Practice Roundtable Meeting Agenda January 21, :30 10:30 am Oregon Medical Education Foundation Event Center

Transcription

1 Practice Roundtable Meeting Agenda January 21, :30 10:30 am Oregon Medical Education Foundation Event Center Oregon Medical Association SW 68 th Parkway, Suite 100 Portland, Oregon (503) For those attending by telephone: Dial , Room Number # Topics 1. Call to Order Danielle Sobel, OMA 2. OMA Toolkit Updates Danielle Sobel, OMA 3. MMIS/ONE System Enrollment Presentation Wes Charley, DHS 4. OHLC EDI Payer Survey Results Rohit Thukral (Thuky), Pam Cotrell and Deb Bartel 5. Pain Management in Your Clinic Melanie Spiering, CNA 6. OMA Updates Upcoming 2016 session update/potential 2017 topics Next Practice Roundtable: April 21, 2016

2 The voice for better medicine in Oregon OMA Toolkit: SB 710 Records Requests for Disability Appeals What is this toolkit about? Senate Bill 710, passed in the 2015 Oregon legislative session, grants a patient or the patient s personal representative, one free copy of their medical record for the purposes of a social security disability benefits appeal. This toolkit is meant to help you understand when you should be providing a copy at no charge and what to include. Why is SB 710 important to our clinic? Prior to the passage of SB 710, health care providers had the ability to charge for medical records, regardless of the intended purpose, when requested by the patient or to another party, with the proper authorization to obtain the record. The fee schedule is clearly outlined in Oregon law and clinics can charge an appropriate fee based on the number of pages, postage and expedited needs. This is true of both paper or electronically provided records. Clinics also have the discretion to waive the fee when a patient has expressed financial hardship. SB 710, effective June 10, 2015, now allows patients who are appealing a social security disability benefits denial to obtain one free copy of their health record, either electronically or on paper. What should our practice do? If your clinic receives a request for records that cites an appeal of social security benefits, the OMA recommends the following: Step one: Step two: Step three: Verify that the request is from the patient or the patient s personal representative. These are the only two entities who may not be charged for these records. If requested by an attorney on behalf of the patient, the OMA suggests you have the attorney attest that they are seeking the records for the appeal. (See page 2 for sample attestation form). Clarify the time period of the request. For the purposes of an appeal, the applicant is required to submit medical records from the date of the denial to the current date. The legislative history of SB 710 clarifies that the free copy of records only was intended for records provided for appeal purposes because all prior relevant records would have been submitted in the initial disability application. Follow your minimum necessary policy and document the purpose of the request. The request should be limited to records related to the disability for which the person is seeking benefits, and you may ask for clarification about which records are needed for an appeal. Do not withhold records, however, if the patient or the patient s personal representative has made a legitimate request for all medical records. OMA Toolkit is an informational resource from the Oregon Medical Association and is not intended as legal advice. If you need legal advice, we highly recommend you hire a good lawyer (please call OMA s Compliance team at if you need some contacts.) Copyright 2015 Oregon Medical Association

3 SB 710 Documentation Form Dear Requestor, We have received your request for health information on behalf of your client. In order to process this request as the individual s one free copy, please attest to the following statements: 1. I am the legal representative of the client listed below 2. I am requesting a copy of my client s individually identifiable health information for my client for the sole purpose of appealing his or her denial of social security disability benefits 3. I understand that my client is entitled to one free copy of his or her individually identifiable health information pursuant to Oregon Senate Bill 710 (2015) 4. I have notified my client that I am requesting one free copy of individually identifiable health information as allowed by Oregon Senate Bill 710 (2015) Signature of Requestor: Printed Name: Date: Name of Client: Date of Birth: DATE OF SS/DISABILITY DENIAL: DATE OF HEARING (if scheduled): Name of Health Care Facility: Please return this document to us at the fax number below within 2 weeks or your request will be closed. Thank you. [Clinic Name] Return document to: [insert preferred method to receive form (i.e. fax or mail)]

4 Oregon Healthcare EDI Usage Survey OHLC EDI Workgroup and the Oregon Medical Association (OMA) Preliminary Results and Recommendations January 2016 Introduction and Purpose EDI Workgroup and OMA collaborated to survey Provider organizations Objectives of survey Analyze EDI usage and patterns key transactions Understand inhibiting issues and barriers to usage Suggest systemic improvements Dates Survey was open during month of September 2015 Sample Invitations sent via industry group mailing lists Focus on Provider Practices Respondent sample was self selecting Total Respondents

