Eligibility and Claim Status Operating Rules and HPID (Health Plan ID)

Transcription

1 The 21 st Annual HIPAA Summit West Eligibility and Claim Status Operating Rules and HPID (Health Plan ID) February 21, :30 am EST Timothy Kaja, MBA, CPC Senior Vice President, UnitedHealth Group President, Provider and Network Service Operations, UnitedHealthcare 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 1

2 UnitedHealthcare Operating Rules and the Payer Experience AGENDA Administrative Simplification Provisions of the Affordable Care Act Overview of UnitedHealth Group Review of Operating Rules for Eligibility and Claim Status UHG s Transactions and Our Roadmap to Compliance Moving the Industry to Adoption and Utilization The PayerID of the Future - HPID Future Considerations to drive Adoption and Utilization 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 2

3 We Have Passed the Deadline January 2013 THE JOURNEY TO COMPLIANCE Administrative Simplification: Affordable Care Act (ACA) Section 1104 ACA adds the requirement that Payers Certify Compliance by December 31, 2013 (Expected Rule Early 2013) Potential Penalties to be Assessed beginning April 2014 Fines up to $20/per member per year 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 3

4 Administrative Simplification Milestones through Nov 2016 Administrative Simplification provisions of ACA Admin. Simplification Wave 2: Implementation of operating rules for EFT payments and remittance advice Admin. Simplification Wave 4: Enumeration of a unique Health plan Identifier Implementation of HPID in all transactions s te a D e c n lia p m o C 1/1/2013 Eligibility and Claims Status Transactions (CAQH Phase I & II) /1/2014 EFT/ERA Transactions (CAQH Phase III) /31/2013 HHS Certification Filing Submission (1) 11/5/2014 HPIDs Assigned 1/1/2016 Claims Attachments, Premium Payments, Enrollment, Auths and Ref. 12/31/2015 HHS Certification Filing Submission (2) 11/7/2016 HPID Implementation Admin. Simplification Wave 1: Implementation of operating rules for eligibility and claims status determination HHS Compliance Certification: Certification of compliance with eligibility inquiry, claims status, EFT payments, and electronic remittance advise operating rules. Admin. Simplification Wave 3: Implementation and certification of operating rules for claims/ encounters, enrollment/ disenrollment, premium payments, referrals/ authorizations, and claims attachments 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 4

5 Compliance Dates UHG Roadmap: Administrative Simplification /1/2013 Elig & Claims Status Transactions (CAQH Phase I & II) 1/1/2014 EFT/ERA Implementation (CAQH Phase III) /31/2013 HHS Certification Filing Submission (1) 11/5/2014 HPIDs Assigned 1/1/2016 Claims Attachments, Prem Pmts, Enrollment, Auths and Ref. 12/31/2015 HHS Certification Filing Submission (2) Program Roadmap /7/2016 HPID Implementation HHS Cert. Phase I/II/III HHS Certification HHS Ops Rules Compliance Certification EFT/ERA EFT/ERA A/O EFT/ERA Q3/Q4 Release EFT/ERA Partner Test Claim, Prem, Enroll, Auth/Ref Clm, Prem, Enroll, Auth A/O Clm, Prem Auth Q3 Release Clm, Prem Auth Q4 Release Claim, Prem, Enroll, Auth/Ref Partner Testing HPID HPID Enumeration Strategy HPID A/O HPID Q1 Release HPID Q2 Release HPIDs Asgnd HPID Partner Testing HPID Implementation / Onboarding 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 5 5

6 CMS Enforcement Date Change ELIGIBILITY INQUIRY AND CLAIMS STATUS CMS Announces 90-Day Period of Enforcement Discretion for Compliance with Eligibility and Claim Status Operating Rules. CMS will not initiate enforcement action until March 31, 2013 for health plans that are not in compliance with the operating rules adopted for Eligibility Inquiry (270/271) and Claim Status (276/277) transactions. The compliance date for using the operating rules remains January 1, UHG systems were upgraded to be in compliance with these operating rules as part of the scope of HIPAA 5010 (CORE Phase I & II Certification) but we are anxious for the industry to be aligned on these transactions UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 6

7 UnitedHealthcare CAQH CORE Phase I and Phase II Operating Rules and CORE Certification Testing 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 7

8 UnitedHealth Group: Corporate Profile OUR HEALTH BENEFITS BUSINESS: UNITEDHEALTHCARE OUR HEALTH SERVICES BUSINESS: OPTUM Helping People Live Healthier Lives Making the Health Care System Work Better for Everyone UnitedHealthcare Community & State UnitedHealthcare Employer & Individual UnitedHealthcare Medicare & Retirement UnitedHealthcare Military & Veterans OptumInsight OptumHealth OptumRx Health care information technology Consumer engagement and support Integrated care delivery Pharmacy Health financial services Health in Numbers Serving 35 million Americans at every stage of life Innovation-driven growth Exceptionally well positioned to evolve and grow through health care reform Good for the System A dedicated and independent business providing services to: 6,000 hospital facilities, 250,000 health care professionals, 60 million consumers FOUNDATIONAL COMPETENCIES Domain knowledge around care management and care resources Actionable health care information and intelligence Advanced, enabling technology 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 8

