Developing Best Practices for Exchanging Healthcare Payment Data

Transcription

1 Developing Best Practices for Exchanging Healthcare Payment Data Gwendolyn Lohse, CAQH Jeff Barnett, VeriSign April 28, 2010

2 Please turn off all cell phones or mobile devices All conference attendees will have free access to PAYMENTS 2010 conference session recordings. Attendees that registered onsite will receive details to access the session recordings within 10 days. Should you wish to purchase a CD-ROM, a special conference rate is offered to all conference attendees. Most of the education sessions at the conference can be counted towards your continuing AAP accreditation. The AAP Documentation of Attendance can be found in the onsite guide. Please take a moment to complete session evaluations! Each evening attendees will receive an link to access session evaluations that are offered each day. Attendees are automatically entered into a daily drawing for a chance to win a $50 gift card. We hope to see you all next year at PAYMENTS 2011 in Austin, Texas April 3-6, 2011 Thanks to all of our track sponsors throughout the conference!

3 Agenda Introduction to CAQH CORE Overview CORE Rules and Impact Example: CORE Phase II Connectivity Rule Industry Collaboration and Coordination Introduction to VeriSign About the CAQH-VeriSign Pilot Questions & Answers 3

4 An Introduction to CAQH CAQH, an unprecedented nonprofit alliance of health plans and trade associations, is a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers CAQH Solutions: Help promote quality interactions between plans, providers and other stakeholders Reduce costs and frustrations associated with healthcare administration Facilitate administrative healthcare information exchange Encourage administrative and clinical data integration Current Initiatives: CORE Committee on Operating Rules for Information Exchange UPD Universal Provider Datasource 4

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6 Universal Provider Datasource (UPD) UPD is a utility that replaces multiple health plan and hospital paper processes for collecting provider data with a single, electronic, uniform data-collection system (e.g., credentialing) UPD is recognized as the industry standard for self-reported provider data collection Over 800,000 providers are registered in UPD; growing by over 8,000/month UPD has more than 550 participating organizations No cost for providers to participate Data refreshed by provider three times each year to support any recredentialing cycle Strong industry support, including AHIP, AAFP, ACP, AHIMA, AMA, MGMA Being considered by a number of state Medicaid agencies Kentucky and New York are the first states to implement Potential source of data for state emergency responder registries 6

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8 8 Examples: CORE Certified Entities

9 Committee on Operating Rules for Information Exchange CORE is a multi-stakeholder collaboration developing industry-wide operating rules, built on existing standards, to streamline administrative transactions Mission: To build consensus among the essential healthcare industry stakeholders on a set of operating rules that facilitate administrative interoperability between health plans and providers Enable providers to submit transactions from the system of their choice (vendor agnostic) and quickly receive a standardized response from any participating stakeholder Enable stakeholders to implement CORE phases as their systems allow Facilitate stakeholder commitment to, and compliance with, CORE s long-term vision Facilitate administrative and clinical data integration CORE is not: Building a database Replicating the work being done by standard-setting bodies, e.g., X12, HL7 9

10 CORE Goals Answer to the question: Why can t verifying patient related financials in providers offices be as easy as making a cash withdrawal from an ATM machine? Participation from 75% of the commercially insured plus Medicare and some Medicaid Short-Term Goal Design and lead an initiative that facilitates the development and adoption of industrywide operating rules for eligibility and benefits Long-Term Goal Apply operating rule concept to other administrative transactions in claims process, using phased approach 10

11 What are Operating Rules? Agreed-upon rules for using and processing transactions do not exist in healthcare outside of individual trading relationships Operating rules encourage an interoperable network and, thereby, can allow providers to use the system of their choosing (remaining vendor agnostic is a key CORE principle) CORE certification informs the industry that entities are operating in accordance with the rules and support industry-wide standardization for administrative transactions Rights and responsibilities of all parties Security Operating Rules: Key Components Response timing standards Liabilities Exception processing Transmission standards and formats Error resolution 11

12 Phased Approach Design CORE Rule Development NACHA was essential to structuring CORE, and assisted with Phase I and II rule development Phase I Rules Phase II Rules Phase III Rules Future Phases Market Adoption (CORE Certification) *Oct 05 - HHS launches national IT efforts Phase I Certifications Phase II Certifications REMINDER: CORE rules are a baseline; Entities are encouraged to go beyond the minimum CORE requirements 12

13 CORE Participation, Certification, & Endorsement Participation: Over 115 multi-stakeholder organizations representing all aspects of the industry CORE participants maintain eligibility/benefits data for over 130 million lives, or more than 75 percent of the commercially insured plus Medicare and statebased Medicaid beneficiaries Certification: To date, nearly 50 healthcare organizations are certified to electronically exchange/receive basic eligibility and benefits information in accordance with the CORE Phase I rules Approximately one-third of all commercially insured lives are covered by CORE Phase I-certified health plans Over 30 organizations are Phase II-certified or committed to becoming Phase II-certified shortly Key organizations such as Aetna and WellPoint are already Phase II certified Endorsement: About 30 organizations have endorsed CORE 13

