’t have it but you have the plan ID in general like you know Kaiser and ID of the patient or at least the name and some other information, yes in the Kaiser system the actual plan product in which that person is enrolled can be discerned. Right?
DR. OVERHAGE: So why do I need a product ID at all then?
DR. SUAREZ: Why do you need a product ID?
DR. SCANLON: I think there is both what we heard in the testimony and then there is a second issue in terms of application. It seems to me that what we heard in the testimony is that providers come in and they want to be able to link sort of this person to a body of information about their insurance. Where do I send the claim? How much am I going to be paid? What services might be covered? We have said that you don’t imbed that all on the plan ID, you make the plan ID a pointer so that they can get that information.
There is a second need which we didn’t talk about much but was in hearing which is the issue of post transaction sort of oversight. This is the need that I think is something that is related to what CMS’s programs or the state Medicaid programs have been doing for years. It is also related now to the exchanges, and it is important.
The issue is at the end when we have claims or encounter data can we then look at them in terms of a product and the specifications of that product relative to the experience under that product. That is what we want to be able to do. There is a question of how do we make that ultimate oversight aggregation simply and it is be able to have sort of somewhere on this claim or encounter information something that identifies product.
DR. OVERHAGE: Can you say more about the bad use again I am not following the –
DR. SCANLON: Well I mean you brought it up sort of the Medicare Advantage in Savannah, sort of its Humana Gold versus Humana Silver. One of the things with Medicare Advantage plans is that you have agreed for a bid to provide a certain set of benefits. There is an issue of did you provide those benefits? What did they end up costing, et cetera? There is that kind of compliance questions. We are having medical loss ratio requirements that are being developed as we speak. There is a question of sort of being able to oversee those and that is something that is going to have to happen in the future. These kinds of things are sort of this post transaction oversight that being able to aggregate at a product level is critical. You want to be able to do that in a way that is as simple as possible.
DR. OVERHAGE: You are going to aggregate?
DR. SCANLON: You are going to aggregate the claims under a product.
DR. OVERHAGE: So the actual individual claims transactions, where are those going to come from?
DR. SCANLON: They are flowing into the claims databases now. They are flowing from providers to the insurers. Medicare Advantage is now putting in a requirement that we have encounter data, which is comparable to claims data, and so there is going to be this databases that we can use for this purpose.
DR. SUAREZ: As a payer one issue being able to identify distinctly products like Medicare Advantage. When a consumer comes that actually has the card and that is a Medicare Advantage enrollee, that particular ID of that product is the one that would be needed to be used in the transactions when sending a claim.
DR. OVERHAGE: I still don’t understand that. You told me that if you have the plan and the person that you don’t need it. So why do we want to add complexity.
DR. SUAREZ: Well, because when I send a claim to Medicare or when I receive it, I see a patient that is enrolled in Medicare Advantage, and I need to do the transaction with that Medicare Advantage information, I need to distinguish my Medicare Advantage product from my commercial product.
DR. OVERHAGE: Right, that is fine but you told me you could do that with a patient ID and your ID.
DR. SUAREZ: An inquiry.
DR. SCANLON: There is a issue, Marc I think of efficiency. What we have said if I understand this right, is when we have someone who comes in and there is an eligibility inquiry, do we send in what I will call at the moment, a plan which is the company, Aetna, and the individual’s identifier. What can come back from that is the product ID which let’s use, be consistent about that, we will call it the product ID, okay? There is the possibility we could just simply get claims with plan IDs, Aetna, and sort of individual names, and every times we wanted to look at one of them we could go look it up in terms of.
DR. OVERHAGE: And where are they coming from?
DR. SCANLON: The overseer. The overseer is potentially the, is the Medicare program, Medicaid program’s insurance commissioners, exchanges.
DR. OVERHAGE: Where is the data coming from to those overseers?
DR. SCANLON: Well Medicare requires encounter data now.
DR. OVERHAGE: Where is it coming from?
DR. SCANLON: From the Medicare Advantage plan.
DR. OVERHAGE: So the plan that has the ID is going to send you data.
DR. SCANLON: Do you want them to have to every time they get a claim match it again against the product database and then attach it there or is it simpler to return it to the provider and have it come from the provider?
DR. OVERHAGE: Then I guess the key question I am asking here is and that is okay. If I ask Kaiser for a plan ID and they give me back a plan ID and I carried it back that is fine. But then why does that plan ID have to enumerated because he is the one who is assigning it and he is the one going to aggregate it and give you the data that you so why does anybody care? Why is that visible outside of the health plan?