9 United Healthcare: CAQH/CORE Involvement A Phase I and Phase II v5010 CORE-certified health plan CAQH Board Member and CORE Transition Committee Member Co-Chair of the CAQH Committee on Operating Rules for Information Exchange (CORE) CORE Code Combinations Task Group Current CAQH Board Chair: David S. Wichmann, Executive VP, UnitedHealth Group and President, UnitedHealth Group Operations and Technology UnitedHealth Group is an active collaborator on industry initiatives that simplify healthcare administration for health plans and providers, resulting in better care experiences for patients and caregivers 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 9

10 UnitedHealthcare: Transaction Services Profile Operational Objective: Collaborate with our provider network to transition phone calls and paper to electronic transactions, and transition batch to real-time. Health Plan Operations > 20 million Benefit/Eligibility and Claim Status calls in 2012 > 411 million claims were processed in 2012 Eligibility and Benefits Supports eligibility transactions both in real-time and batch >264 million EDI transactions annually 95% of these eligibility transactions are handled in real-time Claim Status Supports claim status transactions both in real-time and batch 54 million EDI transactions annually 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 10

11 Scope of CAQH CORE Operating Rules: Phase I and Phase II *Please Note: The Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, CORE 150 and CORE 151 are not included for adoption. Although HHS is not requiring compliance with any operating rules related to acknowledgement, the Final Rule does say we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 11

12 UnitedHealthcare: Transaction Flow and Channels Electronic channels support the following HIPAA ASC X12 transactions: Real-Time eligibility (270/271), claim status (276/277) using v5010 Batch eligibility, claim status, referrals (278), payment advice (835), and claim (837) TRADING PARTNERS LabCorp Quest Large Facilities CHANNEL* Direct Connects 35% SYSTEMS INFRASTRUCTURE Providers Connectivity Director Connectivity Director 1% External Customer Gateway B2B UFE Claims Engines Providers Clearing Houses OptumInsight Clearinghouse 64% Note: UnitedHealthcare (UHC) also supports web portal inquiries but is encouraging the adoption of electronic transaction processing 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 12

13 CORE Certification: Project Rational Results from an internal research analysis indicated as many as 30% (6.6 million) of call center service requests could be resolved by adopting the CORE Operating Rules for eligibility response transactions. Management had a strong interest in leveraging voluntary CORE Operating Rules and the CORE Certification process to gain valuable experience and insight about the benefits associated with implementing industry operating rules prior to federal and state mandates UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 13

14 Next Phase of Operating Rules Can we get the next 30% Call Obviation Potential Cumulative Isolated Current Benefits and Eligibility 32.21% Benefits Vendor #'s 35.21% 3.00% Benefits Notifications Req'd? 38.95% 2.62% Benefits Not Covered 41.20% 2.25% Benefits Spec Proc Code 58.05% 1.87% Benefits Pre X Timeframes 59.55% 1.50% Benefits Lifetime Max 62.17% 0.75% Benefits Referral Req'd 64.42% 0.75% Current Claim Status 23.97% All Additional Information Requests 35.62% 11.56% All Processing Details 52.05% 9.96% Check Information 58.90% 5.82% TAT 65.75% 3.08% Requested EOB 70.55% 1.37% 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 14

15 CORE Certification: Project Approach United Healthcare Executive Management supported CORE certification as a critical organizational priority Enterprise-wide requirements were created for the HIPAA v5010 compliance project as well as for the implementation of Phase I and II CORE Operating Rules CORE Operating Rules implementation was managed as its own project. The timeframe for implementing CORE Operating Rules ran concurrently with the organization s HIPAA v5010 implementation. Pursued Phase I and II CORE Certification concurrently 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 15

16 Lessons Learned A full understanding of CORE Operating Rules requirements and how they impact your organization s IT systems is essential Upfront business/systems planning and analysis is a major component of the project Technical and business analyst resources must be available and work closely together throughout the full lifecycle of the project If you rely on vendors, make sure they are involved early-on in the planning process Consider early on how CORE Master Test Bed Data (for testing eligibility rule) will be loaded and used within the context of your system environment. It took approximately 8 weeks to setup the data due to complexity of the UnitedHealthcare claim platforms Execute the test scripts first that you have concerns with as you can run the test scripts as many times as you want and this will give you more lead time to fix any problem areas 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 16