14 14 The CORE Rules

15 Administrative Transactions In CORE, transaction-based rules are paired with infrastructure rules, e.g. real-times response and connectivity, to help data flow consistency in varied settings/with various vendors Sponsor Provider Charge Capture Clinical O/E Utilization Review Billing A/R 834 Enrollment 820 Premium Payment 278 Referral Request 837 Claim/Encounter 277 Request for Info 275 Claim Attachment 276 Status Inquiry 277 Status Response Health Plan 270 Eligibility Inquiry Membership 271 Eligibility Response 278 Referral Response Benefit Contract Mgt Pre-Adjudication Expert System Claim Adjudication 835 Remittance (EOB) A/P Enrollment DB + Contract Benefits Database 15 Addressed in Phase I or II Under consideration for Phase III

16 Status: CORE Phases CORE Phase I Approved Implemented CORE Phase II Approved Implemented CORE Phase III In development *Built off of HIPAA standards,but goes beyond what HIPAA requires when using standard 16 CORE s first set of rules are helping: Electronically confirm patient benefit coverage and co-pay, coinsurance and base deductible information* Provide access to this information in real-time via common internet protocols and with acknowledgements, etc. CORE s second set of rules expand on Phase I to include: Patient accumulators (remaining deductible)* Rules to help improve patient matching* Claim status infrastructure requirements (e.g., response time) More prescriptive connectivity requirements with submitter authentication CORE s third set of rules focus on: Claim status data requirements (276/277)* Claim Payment/Advice (278), Prior Authorization/Referral (835) infrastructure requirements Standard Health Benefit/Insurance ID Card More prescriptive connectivity requirements as well as digital authentication *More eligibility financials

17 Example: Phase II Connectivity Rule Key Criteria Met by Short Listed Envelope Standards Technical business goals Supports rules based routing Supports Real time (request/reply, or synchronous) transaction processing Supports Point-to-Point message exchange Supports Batch (or asynchronous) message exchange Security goals Supports identification Supports submitter authentication, with ability to encrypt Supports HIPAA security regulations Messaging goals Payload agnostic (to enable interoperability) Message metadata Implementation business principles Language neutral (e.g., payloads like X12, HL7 have language specific envelopes that vary in metadata content and position) Platform neutral 17

18 Example: Phase II Connectivity Rule Interoperability Requires Standards CORE Phase II Connectivity Rule is consistent with Federal efforts, e.g. HITSP, Envelope Standard (SOAP 1.2); version will need to be updated over time CORE Phase II metadata prescriptive to facilitate interoperability of administrative transactions, which is CORE s focus Network Communications (Transport) Protocol Message Envelope + Message Metadata Message Payload (Content) = Public Internet (TCP/IP) CORE Phase I Rule = HTTP over SSL (HTTP/S) CORE Phase I Rule (includes security of payload during transmission) = Message Envelope & Message Metadata CORE Phase II Rule ( independent of payload required by Phase I) = HIPAA Administrative Transactions (X12) HL7 Clinical Messages Zipped Files Personal Health Record Other Content 18

19 Example: Phase II Connectivity Rule (cont.) Rationale for supporting two message envelope standards SOAP+WSDL Well aligned with HITSP and HL7 Lends itself to future rule development using Web-services standards for more advanced requirements (e.g., reliability) HTTP MIME Multipart Relatively simple and well understood protocol framework CORE-certified entities have already implemented HTTP as part of Phase I Incremental phased approach: Facilitates adoption in a market that is still maturing Facilitates interoperability relative to the current state of envelope standard variability in the marketplace 19

20 CORE Phase I Measures of Success Study (July 2009) Study Approach: IBM assessed results achieved by health plan early adopters (representing 33 million covered lives) of CORE Phase I Rules and selected vendor and provider partners Determined ROI by analyzing metrics (i.e., eligibility verification methods and volume) achieved by health plans, provider groups and HIT vendors three months prior to health plan CORE certification and one year later. Key Findings: All stakeholders achieved cost-savings and accelerated use of real-time transactions providers specifically: Increase of 20% in patient visits verified % fewer claim denials. Electronic verifications took approximately seven minutes less than phone verifications, saving approximately $2.10/verification. An industry-wide implementation of CORE Phase I rules would be a win-win scenario for providers and health plans that could yield an estimated $3 billion of savings to the industry over three years 20

