NPAG Clearinghouse Industry Update

Presented by :Sherry Wilson, Chair of the Board of Directors Cooperative Exchange, National Clearinghouse AssociationEVP and CCO Jopari SolutionsMay 9, 2017

Agenda Topics• Brief Overview of Cooperative Exchange

• Information Exchange & Key Industry Updates

Washington D.C. Advocacy Efforts- Proposed Attachment Regulations- EDI Infrastructure Support – Interoperability

Valued Based Payment – 7 Key Stakeholder Challenges

Medical Record Retention Considerations – IT Impact

Industry Collaboration Opportunities

Overview of Cooperative Exchange• 28 Clearinghouse Member Companies• Represent over 90% of the clearinghouse industry• Over 750,000 submitting provider organizations• Maintain over 8,000 Payer connections• 1000 plus HIT vendor connections• Process over 4 plus billion claims annually• Value of transactions –over $1.1 Trillion • Infrastructure framework supports BOTH

administrative and clinical transactions• Leadership engagement across all the National

Standard Setting Organizations

American MedicalAssociation (AMA)AfoundriaApex EDIASC X12NAvaility, LLC AXIOM Systems, Inc.BancTecCernerClaimRemediClinXdata Dorado SystemsChange Health eProvider Solutions

Experian HealthGE HealthcareGreenway HealthHealth‐e‐Web, Inc.HDM Corp.InMediataInstaMedJopari Solutions, Inc. Medical Electronic Attachments (MEA) NextGen HealthcareOfficeAllyOptumInsightPNC Bank 

PracticeInsightRelayHealthThe SSI Group Trizetto Provider SolutionsUtah Health Information Exchange (UHIN)WEX, Inc.WorkCompEDIXerox EDI DirectZirMed

Washington D.C. Advocacy Efforts

Cooperative Exchange Washington D.C. Advocacy Efforts

• Madhusudhan Annadata, Director of National Standards Committee - Proposed Attachment Regulations

• Tom Price, MD,Secretary of Health and Human Services (HHS)- Attachment Regulation Agenda- EDI Interoperability Coordination

• Dr. John Fleming,Assistant Deputy Director of Health Information IT (mission streamline data exchange stakeholders)

• Reed Cornish,Assistant to the president for Intragovernmental and Technology initiatives. Task with bringing Government and Privacy industry together

• Don Rucker, MD, ONC DirectorInteroperability Initiatives

• Roger Severino, OCR Director-Standard Security Clearinghouse Audit Regulations

Attachment Landscape Update Overview Clearinghouse Attachment History CE- CMS Attachment Listening Session

Proposed Attachment Regulations – Advocacy Efforts

• New Administrative Regulation Rules• Every 3 proposed regulations: 2 eliminated • NCVHS recommendations to HHS – Time is Now• Projecting Regulations - 4th quarter 2017• High Priority –clearinghouse industry stakeholders • CE – Industry collaboration to push regs 2017• Director of National Standards Committee

- Industry EDI Attachment Readiness- Implementation/ ROI- CMS Attachment Flag Ship – NGS Anthem- CAQH CORE Attachment Webinar- May

How Attachments are Used Today

Examples of Attachment Utilization - Business Processes• Eligibility • Claims Adjudication (i.e., high% unsolicited)• Post Adjudication (i.e. appeal/audit)• Referral/Notification• Prior Authorization• Utilization Review /Case Management• Itemized Invoices• Emerging regulations, i.e. Value Based Payment• Quality measures requests and responses (HEDIS data)• Transitions of Care (Admit, Discharge, Transfer, and care

management• Gaps in Care (population health analytics)• EMRs – Meaningful Use • Others

Clearinghouse Attachment History• 2005 proposed HIPAA Attachment Regulations adopted

by numerous Property & Casualty Jurisdiction (State) mandates in 2008

• Clearinghouses provided flexible attachment technology solutions to meet clients’ needs (i.e., payers, providers and other vendors).

• Technology Solutions address different levels of stakeholder s EDI attachment readiness (low tech to high tech).

• Same providers and HIT vendors – all lines of healthcare business

• 11 years later, Clearinghouses are processing over 49 Million Attachments a year.

• Adoption is growing not because of mandates, rather makes good business sense and proven stakeholder ROI

Infrastructure EDI Highway is BuiltCooperative Exchange members are processing 49 million

electronic attachments annually

Health Plans

ScriptsFill Notice

EligibilityClaims

ScriptsHistory

CE CLEARINGHOUSES

PHRMaint.