17 UnitedHealthcare Eligibility and Claim Status 4 Year Trends 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 17

18 Deployment: CAQH CORE Operating Rules UnitedHealthcare Eligibility and Claim Status Implementation Final 5010 Implementation 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 18

19 Deployment: CAQH CORE Operating Rules UnitedHealthcare Eligibility Implementation Results 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 19

20 Deployment: CAQH CORE Operating Rules UnitedHealthcare Claim Status Implementation Results 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 20

21 Transactions Statistically Significant Increases for both Eligibility and Claim Status post 5010/CORE Deployment I-Chart of B&E 270/271 EDI Transaction by Month Jan 11-Mar 11-May 11-Jul 11-Sep 11-Nov 12-Jan 12-Mar Date 12-May 12-Jul 12-Sep 12-Nov Claim Status Monthly Average: Jan 11 June M July 12 Dec M Represents a statistically significant increase in Claim Status transactions from 4010 to 5010/CORE UCL= _ X= LCL= Transactions Benefits and Eligibility Monthly Average: Jan 11 June M July 12 Dec M Represents a statistically significant increase in Benefits and Eligibility transactions from 4010 to 5010/CORE I-Chart of Claim Status 276/277 EDI Transaction by Month Jan 11-Mar 11-May 11-Jul 11-Sep 11-Nov 12-Jan 12-Mar Date 12-May 12-Jul 12-Sep 12-Nov UCL= _ X= LCL= UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 21 1

22 Moving from PayerID to Health Plan ID (HPID) 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 22

23 Health Plan ID (HPID) Why Health Plan ID? Adoption will allow for a higher level of automation for health care provider offices, particularly for provider processing of billing and insurance related tasks, eligibility responses from health plans, and remittance advice that describes health care claim payments. 1 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Secretary to adopt unique identifiers for each of the following: Individuals(status: Congress delayed indefinitely) Employers (status: EIN adopted) Health plans (status: HPID adopted) Health care providers (status: NPI adopted) Structure 10-digit, all-numeric identifier with a Luhn check-digit as the 10th digit. Intelligence- free identifier except for 1 st digit 1 Federal Register / Vol. 77, No. 172 / Wednesday, September 5, 2012 / Rules and Regulations, UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 23

24 Health Plan ID (HPID) Definitions Definitions Controlling Health Plan (CHP) means a health plan that (1) Controls its own business activities, actions, or policies; or (2)(i) Is controlled by an entity that is not a health plan; and (ii) If it has a subhealth plan(s), exercises sufficient control over the subhealth plan(s) to direct its/their business activities, actions, or policies. Subhealth Plan (SHP) means a health plan whose business activities, actions, or policies are directed by a controlling health plan. Other Entity ID (OEID) An entity may obtain an OEID to identify itself if the entity meets all of the following: Needs to be identified in a transaction for which the Secretary has adopted a standard Is not eligible to obtain an HPID Is not eligible to obtain an NPI Is not an individual (defined as the person who is the subject of protected health information ) 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 24

25 Health Plan ID (HPID) Important Dates Compliance Dates Enumeration November 5, 2014* Health plans must enumerate by this date A Controlling Health Plan must obtain an HPID from the Enumeration System for itself must disclose its HPID when requested may obtain an HPID from the Enumeration System for Subhealth plan of the Controlling Health Plan may direct its Subhealth plans to obtain HPIDs A Subhealth plans may obtain an HPID from the Enumeration System; once enumerated, a Subhealth plan must disclose its HPID when requested Full Implementation November 7, 2016 All Covered entities must begin using HPID in the HIPAA transactions * November 5, 2015 for small health plans 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 25

26 Health Plan ID (HPID) Key Concepts HPID Usage only required when the health plan has an HPID and the Covered Entity (e.g., Provider) is identifying the health plan in standard HIPAA transactions We consider a health plan as having an HPID if that health plan communicates with its trading partners that it consistently uses a particular HPID, even if the HPID it uses is associated with another health plan, such as its controlling health plan. The phased-in approach for HPIDs, where there is lag time between when health plans are required to obtain an HPID and when covered entities are required to begin using HPIDs in the standard transactions, will allow the opportunity for dual use and sufficient time for a successful transition. The additional time will allow industry the opportunity to perform extensive testing of the HPID with trading partners prior to full implementation. This additional time and phased-in approach to compliance should reduce denied or misrouted claims during the early use of the HPID UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 26