21 21 Industry Coordination and Collaboration

22 Industry Collaboration and Coordination CORE was developed to support and integrate with state/regional efforts, Federal efforts as well as to build off of existing standards: Federal examples: Office of the National Coordinator for Health Information Technology (ONC) sponsorship of HITSP interoperability specifications ARRA s HITECH: Health Information Technology for Economic and Clinical Health Act Meaningful use (CORE rules referenced in draft specifications) State health information exchange (HIE) efforts MITA: Medicaid Information Technology Architecture HIPAA 5010 State examples CORE has been recommended to state legislature by several statesponsored, multi-stakeholder committees, e.g., TX, OH, and CO 22

23 Industry Coordination and Collaboration: Health Reform The concept of operating rules was addressed in the health reform bill Section 1104 of the Patient Protection and Affordable Care Act (HR 3590) Requires the Secretary to adopt and regularly update standards, implementation specifications, and operating rules for the electronic exchange and use of health information for the purposes of financial and administrative transactions Examples of goals and deadlines Eligibility verification and claims status operating rules must be adopted by July 1, 2011, and effective by January 1, 2013 Claims remittance/payment, and electronic funds transfer operating rules must be adopted by July 1, 2012, and effective by January 1,2014 Other operating rules (including health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization) must be adopted by July 1, 2014, and effective by January 1, 2016 CAQH will contribute its learnings with CORE as the regulatory process regarding this aspect of reform is addressed 23

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25 About VeriSign A world leader in enabling trusted online experiences Operating in 75 countries with 1700 employees Headquartered in Mountain View, CA 2008 Revenue: $936 million S&P 500 Index company Fortune Most Admired Companies

26 Vision Requires Focus Our Vision: Bring Trust to the Internet Registry Services Security Software & Services Network threat intelligence Mitigation of web site attacks Encrypting/protecting online transactions Protect identities Verifying devices Online Fraud Detection Services Enabling digital signatures Services that validate web site reputation Key Strategies: Leverage our massive internet infrastructure to drive in the cloud solutions to deliver services more quickly and reduce customer capital and overhead requirements 26

27 VeriSign s Vision Continues - Healthcare Bring Trust to Healthcare Secure and Authenticate Transactions among payers, providers, and patients Protect Identities of physicians and patients Enable Trusted Interoperability for privacy and security 27

28 Emerging Trends in Healthcare IT Stimulus funding: Driving adoption of EMR capability at providers Changes to reimbursement models: Alignment of pay for performance will require more advanced informatics (including EMR infrastructure) and reduce the barriers for creating HIEs NHIN development: Support and commitment to the NHIN is growing, and perspective architectures are being cast New clinical models for patient treatment: Personalized medicine, safety surveillance and new research models are emerging, and some are happening right now New compliance requirements: Became effective with HITECH in February 2009, with more changes becoming effective in 2010 Reduction in healthcare administrative costs aligns with White House Goals: Provides opportunity for payers and providers to show ROI related to stimulus investments 28

29 29 CAQH and VeriSign Pilot

30 Why CAQH and VeriSign are Working Together In the next few years, it is estimated that more than 700,000 physicians and more than 185 million consumers will go online to exchange sensitive health information. How will the industry ensure: Security Interoperability Privacy Authentication Currently, there is no industry consensus on requirements for the healthcare industry to authenticate administrative data exchange Stakeholders are connecting differently with their trading partners in one-off solutions 30

31 Overarching Pilot Goals Identify best practices and test data encryption operating rules to safely transmit patient administrative information among providers, payers and healthcare vendors. Gather lessons learned to promote industry-wide adoption of authentication policies and procedures Fill the gap in the industry by rolling out rules of the road for trust and certificate practices 31

32 Pilot Overview Pilot findings will be assessed to develop industry operating rules on vendor-agnostic approaches to: Conduct secure and authenticated transactions among payers, providers and patients Protect physician and patient identities Maximize transaction privacy and security Reduce the cost and complexity of secure data exchange Participants CAQH VeriSign Harvard Pilgrim Health Care, and other CORE-certified health plans PKI vendor-partners of pilot participants New England Health Exchange Network (NEHEN) providers and vendors The pilot is being conducted over a six-month period in Massachusetts 32

33 Pilot Interactions The CORE/ VeriSign pilot will provide identity credentials to participants, demonstrating secure, authorized communication between parties. Patients Existing Clearinghouses, Portals, & EHRs Payers Pilot Focus Providers 33

34 Pilot Objectives: Details Identification of policy and standards gaps in the implementation of X.509 Digital Certificates for a vendor neutral PKI environment for streamlined node authentication: Evaluate policy and standards requirements for interoperability while supporting a limited set of PKI providers (Certificate Authorities) to ensure vendor neutrality Pilot using VeriSign PKI, but with ability to add other PKI vendors Evaluate requirements for a single digital credential per Healthcare Provider issued and potential rules-of-the-road for PKI vendors such that all entities can recognize and accept that credential Administrative simplification Determine alignment with direction of ONC, Nationwide Health Information Network (NHIN) and other national regulations and standards Lessons learned will be incorporated into the CORE rules, if appropriate 34

35 Questions & Answers