DR. SCANLON: It is usable outside of the health plan because the health plan is being bought by some bigger entity. It is being bought by a Medicare program, a Medicaid program, an employer, an exchange, et cetera. It is their issue of oversight in terms of their.
DR. OVERHAGE: If your oversight is coming from him and he is going to give that code to you.
DR. SUAREZ: That was in error. The other one is in the eligibility inquiry response yes one could probably deal with that but then the provider sees a patient and then sends the claim through the payer. Now the expectation is that the claim will have the plan product ID.
DR. OVERHAGE: I’m okay with that. The question is why are those enumerated outside of the health plan?
DR. SUAREZ: The plan ID needed to be raised so that the provider can send in any claims.
DR. OVERHAGE: No, no, no it doesn’t. I mean it is like NDC cuts today, right? They are not enumerated outside of the company. NDC Codes are made up by the drug company.
DR. SCANLON: These could be made up by the company too. I think it is.
DR. OVERHAGE: Your bringing it to me implies some national; you know he can’t have code 1, 2, 3 because I’ve already got code 1, 2, 3 so maybe that is my confusion.
DR. SCANLON: You are both going to have code 1, 2, 3 unless you have some kind of prefix on it that says that you are Marc and you are Walter. That would be fine. You can all have 1, 2, 3.
DR. WARREN: There is no prefix on it.
DR. SUAREZ: I have a ten digit plan ID at Kaiser and then I have separate ten digit ID product ID.
DR. OVERHAGE: I don’t care what those are. I mean you make those up and that is fine.
DR. WARREN: Karen.
MS. TRUDEL: Actually I think the notion of the NDC is very apt because it only works on a very granular level. If you want to try to look at drug data across plans, across providers, across manufacturers, it doesn’t work because of exactly what you said. Everybody has enumerated their own so the only way you can do it is if every single time you want to do that whoever wants to do it has built a crosswalk. So what we are saying is that if you enumerate at a more granular level it gives you the ability to tack that more granular piece of information along on your transaction so that for instance when the plan goes to do its oversight it doesn’t have to yet again do that crosswalk of the upper level plan and who the patient is.
DR. OVERHAGE: I’m not sure what you mean by the crosswalk. May be a patient in our statement was that the oversight might want to compare Product A and Product B from two different straight. Is that what you were describing?
MS. TRUDEL Right but it would not necessarily just be that plan. You know I mean we are talking about potentially cross insurer potentially databases. We are talking about.
DR. OVERHAGE: It can be because the products you would have to understand what are the characteristics of the products that matter in order to do that comparison.
MS. TRUDEL: Right and that is what is in the database.
DR. OVERHAGE: The database of what, where enumeration?
MS. TRUDEL: The enumeration database.
DR. OVERHAGE: So it is going to have description of the plan benefits and the
DR. WARREN: No.
MS. TRUDEL: At some level. The detail level is not specified. Some people want to see a lot. Others not so much because the change is too –
DR. OVERHAGE: So again I will ask why is that and I think I heard you say it is not necessarily a global enumeration but I mean if you guys here are the some things you need to tell me about the plan or about your product and you tell me about a product assign 1, 2, 3. I will assign 1, 2, 3 and I will give you the description of the product even though the identifier doesn’t help you there.
MS. TRUDEL: I think we are talking about a global enumeration. We are taking about the identifier being unique for each plan. The point to it is how else do you get all of the data in one place.
DR. SCANLON: I think that we still have this issue of planner product. I think one of our problems is that we may be in reality talking about more than one variable. This is not going to be one variable because everything is for everybody. There is more than one variable. Walter wants a variable that he sends in with the person ID and the entity receiving that Kaiser or, etcetera comes back and tells him what the product is. Coming back and telling you what the product is we should maybe think of as a different variable. Don’t call them both the plan IDs because that is just a source of confusion. I think that one of the things to be decided in a different context is okay I send back the plan ID to Walter, how is it used? I mean it could just end with going back to Walter but I guess what I am saying is that we potentially reduce administrative burden over the longer term if we have Walter attach it to the claims that we then submits because there is no need to take every claim and run it through this database that is comparable to the eligibility base.
DR. OVERHAGE: So we say Walter submits. I assume he means the oversight bodies.
DR. SCANLON: First of all he submits to the payer.
DR. OVERHAGE: I am assuming he is a payer.
DR. SCANLON: Well he is one of those unique individuals but he is a provider.
