AGENDA INDUSTRY UPDATE Brief Overview Cooperative Exchange Clearinghouse Role ICD 10 Testing Opportunities for NPAG Collaboration Health Plan Certification Clearinghouse Clinical/ Attachment Landscape Presented by: Sherry Wilson, President,Cooperative Exchange (CE) and EVP and CCO Jopari Solutions Debra Strickland, CE Executive Advisory Committee and Senior Consultant Xerox Corporation Betty Gomez, CE Past Vice President and Industry Consultant Lenel James, Past Co chair HL7 EHR/PHR WGs, Senior Project Manager, Industry Standards & ehealth, BCBSA Brief Overview Cooperative Exchange 25 Clearinghouse member companies Representing over 80% of the clearinghouse industry Supports BOTH administrative and clinical transactions Over 750,000 submitting provider organizations Maintain over 7,000 payer connections 1000 plus HIT vendor connections Process over 4 plus billion claim transactions annually Transaction value over $1.1 Trillion 1
Brief Overview Cooperative Exchange Flexible solutions to accommodate different levels of stakeholder EDI readiness Provide interoperability by normalizing disparate data to industry standards Strong leadership representation across all national standard organizations ASCX12, WEDI, CORE, HL7 and NCPDP as well as participate in NCVHS process) ASCX12 Clearinghouse Caucus Stakeholder Information Exchange Forum Combined with our non profit members (AMA, ASC X12N and UHIN) and Supporting Organizations (Axiom, BancTec and MEA) the Cooperative Exchange truly represents the healthcare industry EDI highway infrastructure. American Medical Association (AMA) Apex EDI ASC X12N Availity, LLC AXIOM Systems, Inc. BancTec ClaimRemedi Emdeon eprovider Solutions Dorado Systems GE Healthcare Greenway Health Health e Web, Inc. HDM Corp. InstaMed Jopari Solutions, Inc. Medical Electronic Attachments (MEA) NextGen Healthcare OfficeAlly OptumInsight PassportHealth PracticeInsight RelayHealth Secure EDI Siemens HDX The SSI Group Trizetto Provider Solutions Utah Health Information Exchange (UHIN) WEX, Inc. WorkCompEDI Xerox EDI Direct ZirMed 2
Clearinghouse Role ICD 10 Testing Opportunities for NPAG Collaboration ICD 10 Clearinghouse Role Education Tools Coordinating testing with providers, vendors and payers Payer status and dashboards Provide results to date lessons from testing Front end editing Help with denials and rejections Reports Fixing errors 3
NPAG Collaboration Opportunities Work with the clearinghouse to get a wide variety of clinical scenarios Identify the Right Providers good mixture of provider types Provide Edits Medical Policies, benefits coverage Notify the clearinghouse of your testing schedule Health Plan Certification 4
Compliance Certification Current Status of the Health plan certification proposed rule How are you going to show your compliance to your CEO Use internal Validation tools Partners that can help you with validation of your transactions What you should know now! Competing Priorities CAQH CORE Phase IV operating rules 1/1/2016 Are they necessary what is the ROI Concerned that additional rules will become a financial and resource burden on the industry at this time of competing priorities Same timeframe as preparation for Certification ICD10 October 2015 Implementation and testing Health plan Certification 1/1/2016 Attestation CORE Seals 5
Clinical/ Attachment Landscape Clearinghouse Engagement Brief Historical Snapshot of Attachments Early 1990 s Numerous industry experiments using bulletin boards like technology Early 2000 s Property and Casualty Industry identified business need to eliminate manual labor intense paper processes 2008 State of Texas mandated Workers Compensation providers and payers EDI medical billing and attachment with established rules 6
Brief Historical Snapshot of Attachments Many shared stakeholders with NPAG (providers, PMS and clearinghouses) Similar regulations being adopted in multiple states Necessitated provider technology vendor solutions to comply with state P&C regulations Today those same technology solutions are being deployed to support Group/Commercial and Government clinical/attachment business needs Clearinghouse Stakeholder Engagement Increase stakeholder EDI adoption by: Leverage existing IT investments Connectivity and resources to improve end to end automated workflow processes Provide flexible solutions based on stakeholder EDI readiness (low tech to high tech) Critical key to success is payer collaboration to improve business processes to yield end to end workflow automation ROI 7
