Prior Authorization; Organizational Updates. WEDI Summer Forum July 31- August 1, 2019

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1 Prior Authorization; Organizational Updates WEDI Summer Forum July 31- August 1, 2019

2 Disclaimer Conference presentations are intended for educational purposes only and do not replace independent professional judgment. Statements of fact and opinions expressed are those of the participants individually and, unless expressly stated to the contrary, are not the opinion or position of the Workgroup for Electronic Data Interchange, its cosponsors, or its committees. The Workgroup for Electronic Data Interchange does not endorse or approve, and assumes no responsibility for, the content, accuracy or completeness of the information presented.

3 ORGANIZATIONAL UPDATE August 2, 2018 Betty Gomez MedInformatix

4 The Healthcare Administrative Technology Association (HATA) National organization representing the Practice Management System Industry ( Any healthcare administrative technology business entity that creates, installs or supports practice management system ) Formed in Members Practice Management Systems Supporting Technology Vendors Associations

5 HATA MEMBERS Practice Management System Vendors Representing over 750,000 providers

6 HATA Strategic plan (2016) We wanted to eliminate the possibility of the PM Vendor as the barrier to a streamlined electronic Prior Authorization workflow. We wanted to ensure that the PM Vendor was not forgotten as an integral part of the PA workflow consideration. Created Prior Authorization Workgroup. 6

7 PRIOR AUTHORIZATION WORKGROUP RESEARCH AND UNDERSTAND The barriers to adoption for Prior Authorization. The current utilization within our membership world. The barriers to a meaningful workflow within the practice. How Value Based Payments might impact Prior Authorization. ACTION ITEMS UNDERWAY To create a whitepaper to share with the industry from the perspective of the PMS vendor. Define the PMS business case (generic) and survey our members to have that conversation with the payers. Explore the provider demand. Understand what they need to utilize the transaction for more than a referral. Collaborate with other industry stakeholders. C O P Y R IG H T H A T A

8 HATA PRIOR AUTHORIZATION SURVEY RESULTS

9 HATA PM Vendor Membership surveyed 33% offer the 278 transaction to their providers. Of those clients utilizing the 278, 100% are using it for Referrals only; not Prior Authorization.

10 Reasons PM vendors do not offer the 278 Lack of provider interest 63% Lack of payer commitment 63% Development limitations 50% Unreliable information exchange 25% Interoperability challenges 12.5 Biggest comment: General industry lack of understanding due to non-use and implementation.

11 278 Utilization 100% of respondents answered that only 1-10% of clients currently utilize the 278 transaction.

12 CRITICAL SUCCESS FACTORS With utilization of the 278 transaction, make certain that it functions full circle from point of request (EMR) back into the billing system (PM) With as little manual intervention as possible (ten minutes a day = two full work weeks/year) Eliminate unnecessary Prior Auth transactions (for routine care as an example) Eliminate the need for Prior Auth workgroups across all stakeholders! 12

13 HATA PRIOR AUTHORIZATION INCUBATOR PROJECT Bring real live examples to the payers AND follow the electronic transaction workflow from beginning to end. Bringing together a single PM system, a single practice and a single payor with a very narrow focus to follow the process end-to-end. HATA will report the results to the industry once the case study is nearing a close. 13

14 MANY OPPORTUNITIES TO JOIN HATA Take a look at some of our other initiatives: Monthly Membership Calls 4 th Thursday/month Fall Meeting (Optum HQ in Schaumberg, IL) November 13, 2018 Eligibility Workgroup: Completing summary of findings &recommendations Prior Auth Workgroup: Completing summary of findings &recommendations Prior Authorization Incubator Project A Variety of Webinars are held about once a month HATA CMS/ONC Day Fall 2018 Strategic Planning Meeting Winter 2019 (Irvine, CA) The HATA Industry Roadmap EFT ERA Resource Library Value Based Payment Resources 14

15 More Information on HATA (844) 440-HATA (4282) Tim McMullen, Executive Director Sherri Dumford, Director of External Affairs HATA 2018 All Rights Reserved 15

16 Prior Authorization CAQH CORE Operating Rule Development Update Rachel Goldstein, CAQH CORE Joe Holtschlag, athenahealth

17 Disclaimer Conference presentations are intended for educational purposes only and do not replace independent professional judgment. Statements of fact and opinions expressed are those of the participants individually and, unless expressly stated to the contrary, are not the opinion or position of the Workgroup for Electronic Data Interchange, its cosponsors, or its committees. The Workgroup for Electronic Data Interchange does not endorse or approve, and assumes no responsibility for, the content, accuracy or completeness of the information presented.