DR. WARREN: Marc sends a claim to Walter who is Kaiser. Now what is Walter?
DR. SCANLON: Okay use one of your out of network for the providers. You send a claim to him. He sends you back sort of the product ID. Do you then attach it to your claims?
DR. OVERHAGE: Fine, I have no problem with that.
DR. SCANLON: I think that would satisfy.
DR. OVERHAGE: In order to do that I need a –
DR. SUAREZ: ID.
DR. SCANLON: Yes, so make one up. I don’t care.
DR. SUAREZ: Apply for one, yes.
DR. SCANLON: Well make it up. It doesn’t matter.
DR. SUAREZ: No, no, no I need to have a standard because the same product ID that you send me, I need the same ID to send to Mayo. It needs to be so it needs to be a national standard.
DR. FITZMAURICE: So somewhere all of this has got to get down from the claim to the payment rate schedule. So within the health plan there are probably different payment rate schedules for that particular physician, maybe that particular patient depending on where the treatment is being given: hospitals; physician’s offices; clinic and so are network. So you need to identify the patient. You need to identify the plan. I mean it is not just Aetna. Aetna has all of these contracts so you need to be an identifier for each on of those contracts, which links to the payment rate schedule for that doctor.
DR. WARREN: That contract is not what we are recommending.
DR. FITZMAURICE: No, then how are we defining product?
DR. WARREN: Right now we are kind of doing it by example.
DR. FITZMAURICE: Okay so in an example a product couldn’t get a payment rescheduled for that service?
DR. WARREN: So like if you go to Tricare you could have Tricare Prime, Tricare for Life and there is another Tricare I can’t remember. If you go to Blue Cross Blue Shield like Marc said there is a Blue Cross Blue. There is a Blue Cross Gold that have different services that they will give. So each one of those would be a different product.
DR. FITZMAURICE: So in that payment reschedule some of them have a payment of zero. Sorry, the patient is covered by our plan but we don’t pay anything for that service. That service you could say is not covered. We just say we don’t pay anything for it.
DR. SCANLON: What we are talking about is we need the information for these sufficient to point to something that says that service is not covered. There will be zero payment or it could be that that service is covered but this physician is in network, this physician is out and we pay out of network physicians at a different price. That is the issue of the database that we are pointing to and I look up function as opposed to try to use this enumerated ID to essentially contain all of that information.
DR. WARREN: Okay, so I am going to let Karen say something and then I would like to make an observation as co-chair.
MS. TRUDEL: I just want to remind people that there are a variety of ways that data moves around and a lot of this data is coming back as content in the eligibility response. You don’t have to go to a database to look it up. You have used that plan ID, whatever it is, to send a transaction to Walter. Walter looks and he knows he is not going to pay anything on this service and so he can send that back in a 271 and sends it back. So it doesn’t all have to be elsewhere. Some of this is in the content of the 271. Part of the reason that we are in this place is that in the absence of operating rules not all health plans are sending back the most comprehensive set of data that they can or in the correct places. So we are kind of moved in the direction of getting the data right back to people not just using the plan ID but also maximizing the existing content of transactions.
DR. WARREN: So one of my observations is if you will pull up I think it is the second bullet on observation, no number three, no yes, number two. So number two up there reads, work with the industries. So we are asking HHS to work with the industry to reach consensus on names and, go to observation. There, 2.2, so we are asking HHS to determine what qualifies as a health plan at the product level to be enumerated using input from stakeholders and to identify in regulation that such health plans must be enumerated.
So what we are saying is we have given this our best shot in consideration of the timeframe that we have had, tried to understand this stuff and we still don’t clearly understand it because there is still you know a lot of different ways that you can look at this.
I am wondering if we clarify that or modify that one, if that will handle this issue because I really do think that listening to the conversation, trying to go back and remember what we have heard in testimony, that there is still a lot of unknowns about what it is that we need to enumerate. I don’t know that it is the product. I don’t know that it is the legal entity that creates themselves the product. It could be any or all of those things because I understand from Marc’s perspective if I have an Aetna or Blue Cross, I should be able to query them with the ID they have given the patient and their ID and get something. I also understand it has been a lot of concern down at the lower level of what product is being used.
DR. SUAREZ: This is sort of like writing a plan, a provider identifier so we know that we need to identify each individual hospital. That is 2.1 there. We don’t know beyond the hospital which component of the hospital we need to identify at this point. We heard several things. I mean they are now used in a hospital, the health plan. We know every health plan needs to be enumerated but we don’t know within a health plan what part, what product is what we are calling. So we are asking HHS to work with the industry to make that determination of which are the products beyond the health plan legal entity level that must be enumerated.