27 Health Plan ID (HPID) UHG Considerations UHG currently utilizes 48 PayerIDs UHG may have 75 Controlling Health Plans (CHPs) and 5 Sub Health Plans (SHPs) Additional Considerations: UHG has 224 other entities. Other Entities do not necessarily require enumeration. If there is a business need to have an Other Entity identified in the standard transaction the Other Entity will need to obtain an OEID (different than HPID). 1 PayerID may route to multiple claim platforms. Currently, some Member ID Cards include a 10 digit PayerID (health plan ID), this is not the same as the HPID that is being implemented so ID cards may need to be reissued Plan moving forward Develop an Enumeration Strategy Determine Governance, Implementation and Usage of HPID & OEID Communicate and educate internal and external partners especially physician and hospital partners 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 27

28 Adoption to Utilization If you build it they will come. May work in baseball, but not the case here What is Nirvana? The Shift - How do we shift the Industry s move to EDI Practice Management Systems: Will vendors find value in supporting Vendors are not HIPAA covered entities; clearinghouses are covered 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 28

29 Industry Context: A Spectrum of Change During the next several years the entire revenue cycle process will experience significant transformation due to the introduction of operating rules. This change can drive interoperability, facilitate greater adoption of standards and generate a responsive, and adaptive, system-wide approach that aligns with other strategic initiatives. Sponsor Provider 834 Enrollment 820 Premium Payment 270 Eligibility Inquiry 271 Eligibility Response Health Plan Membership Enrollment Charge Capture Clinical O/E Utilization Review Billing A/R and Treasury 278 Referral Request 278 Referral Response 837 Claim/Encounter 277 Request for Info 275 Claim Attachment 276 Status Inquiry Pre-Adjudication Claim Adjudication 277 Status Response 835 Remittance A/P CCD+ (EFT) Bank 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 29

30 Healthcare Administrative Data Exchange: An End-to-End Perspective Health Plans only group penalized for non-compliance Health Plans CORE- Required Data & Infrastructure Vendors and Clearinghouses (includes TPAs) CORE- Required Data & Infrastructure Providers Vendor-Agnostic Operating Rules All HIPAA covered entities involved in the electronic exchange of administrative transactions have a role to play in the adoption of CAQH CORE Operating Rules, i.e., providers, health plans, and/or clearinghouses HIPAA covered entities work together to exchange transaction data in a variety of ways. The applicability of a given CAQH CORE Operating Rule will depend upon the nature of the trading relationship between HIPAA-covered entities, e.g., Non-covered entities, such as Practice Management System Vendors, also have a significant role in ensuring these processes work but the driver is not legislation it is economic UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 30

31 Electronic vs. Manual Volumes July December 2011 July December 2012 Electronic Eligibility Inquiry (270) M M Electronic Claim Status Inquiry (276) 21.5 M 30.8 M Manual Eligibility Calls 3.6 M 3.7 M Manual Claim Status Calls 2.1 M 2.1 M Significant Increase in Electronic Transactions while Manual Transactions remain stable Should we offer additional tools to help drive down the manual (and costly) process? 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 31 Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.

32 Scheduling / Registration Workflow ~The Art of the Possible~ Objective: Build out an application to streamline the patient scheduling and registration process by matching provider and patient information to confirm eligibility and benefit coverage while ensuring authorizations are obtained prior to patient seeing the physician. The goal is to eliminate any calls a provider has to make prior to service being rendered. Patient Makes Appointment OptumX Desktop 270 Challenge: Providers work across multiple practice management systems that provide inconsistent tools to leverage EDI transactions 271 preventing providers to utilize this within their practice workflow. 1. Link provider network status to B&E verification Provider s PMIS UHC Systems Ideal link between Provider s PMIS and OptumX Desktop Goal: Simplify scheduling and registration process by capturing key information up front prior to patient arriving in the office to validate patient s eligibility, services are covered, and financial responsibility Scheduling / Registration Solutions 2. Clarify copay Workflow / deductible Tool information Confirms Patient Eligibility / COB Patient eligibility status and effective dates Identify secondary coverage (COB) * 4. Simplify Validates what Provider is provided Benefit Level back in a 271 response Provider s network status with Patients plan * Determines patient s out of pocket Validates Benefit Coverage Verifies coverage in general or at code level Captures patients lifetime / benefit max * Determines if Auth is Required Determine if authorization is required * Auto links next steps to capture auth online Summarizes Product Information Identifies Patient s plan / product information Verifies if referral is required * Provide copy of patient s ID card Captures Patient Responsibility * Not provided through Core 5010 Transactions Prior authorization requests via online 3. Provide clearer member product information on card 5. Link authorization/referrals required to B&E verification 6. View network providers for scheduling purposes Provider referral obtained Provider s PMIS Patient Arrives at Appointment Did you know? Provider offices are 20% successful in collecting patient responsibility once a patient leaves the office UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 32

33 Questions??? Timothy Kaja, MBA, CPC 2012 UnitedHealth Group. Any Any use, use, copying copying or distribution or distribution without without written written permission permission from UnitedHealth from UnitedHealth Group is Group prohibited. is prohibited. 33