ClaimsPayments

ConsumersEmployers

Retail Pharmacy

Reference Labs

FinancialInstitutions Public Health

UtilizationReports

RequestsResults

PBM’s

ClaimsReferrals

Minute Clinics

RemitsLockbox

Bio-Surveillance

Reports

Hospitals and Provider Offices

Claims Referrals

Clearinghouse Electronic Attachment Survey Results

1. Over 49 Million Electronic Attachments Processed Annually

2. Electronic Attachments by Healthcare Lines of Business • 55% Property and Casualty • 15% Dental• 15% Commercial• 15% Government

* High % Voluntary Industry Participation

3. Electronic Attachment Utilization – Business Process• 83% Claims Adjudication (high% unsolicited) • 11% Post Adjudication (e.g. appeal/ audit)• 3% Referral/Notification • 3% Prior Authorization

4. Electronic Attachment Format Type • 95% Unstructured (e.g., TIF, PDF)• 5% Structured (C-CDA)

Clearinghouses Attachment Survey Results

6. Attachment Transport Methodology Variation• 53% Web Portal Upload ( Single or Batch)• 27% EDI using ASCX12 275• 14% EDI (e.g., SFTP with PGP Encrypted) • 3% Secure Fax • 1% Secure Email• 1% IHE Profile (XDS,XDR)

7. Utilization of Report Type Identification Codes(LOINC “ Missing Chain” to full automation )

• LOINCs are not widely used at this time• X12 Report Type codes most common way to identify an

Attachment Type

Supplemental HIPAA Panel LOINC code set as part of a phased in approach will provide the minimum necessary standards for attachment processing.

Cooperative Exchange Responseto CMS WEDI Attachment Forum

Questions

What X12 transaction version of the 275/277 do you recommend HHS consider adopting for attachments – 5010 or 6020? Recommendation for Standards

The Cooperative Exchange concurs with the ASCX12 NCVHS February 16 Attachment Testimony recommendations in addition to the noted consideration stated below:

• ASC X12 275N Additional Information to Support a Health Care Claim or Encounter version 6020

• ASC X12 275N Additional Information to Support a Health Care Services Review version 6020

• ASC X12 277N Health Care Claim Request for Additional Information version 6020

• ASC X12N 278 Health Care Services Review – Request and Response version 6020*

*This will require a modification to the Transaction and Code Sets to update the X12N 278 from the current 5010 mandated version to the 6020.

What are the advantages and disadvantages of each version?

Advantages • Enhancements made to 6020 X12N 275 current published version to

support the exchange of supporting documentation:• BDS Binary Segment was added to replace the BIN binary segment. • BDS Segment includes a data element to identify the Filter ID Code used to identify the

encoding format of the data contained within the BDS• REF Segment was added for Property & Casualty Claim Number• HI Segment was added to support the Diagnosis Codes • SVC Segment was added to support the Procedure Codes • Several segment and data element notes were added to provide further clarification. • BDS segment to fully encode the HL7, or other body in Base64, thus making any

content compatible for transport within X12. This also sets up the industry to move forward to 7030 when the time comes.

• Base64 support of the BDS segment is very important for compatibility between X12 and the data format of content carried in the binary segment.

• Guidance has been included in the documentation for attachments with clarification on how to use the 6020 275 BDS segment for the Attachments.

• Note :Since the 5010 X12N 275 BIN segment does not have support for field content encoding, un-encoded content into the BIN02 could cause invalid characters to appear in the X12 data stream should the embedded content not support X12 compatible character encoding within its own specification.

What are the advantages and disadvantages of each version?

Disadvantages • Enhancements made to 6020 X12N 275 to support the

exchange of supporting documentation will not be available in 5010.

• If consideration is not given to moving the current HIPAA standard for Prior Authorizations and Referrals to version 6020 payers and providers will need to support two ways of requesting and responding depending on the need for supplemental information

What are the questions/issues that HHS needs to keep in mind as we develop this regulation?

• Recognize the evolving healthcare landscape -- allow flexibility to accommodate the varying and constantly changing business needs for the exchange of information/data.

• Recognize the need to leverage the existing IT investment, connectivity and resources for multi-stakeholder exchange as appropriate for both administrative and clinical business needs. And continue to expand connectivity where it does not exist.

• Ensure that the Federal Attachment Regulation’s supersede state laws, as appropriate, to mitigate conflict between state and federal regulations that affect HIPAA covered entities.

• providers are the same across all lines of healthcare business.

• Many payers, providers and technology vendors operate within all 50 states.

What are the questions/issues that HHS needs to keep in mind as we develop this regulation?

States are moving forward with additional attachment regulations that affect HIPAA Covered Entities

Could require support of two different 275 versions (similar to the ICD-10 mandate scenario) For example, Minnesota Statutes 2015 Supplement, section 176.135, subdivision 7a, amended (d) Mandated 275 5010 , January 1, 2017:….using the ASC X12N 5010 version of the ASC X12N 275 transaction ("Additional Information to Support Health Care Claim or Encounter"), according to the requirements in the corresponding implementation guide. The ASC X12N 275 transaction is the only one that shall be used to electronically submit attachments unless a national standard is adopted by federal law or rule.If a new version of the attachment transaction is approved, it must be used one year after the approval date; workers' compensation payers and all clearinghouses receiving or transmitting (2) workers' compensation bills must accept attachments using the ASC X12N 275 transaction and must respond with the ASC X12N 5010 version of the ASC X12 electronic acknowledgment for the attachment transaction. If a new version of the acknowledgment transaction is approved, it must be used one year after the approval date; and (3) if a different national claims attachment or acknowledgment requirement is adopted by federal law or rule, it will replace the ASC X12N 275 transaction, and the new standard must be used on the date that it is required by the federal law or rule.