DR. WARREN: Right.
DR. SCANLON: I agree with you but I think the problem is with one, is that we are not identifying the equivalent of the hospital. We are identifying the equivalent of something like HDA or Davida. These are huge. I think 2.2 is on target. I think we need to clean up a little of the language in identifying regulations, which products must be enumerated because I think if we keep going back and using health plan with different meanings is confusing to people.
DR. WARREN: Like us.
DR. SCANLON: Right. There is a this question about why does one tell someone to initially enumerate and then have something about another kind of enumeration. If it is a separate variable then that is very clear but given that we have only been talking about a health plan ID as if it was a one, a single entity or single variable then this becomes a little confusing.
I think we really would be better off if we said that there is a need to identify the legal entity and there is a need to identify products. We are not specifying what products there is a need to identify. We are telling them to work with stakeholders to do that. That is fine but it is just from reading the letter I think we are all hopefully on the same page but from reading the letter we are going to leave the readers confused.
DR. SUAREZ: Let me ask, Bill because 2.1 is very clear. It says every legal entity that is called a health plan must obtain a number. That is what it says on 2.1. Every legal entity that is a health plan must. That is by analogy with a hospital. A health plan is a legal entity. A hospital is a legal entity. Now beyond that we are saying we know that there are going to be needs to identify products. We don’t know what is considered a product and what is the right ones that need to be identified.
So we are asking HHS to work with industry to define those because during the hearings we heard a wide variety of perspectives on what are products; what are health plans, lines of business, what are different things within a health plan. It would not be appropriate for us to go into making a form of recommendation on a particular categorization of products within a health plan that needs to be identified.
DR. SCANLON: Okay. Let me sort of say I should have been reading the observations because maybe the observations covers this well. We say as such the HPID enumeration process needs to ensure that the right entities including at least the transaction recipient, administrator, etcetera, and as appropriate, their products. We have set up the duality: the two things.
DR. SUAREZ: Two things; two levels.
DR. SCANLON: Right so then I think we probably would, it might help things by not saying however even the definition of a health plan is subject to interpretation and there are many intermediary entities without consensus definition some of which may be suitable to be enumerated. That kind of like sets it again.
DR. WARREN: That I can see we can take that out because it is in our briefing background.
DR. SCANLON: Okay. I think that would be helpful in clarifying what we are doing.
DR. WARREN: Okay.
DR. SUAREZ: Okay.
DR. OVERHAGE: You guys are much more expert in this phase than I am.
DR. WARREN: Okay, so I have dealt with Marc at other issues. He is never stupid. You have wonderful insights. I value them and I forgot what I was going to say.
Oh, one of the things that I was made aware of at lunch by Jim Scanlon is health plan ID is going to be needed in other areas. So like when CMS has to check their compliance with operating rules we will need to identify who the health plans are so there is some interaction that needs to go in. Our job with this is not over. What we are doing is getting everything started. We are going to have to go back and take a look at where else is health plan ID used and I believe that Jim said it was mentioned in other parts of legislation.
DR. SCANLON: We even have like recommendations.
MS. TRUDEL: Right, the portal is that what it is called, the consumer portal that is being built right now by a different part of HHS is also collecting information about plans and because there isn’t a standard plan identifier they are just sort of using whatever they can use based on what is in existence. So it would be good for purposes of ACA Implementation and also just general insurance oversight. If we are going to have a plan identifier it should meet everybody’s needs.
MS. DOO: A plan shouldn’t have to go back and get another number. We should see what can be used or leveraged.
DR. WARREN: Okay so given that, does everybody agree on 2.1 and 2.2? I am assuming silence is agreement.
Observation three we had no problems with. That is pretty straight forward. Go back to number one. Are we still okay on this one that said we were going to uphold HIPPA?
DR. OVERHAGE: I am basically okay with that. I just have a question. When I read this yesterday again, 1.2 almost feels like it is part of two to me or how is it different? I guess what is the point we are making as distinct from two?
DR. WARREN: Yes and when I reading it earlier I almost made the same mistake so maybe it should be moved?
DR. SUAREZ: We could move that.
MS. DOO: Walter, the only reason this and it may be fine to merge them, as I recall the reason this was called out was because the legislation really only says health plans and we know that more entities than health plans need to be enumerated even though we don’t have authority because they are not covered entities that the Committee may suggest to us find a way to identify who they are like these third party administrators and list them also. I think that is why you were calling them out.