5 Usage Profile Average size of practice is 20 Providers 94% Providers submit transactions via Clearinghouses Practices using major service Providers in Oregon Availity (24%) Emdeon (15%) Navicure (15%) Gateway (9%) Office Ally (7%) Relay Health (6%) 3 Usage Profile 4 24% Provider practices submitting direct to Payers Oregon Medicaid (15%) Regence BCBS (11%) Aetna and Medicare (8% each) Cigna, Lifewise, Moda, Oregon s Health Co-Op, PacificSource, Providence, United Healthcare (5% each) Kaiser, Samaritan, Trillium Community (3% each) Health Republic, OHP Secondary, Tuality Health Alliance, Zoom+ (2% each) Key reasons Clearinghouses (CCH) preferred CCHs Have one to many relationships with Payers Accuracy and error checking prior to submission Software vendor relationships with CCHs CCH services integrated with EHR systems 2

6 Transaction Usage Claims (837, 276/277) 80%+ able to submit 75%+ claims via EDI % respondents submitting all claims and key issues Primary 40% Workers Compensation is paper based Lack of CCH to Payer connectivity Need to send attachments Secondary - 27% Some Payers require EOBs to be attached Some Payers require paper submissions 27% able to get claims status via EDI 40% not able to get claims status Lack of universal support among Payers Lack of practice management technology support 5 Transaction Usage Eligibility & Remittances (270/271, 835) 16% can reliably use eligibility for all patients 52% not able to use or reported severe deficiencies Returned information not usable incorrect, incomplete Payers will not always acknowledge veracity of information Only major Payers support capability but not universally Clearinghouse connectivity for these EDI transactions is weak 26% receive ERAs and EFTs from Payers 42% reporting inability to receive Payers unable to send ERAs or/and EFTs Payers who will only pay by check On-boarding/set up can be challenging 6 3

7 Everything EDI? some distance to go 19% of Providers execute all business EDI 48% have issues inhibiting greater adoption Wish list of improvements Full Payer support for COBs, ERA, EFT, Claims Status functions Accurate and binding eligibility reporting by Payers Improved connectivity between Clearinghouses and Payers Consistent aggregation of payments and transactions 50% of Providers were well served by Clearinghouses All EDI business supported by intermediaries Connectivity with trading partners needs improvement 7 Recommendations high priority 8 Eliminate EOB requirements from COB claims Resolve information gaps and adopt 837 only requirement for COB claims Research issue and define appropriate solution (add to Oregon Companion Guide requirement?) Address gaps in Payer to Clearinghouse connectivity Encourage Payers to establish relationships with major CCHs Availity, Emdeon, Navicure, Gateway, Office Ally, Relay Health, and others Build trading partners relationships Establish complete Payer/CCH trading relationships across all major txns Define connectivity requirements and on-boarding for Providers Identify key contacts at Payer EDI organizations for trading partners Improve eligibility reporting Engage with Payers on accurate eligibility reporting Research and define a solution with limitations such as retro-active member cancellations Consider a best practice around transaction information integrity and accuracy? Simplify and improve ERA and EFT set up for Providers Define and implement simplified on boarding process Potentially define rules/practices for remittance aggregation and reporting Contractual (Payer / Provider) best practice? 4

8 Recommendations longer term priority All HIPAA standard transactions should be supported Survey Payers for supported transactions Define EDI remediation strategy for Payers and implement Adherence to HIPAA and other regulations Establish process of issue identification, prioritization, resolution (with trading partners) Increased coordination with Provider groups Develop policy to move Worker Comp claims to EDI (?) Is this in OHLC/OHA scope? Consult with SAIF? Develop electronic process for Prior auths (278) (?) Symptom of larger industry issue Desire for a simplified and automated process for pre-authorizations and pre-certifications Is there potential for simplified Oregon or regional solution (to be researched)? 9 Next Steps Review recommendations Identify any follow up research/analysis Determine priorities and potential initiatives Available resources for prioritized initiatives Initiate efforts as prioritized and authorized by OHLC Admin Simplification Executive Committee Approve follow up efforts Timing and resources 10 5