Understanding the Administrative Simplification Provisions of the PPACA

Transcription

1 Understanding the Administrative Simplification Provisions of the PPACA Annie Boynton BS, RHIT, CPCO, CCS, CPC, CCS-P, CPC-H, CPC-P, CPC-I Director Communications, Adoption&Training Regulatory Implementation Office UnitedHealth Group 1

2 700 Billion annually in wasteful spending What is Administrative Simplification? 2

3 Defining Administrative Simplification Patient Protection and Affordability Act (PPACA) H.R now referred to as Affordable Care Act (ACA) Administrative Provisions identified in two sections of health care reform bill Section 1104 Administrative Simplification Section Development of Standards for financial and Administrative Transactions Significant changes to the HIPAA requirements Allows for adoption of standards and operating rules via Interim Final Rules, eliminating the need for NPRMS Administrative Simplification What is it? Affordable Care Act * The Administrative Simplification provisions of the Affordable Care Act of 2010 (ACA), build on the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with several new, expanded, or revised provisions, including requirements for: Operating rules for each of the HIPAA transactions Enumeration of a unique, standard Health Plan Identifier (HPID) New standards for electronic funds transfer and electronic health care claims attachments Health plans to certify compliance with the standards and operating rules Penalties for health plans that fail to comply or to certify their compliance with applicable standards and operating rules. * Source: CMS.gov web site 3

4 Who is impacted? All HIPAA-covered entities would be affected including: All health benefit plans Health care clearinghouses and vendors Physicians, facilities and health care professionals Software vendors Any other business associates providing transaction-related services, such as billing support and third party administrators. No Really What does it mean? Simplify! Make it more efficient! Make it more convenient! Spend less time on paperwork more time with patients! Applies to all areas of healthcare: Billing Coding Providers Health Plans Vendors 4

5 In order to get there, US Healthcare needs a few changes. 5

6 CAQH* Initiatives *Council of Affordable Quality Health Care CAQH CORE The Rule Makers 6

7 What are Operating Rules? Goals of Administrative Simplification 7

8 Timing Jan. 1, 2013 May 6, 2013 Jan. 1, 2014 Eligibility and claim status operating rules compliance date. National Provider Identifier compliance date. Electronic funds transfer and electronic remittance advice compliance date. Nov. 5, 2014 Health Plan Identifier compliance date. For small health plans, the date is Nov. 5, At least Oct. 1, 2015 ICD-10 new compliance date. Scope of Administrative Simplification HPID EFT/ERA CORE Operating Rules Next set of Operating Rules Administrative Simplification 8

9 To date, the CORE Rules tend to fall into one of two categories: 1. Infrastructure rules which promote interoperability and exchange of information to support business processes. 2. Enhanced data content to the information exchange, usually building beyond the requirements of the HIPAA X12 standards by requiring the use of specific data elements that are specified as situational in the standard. 9

10 EFT & ERA CORE Operating Rules CORE 360 Operating Rules CORE 380 Operating Rules CORE 382 Operating Rules CORE 370 Operating Rules CORE 350 Operating Rules What if providers do not submit transactions electronically? Some health care providers may choose not to conduct transactions electronically. But they are required to use these operating rules for HIPAA transactions that they do conduct electronically. In practice, health plans will only have to use the health care EFT standards if the provider wants to receive claim payments via EFT through the Automated Clearinghouse Network (ACH)Network. 10

11 What do providers need to do to prepare for conducting transactions electronically? The EFT standards are the implementation specifications for the electronic format that a health plan is required to use. The standards do not impact how a provider's financial institution transmits the TRN segment to the provider. There will be no direct systems costs to physician practices and hospitals to implement the new EFT standards. What if a provider chooses not to accept electronic funds transfers? Physician practices and hospitals drive overall adoption and usage of EFT. Most health plans give physician practices and hospitals a choice of payment between paper checks (sometimes accompanied by paper remittance advice) or EFT. 11

12 What if a health plan does not transmit payment electronically? HHS estimates that it will cost health plans, on average, $4,000 to $6,000 to implement the EFT standards. This is a one-time cost to health plans. HHS assumes that many commercial health plans will have minimal to no costs; for example: Health plans that must simply update their vendor contracts to accommodate this change without any additional operational costs. What are the financial benefits of EFT for the health care industry? The Interim Final Rule cited a 2009 UnitedHealth Group working paper that reported: $108 billion could be saved industry wide over the course of 10 years if electronic health care claim payments were required. 12

13 Health Plan Identification (HPID) The Health Plan Identifier (HPID) and Other Entity Identifier (OEID) were the result of the Simplification and Affordability Care Acts, which require the adoption of a standard for a unique health plan identifier to be used in HIPAA standard transactions, according to the Federal Registry/ Final Rule announced by the Department of Health and Human Services (HHS) Currently, health plans and other entities are identified in standard transactions using multiple identifiers that differ in length and format. Health care providers are frustrated by the lack of a standard identifier for health plans and other entities in use of standard transactions The adoption of the HPID and the OEID will increase standardization within HIPAA standard transactions and allow for a higher level of automation for health care provider offices and billing processes 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,

14 Health Plan Identification (HPID) Timeline Entity Type Compliance Date Full Implementation Date for Use in Standard Transactions Health Plans (excluding Small Health Plans) November 5, 2014 November 7, 2016 Small Health Plans November 5, 2015 November 7, 2016 SHPs Other Entities Not required to obtain HPID Not required to obtain OEID Not required but can use in standard transactions as of November 7, 2016 TBD (upon enumeration?) 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 ) 14

15 Administrative Simplification Key Dates Next Set of Operating Rules Includes the following transactions as scope: Health Claims or equivalent health encounter information Claim attachments Enrollment and disenrollment in a health plan Health plan premium payments Referral certification and authorization CAQH has not published draft rules to date Expecting CAQH to publish by end of year 2014 Comment period after draft publication Finalized rules not expected until

16 Does Healthcare Need Simplifying? What s Happening to Your Payer? Over the past decade, premiums for Americans who get their insurance at work have more than doubled, says Jessica Santillo, a Spokeswoman at the Department of Health and Human Services. Employers already are passing on a bigger share of their healthcare costs to employees than they have over the previous decade, according to data from the Kaiser Family Foundation. The Menlo Park, California-based nonprofit found this year that family premiums went up 3 percent in 2010, but worker s share of those costs rose by 14 percent. But some companies, citing the new mandates, say costs are rising too fast: In a survey of more than 1,000 employers, Mercer, a humanresources consulting firm, found that corporate healthcare costs would rise by 10 percent next year if firms made no changes to their plans. Many are finding that they have little choice but to switch a greater share of costs to employees. Source: Wall Street Journal, October 9,

17 Act Now Get Involved If you build it they will come. May work in baseball, but not the case here Refuse to transact with paper Go Green Adopt the new standards! Appoint someone form your practice/organization to spearhead adoption efforts Providers work with your payers Payers work with your providers Vendors bridge the gap between payer and providers Look for vendors and payers who can guarantee their compliance CORE Certified 17

18 We will ALL need to work together to get there Most industry stakeholders agree that electronic payment/transactions will become the industry standard. Getting there will require industry wide cooperation: Providers need better IT capability Payers need to assist with more options Banks need to develop better tools Clearinghouses need to focus on process improvement between payers and providers All will depend on how fast and how well we can work together. Speaker Contact Annie Boynton BS, RHIT, CPCO, CCS, CPC, CCS-P, CPC-H, CPC-P, CPC-I Director Communications, Adoption & Training Regulatory Implementation Office UnitedHealth Group 18