DR. WARREN: It can back up in the observation and it tries to set that up.
DR. SUAREZ: I think what we were trying to do was who is eligible to obtain a number.
DR. WARREN: Well no on that one it was just trying to get clarity on who these people were and what role they played.
DR. SUAREZ: Well but we say consider make them eligible to obtain a number on 1.2.
DR. SCANLON: In 2.2, I mean I think we ultimately sort of get to a set of mutually exclusive numbers and the problem with the intermediaries is how do they relate to that set of mutually exclusive numbers? An intermediary could deal with dozens of what we just said down on 2.2 and so again this issue of the language suggests it is all this single identifier. Intermediaries may need to be identified but they need to be identified separately.
DR. SUAREZ: Yes, because they are not part of the health plan. There is a health plan and a health plan product. There is something else called intermediary.
DR. SCANLON: This is part of starting with HIPPA’s definition of health plan. It is confusing to say the least. Now we are sort of piling on to that with this discussion of the intermediaries which is another dimension and we should treat it sort of as another dimension. Maybe it needs to be broken up as a recommendation that providers at times need to know about intermediaries. They need to be enumerated and there must be some provision.
DR. SUAREZ: In the introduction to the letter we talk about them.
DR. SCANLON: But we go back and forth in the recommendations. I think it is a question of clarity.
DR. SUAREZ: We say it is common in the health care to utilize a variety of administrative and processing intermediaries to assist in the performing of dah, dah, dah, dah, dah. Examples are this. These are different entities different from a health plan that are likely needing to be identified with a plan identifier.
DR. SCANLON: For a very different reason. That is the problem. The paragraph before is talking about and I have to say again that this is not a good taxonomy but the paragraph before is talking about what we are getting at in 2.2, this multitude of different plans.
DR. WARREN: So Bill, if we give them an ID who cares what the reason for use is. Let me just you an example. For NPI we came out with it had to be a provider for lots of discussion of what providers we meant. At that point in time we decided to make it as broad as possible and put in anybody that was seeing a patient because we could not predict what the future use of the NPI was going to be and so we left the door open. This is the same strategy. We had these things up here that we don’t fully understand. They have grown into a market spot within the health care system. Let’s give them an ID and then we use that consistent ID in the places that we currently need it and in other places that we don’t anticipate but we might need it.
DR. SCANLON: Right, but I think that you don’t want them in the same category as the health plan ID or the health plan product ID.
DR. SUAREZ: They need an ID.
DR. SCANLON: Well but again I think we need to treat them totally separately. Don’t kind of go back and forth in terms of health plans. They are mentioned in the observations to one, then they are in here. It is confusing because they are just different things.
DR. WARREN: So then what we need to do is go back to the SDOs and say completely restructure eligibility and claims to allow for a slot for intermediary IDs.
DR. SUAREZ: It is not just intermediary IDs. It is all of the transactions there are spaces, there are segments and data elements that require identification of certain entities. Ninety-five percent of them are called health plans. Every now and then you have to identify something called an intermediary, as the way we say it here, in that place where all the time you identified health plans in the transaction. In order for them to have an ID they need to become eligible to obtain an ID. It is called a health plan ID identifier. That is what they need to have as a number to go in the transaction, otherwise they won’t be able to.
DR. SCANLON: You can tell me this is going to solve a problem for me but let’s go back to Karen’s sort of needs. We want to look at these products. We handled that in 2.2. When a provider or some other entity uses an intermediary ID am I going to be able to satisfy Karen’s needs in terms of identifying the product?
DR. SUAREZ: You combine intermediary and product.
MS. TRUDEL: They won’t be answering the same question.
DR. SCANLON: Then we are not clear about that. We definitely are not clear about that. We have been talking – health plan ID, we start the letter off as a singular and we need to be thinking about if we are going to deal with intermediaries it is a different type of a variable and we need to make that distinction for people.
DR. WARREN: Okay, so I am going to be the ugly person of truth here. It is now ten to four and I think Privacy gets this room at 4:00. I am not sure – the rest of the letter except for this one issue I think is fine, right? Do I have consensus on that? Did you have any other concerns, Bill except for the intermediaries? All right. Why don’t you let –
DR. SUAREZ: Just one thought because I think it covers the other point of what is made by Jim, about using the ID beyond into the future that 1.4 we already talked about collaborating across federal agencies to develop consensus on the use of the plan for the purposes. That is where we can include some language about including identification of programs from the Affordable Care Act or something like that; something that references Affordable Care Act in that particular 1.4 recommendation. That opens the door for that.