Clearinghouse Infrastructure Framework Support flexible formats (PDFs, TIFs, Objects, HL7, XML,etc.) Adoption X12 Acknowledgment Reference Model (mandated states voluntary) Support ASCX12 275 transaction Flexible transmission methodologies Provide interoperability by normalizing disparate data to industry standards Industry Example Clearinghouse processing over 1 million plus attachments a month Leveraging existing IT investment, connectivity and resources across all lines of business Reference Labs Interoperability Clinical and Administrative Stakeholders Financial Institutions Public Health PBM s Remits Lockbox Bio- Surveillance Reports Hospitals and Provider Offices Requests Results CE CLEARINGHOUSES Scripts History Health Plans Claims Claims Referrals Referrals Eligibility Claims Scripts Fill Notice Claims Payments Utilization Reports PHR Maint. Retail Pharmacy Minute Clinics Employers Consumers 8
Putting the Pieces Together to Improve Care ADT Care Summaries Lab Results Medication List Analytics Care Gaps Devices Telehealth mhealth PCMH ACO Information Exchange HL7 Then, Now & Coming THEN: V2 Messages ADT& Lab Results Clinical Document Architecture (CDA) NOW: Consolidated CDA R1.1 (Meaningful Use Stage 2) Consolidated CDA R2 (with new Care Plan template, MU Stage 3 candidate) COMING: Clinical Documents for Payers, Set1 (CDP1, CMS Fee for Service) FHIR Key Initiatives and Dates: HL7 Payer Summits September 2014, January 2014 HL7 Payer User Group April 1, first call, October 4, anticipated first meeting HL7 Attachments WG April 27 29, Out of Cycle Meeting in Nashville 9
WEDI ASCX12 HL7WEDI X12 HL7 Attachment Collaboration Project (ACP)) Joint project to assist the industry in implementing electronic capable claims/service review authorizations and attachments with clearly defined parameters around how attachments work. The objectives of the project are to: Provide implementation guidance of attachments processing. Provide implementation guidance of attachment processing not recommended by NCVHS. For example, unsolicited attachment processing, prior authorizations. Provide a single resource document which provides guidance for attachment implementation. How to participate: Send an email to info@disa.org with subject line of, CD workspace for Attachment Collaboration work group and provide the following information in the body of the email: Full Name Title (or role in the organization) Facility/organization name E mail address NPAG Collaboration Opportunities Share lessons already learned Interoperability Best Practice Models Pilot Program Opportunities Cooperative Exchange Members ready to pilot 2016 Considerations Connectathon and/or Interoperability Showcase 10
Appendix Reference Resources easy link access ICD 10 Consolidated CDA R2 FHIR HL7 Payer Use Group 11
Thank You Resource Contact Information: Tim McMullen, JD, CAE Cooperative Exchange Executive Director 866 238 4440 tim@cooperativeexchange.org www.cooperativeexchange.org Sherry Wilson, President Cooperative Exchange EVP and CCO Jopari Solutions 510 504 4100 sherry_wilson@jopari.com 510 504 4100 ICD 10 Reference Resources CMS End to End Test Results http://www.cms.gov/medicare/coding/icd10/downloads/2015 Jan End to End Testing.pdf WEDI ICD 10 Reference Resources http://www.wedi.org/knowledge center http://www.wedi.org/workgroups http://www.wedi.org/topics WEDI Property and Casualty ICD 10 State Readiness Update http://www.wedi.org/knowledge center/resource view/resources/2014/11/05/propertyand casualty icd 10 state readiness resource center Cooperative Exchange Payer ICD 10 Testing Directory http://www.cooperativeexchange.org/ 12
C CDA R2 DOCUMENTS: Continuity of Care Document Consultation Note Diagnostic Imaging Report Discharge Summary H&P Operative Note Procedure Note Progress Note Unstructured Document Care Plan (new in R2) Patient Generated (New in R2) May Be Cited in Meaningful Use Stage 3 Consolidated CDA R2 Nov 2014 http://www.hl7.org/implement/standards/product_brief.cfm?product_id=379 Fast Health Interoperable Resources (FHIR) 1. Developed using an ISO standard information model 2. Composed of reusable resources 3. Built on an information model, without the need for implementers to know or learn the model or modeling 4. Uses globally supported web technologies, rather than messaging 5. Leverages existing web standards for security, authentication, queries, & analytics http://hl7.org/implement/standards/fhir/overview.html 13
HL7 Payer User Group 1. Co Chairs: Durwin Day, Health Care Service Corporation David DeGandi, Cambia Health Solutions 2. HL7 Membership: Payer User Group: $100 Individual HL7 membership: $775 (user group included) Corporate membership: $1,400 $21,600 http://www.hl7.org/participate/usergroups.cfm?ref=nav 14