Lessons Learned1. Electronic Solicited Attachments

• Electronic solicited attachment capability is critical to widespread adoption by payers and providers

• Reduce manual processing, such as mail and fax• Facilitates an automated workflow and drives increased efficiencies

2. Electronic Unsolicited Attachment Front End Edits and Payer Attachment Rules

• Upfront payer/ state attachment rules increase provider’s first time claims pass rate of 75% for those claims requiring attachments (80/20 rule).

• Claim submission with attachments, reduce providers burdensome rework.• First time claim submission for providers results in faster payment,

3. Unstructured Documents• Most common exchange of additional information allowing for different levels

of stakeholder EDI Readiness.

4. Identification of Documentation Type • Internal routing expedited by the health plan to the right entity applicable for

clinical and administrative processing. • Prevents manual intervention in many cases by using::

LOINC Codes Report Type Codes (PWK)

5. Electronic Acknowledgments • ROI Impacts overall administrative costs and time (50% reduction)• Transparency - provider knows immediate status of the claim• Eliminates phones calls and ‘black hole’ (duplicate submissions)

Alternative Payment Models

Challenges for Health Plans

Movement throughout the Industry

Payers and health systems have also been adopting some of these models

• Commercial payer ACOs (e.g. Aetna)

• Employer based ACOs and programs (e.g. Boeing)

• BCBS IL, Highmark, BCBS KS among Blue plans established ACO arrangements

• Empire BlueCross BlueShield and other Blue Cross Blue Shield health plans across 13 states are providing financial incentives to their hospital networks for reaching Integrated Care Certification from The Joint Commission.

• CMS - QPP

Identified 7 Key Industry Challenges1. Different quality measures among plans places a burden on

providers2. Patient understanding of different models is often lacking3. Providers need to know what patients are part of what

program4. Providers need to know how to thrive in this environment5. Health plans may have different definitions of bundling

episodes6. There are a variety of reporting mechanisms used by

different plans.7. Vendors need to know how to support plans and providers in

these programs.• What are the payer challenges?• What is working ?

Clearinghouses Can Assist

Clearinghouses can provide services to providers and plans

• Clearinghouses can take some of the “raw” administrative and clinical data and produce reports

• Clearinghouses can help educate providers (their customers) about the various plan programs

• Clearinghouses can help track provider progress toward financial goals

• Clearinghouses can help providers share data among one another and also with plans.

Medical Record Retention RegulationsConsiderations – IT Impact

HIPAA Privacy Rule “Medical Record” Retention • HIPAA Privacy Rule does not include medical record

retention requirements.

• Rather, State laws generally govern how long medical records are to be retained.

• However, the HIPAA Privacy Rule does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal. See 45 CFR 164.530(c).

CMS & State Medical Record Retention Regulations• CMS Managed Care Vendors Records - 10 Years

• States Requirements Max 10 years or dependent on record type States Minor records – 18 to 23 years Max

• EMR Vendors 10 year Max

• The Centers for Medicare and Medicaid Services (CMS) requires that patient records for Medicare beneficiaries be retained for a period of 5 years (see 42CFR482.24 (b) [PDF]). Medicaid requirements may vary by state

• Refer to 50 State Mapping at "http://www.healthinfolaw.org/comparative-analysis/medical-record-retention-required-health-care-providers-50-state-comparison

Federal Laws Relating to Medical Records, Collection, Retention and Activities

42 CFR Part 2

A Summary of the Proposed HIPAA Regulations Implementing HITECH

Complete Overview of Regulations: 42 CFR Part 2

Federal Information Security Management Act (FISMA)

General Admin Reqs - All HIPAA Rules

General Provisions Applicable to Part 164

Genetic Information Nondiscrimination Act of 2008

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

HITECH/ARRA

Medicaid (Title XIX of the Social Security Act)

Patient Protection and Affordable Care Act

State Preemption Requirements

The Breach Notification Table

The Common Rule

The Enforcement Rule Table

The Family Educational Rights and Privacy Act

The Privacy Rule Table

The Security Rule Table

“Attachment” Definition Impacts - Record Retention Requirements

• Terminology significant factor• “Medical record” retention regulations are

specific to Providers governed by State, Medical Board and or State Medical Association

• States have no clearinghouses and or payer medical record retention requirements

• Consideration- How long do we store “medical records” best practice ?

• Best Practice Discussion - 90 Day Retention

Industry Opportunities for Collaboration

Thank YouCooperative Exchange Contact Information

Lisa Beard, Executive Director, Cooperative Exchangelisa@cooperativeexchange.orghttp://www.cooperativeexchange.org/

Sherry Wilson, Chair , Cooperative ExchangeEVP and Chief Compliance Officer Jopari Solutionssherry_wilson@jopari.com