DR. WARREN: So, we have made arrangements for Lorraine, Margaret and I, to get together to try to clean these letters up really quickly so they will be ready for the morning. We will try to do that and come up with language that we will show you in the morning. What I would like to do is I know that AMA has been sitting there. She has been sitting on her hands so wonderfully, and I am sorry I can’t remember your name but I know where you are from. Any comments that you want us to hear about this issue?
SPEAKER: I think the only comment I would make for your consideration tonight is you are talking about health plan as a singular and you are talking about intermediaries and that is exactly how we started three years ago. We could not get our arms around this. The only way we could get our arms around this expanding marketplace that we work in is roles and what entities serve in which roles.
It used to be a fully insured health insured you would contract, they would have the provider network. It was a singular. It would make it so much easier but because of our marketplace and the different demands that are there, now there is other entities that come in this space to serve those roles. So we have the self insured employer. We have the TPA that takes over administrative functions. We have provider networks or the rental networks that physicians will contract and health insurers will contract with in order to expand their geographic reach that recognize the plan ID and that contract that fee schedule contracts they are independent. They are not the same thing. Just because you know the plan ID you don’t know your fee schedules and your points were very astute with a plan ID is you need to know what part of the contract because now a contract is not just one fee schedule and one plan. It can be five different plans with various, different associated fee schedules. So you need to know which plan because you need to do your utilization review, your prior auth, you need to know what requirements are there. Sometimes your rental network or provider network will have different utilization review. So when you try to look at it as a singular entity it is hard. It is hard to unravel it but if you look at the roles it is much easier and so that is kind of where we were coming from just for your consideration is if you enumerate the entities that serve in the roles, the transactions can support or will in the future be able to support the identification of the role within those transactions.
So like you were saying you do an eligibility which you can do with a last name, date of birth. You don’t have to have. If the person doesn’t present with a card and unfortunately they don’t. It is real world; real life especially with the ER so you send that eligibility and if you get into the right entity you are going to find out that you can get this information back. You need this information to adjudicate a claim. That from a physician perspective we are just asking that the sooner we get it before the transaction occurs with a patient, the more there can be that one-on-one discussion and understanding of what the UR is or the prior auth with the different utilization review requirements also what is the financial constraints. Is it in network, out of network? You will know at that point in time. You will know what the specific fee schedule is for those when you are only doing one or two service you can possibly even give an estimate of the service anyway. My only consideration would be looking at it from a role perspective.
DR. WARREN: Okay, so let me kind of rephrase from my perspective. So we have these standards. We have slots that require a plan ID. That is just a label for whatever we say that is in the slot. What you are suggesting is that we enumerate entities that serve in the roles needed for transactions.
SPEAKER: Right. You are right that there is one slot with a plan ID. So the thing is there is other fields for different functions like if there is a contract you would put it in that field. You would put the other one or through, there is other ways. There is operating roles you can go through.
DR. WARREN: So then the problems that we have are by law we are designated to suggest a plan ID that goes in that transaction slot. We also have operating rules for coming down the pike that will tell us where to put this other information. So I mean this really isn’t two separate independent things although we have to treat them as two separate letters and pull them apart. So I think we are still in the point where we have this nebulous thing called plan ID and so if we start here with let’s take this legal entity that is already identified for us. Let’s come down and work through the roles and whatnot and see where they work in slots or to help us look at where do they fit in these standards and then feed that back to standard needs to change and we make that change.
DR. SUAREZ: I totally understand the point. The term that we using to call this is the health plan ID because that is the term that is used and evolved but it identifies more than just health plans. At least let me say four things. One is who is the recipient of this transaction? Who is the benefit administrator? What is the product in which the person is enrolled? Who is the entity financial responsible for? Leave those four. We can identify even more but in the actual transaction today those are at least the four things in which an ID has to go. Now in some cases the benefit administrator might not be a health plan. It might be a TPA. They might not qualify as a health plan to be eligible to obtain a number. That is why in recommendation 1.2 we are asking CMS to expand the eligibility of applying for a number to entities that have to be reported in those segments that might not be a health plan as in a traditional term of health plan. That is why we are in many respects, we have to go down to the functional responsibility or the role of the entity not just the definition of a health plan. I totally agree with that.
DR. WARREN: We are now at 4:00. So if you want to lobby this you need to go out into the hall because another group is coming in here. So we need to vacate and give them their time.
(Whereupon the subcommittee adjourned.)