18 Agenda CAQH CORE Overview Challenge of Prior Authorization and CAQH CORE Vision CAQH CORE Scope and Draft Phase V Operating Rules Next Steps and How to Engage 18

19 CAQH CORE Overview

20 CAQH CORE Mission & Vision MISSION VISION DESIGNATION Drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative and clinical activities among providers, payers and consumers. An industry-wide facilitator of a trusted, simple and sustainable healthcare data exchange that evolves and aligns with market needs. Named by Secretary of HHS to be national author for three sets of operating rules mandated by Section 1104 of the Affordable Care Act. Maintain & Update Track Progress, ROI & Report Research & Develop Opportunities Integrated Model for Working with Industry Design Testing & Offer Certification Build Awareness & Educate BOARD Multi-stakeholder. Voting members are HIPAA covered entities, some of which are appointed by associations such as AHA, AMA, MGMA. Advisors are non-hipaa covered, e.g. SDOs. Promote Adoption Provide Technical Assistance 20

21 CAQH CORE Operating Rule Overview CAQH CORE is the HHS-designated Operating Rule Author. HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules. Phase I Phase II Phase III Phase IV Health Claims (or equivalent encounter information) X Transactions Health Plan Eligibility X12 270/271 Health Plan Eligibility Claim Status X12 276/277 Electronic Funds Transfer (EFT) Health Care Payment and Remittance Advice (ERA) X Referral, Certification and Authorization X Enrollment/ Disenrollment in Health Plan X Health Plan Premium Payments X Manual to Electronic Savings per Transaction (2017 CAQH Index) Eligibility: $6.46 Eligibility: $6.46 Claim Status: $7.98 Mandatory Claim Payment: $0.88 ERA: $4.14 Claim Submission: $2.35 Prior Authorization: $6.84 Voluntary 21

22 Challenges of Prior Authorization and CAQH CORE Vision

23 Why the Continued Focus on Prior Authorization? The CAQH CORE Board committed to developing additional operating rules that promote uniformity of the complex prior authorization (PA) process and accelerate industry adoption of electronic PA; the Phase IV Operating Rules were the initial foundation of this commitment. This approach is especially important for PA, a complex business process that is iterative and has successive milestones. The National Committee on Vital and Health Statistics (NCVHS) recommended additional industry evaluation of the prior authorization process in its July 2016 letter to the Secretary of the Department of Health and Human Services (HHS). Significant industry interest to continue addressing PA challenges. E.g., consensus statements, provider coalitions and administrative burden reduction efforts, HATA survey research, WEDI PA Subworkgroup, etc. Given current adoption data, there is significant opportunity to improve industry ROI for PA and increase adoption. 23

24 2017 CAQH Index Update Prior Authorization Percent Adoption of Standard Electronic Transactions (HIPAA Standard), 2016 vs Prior Authorization Submission Method 8% Fully Electronic ASC X12N v Prior Authorization Request and Response (278) 57% Partially Automated Web Portal Interactive Voice Response (IVR) 35% Manual Phone Fax 24

25 The Prior Authorization Challenge Fast Facts PA within the Context of Other Administrative Transactions The PA process is separate from the patient eligibility and claims processes. Siloed processes can jeopardize provider reimbursement and/or result in unintended patient out of pocket costs. Example 1. Even if a PA is approved, the patient s eligibility may not be confirmed, or may have changed. Example 2. Even if a PA is approved, edits may be applied to the claim, and the service may still be denied. Volume Submission Method* At least 80 million* prior authorizations submitted and responded to per year (in commercial market alone). On average, one physician will submit 29.1 total PAs** per week. 8% fully electronic; 35% manual (phone, fax, ); 57% partially automated (web portal, Interactive Voice Response (IVR), ASC X12N v Prior Authorization Request and Response (278)). Wait Times** Approx. 64% of physicians report waiting at least one business day for a PA response, and 30% report waiting at least 3 busin ess days. Time & Cost* For Providers Approx. 14 minutes per request prepared and submitted manually. Approx. 7 minutes per request prepared and submitted electronically. Approx. $245M per year in savings potential. For Health Plans Approx. $128M per year in savings potential. 92% of Providers surveyed by the AMA reported that the PA process delays patient care.** 92% of Providers reported that the PA process can have a negative impact on clinical outcomes.** Sources: * CAQH Index (2017); commercial market figures only. ** AMA PA Physician Survey (2017). 25

26 CAQH CORE Vision for Prior Authorization CAQH CORE Vision for Prior Authorization (PA) Introduce targeted change to propel the industry collectively forward to a PA process optimized by automation, thereby reducing administrative burden on providers and health plans and enhancing timely delivery of patient care. rules The Phase IV Operating Rule established foundational infrastructure requirements such as connectivity, response time, etc. and builds consistency with other mandated operating required for all HIPAA transactions. CAQH CORE not only develops operating rules to automate the PA process, but also drives adoption to realize meaningful change. Automation Spectrum Manual Partially Automated Optimized Entirety of provider and health plan workflows, including request and submission, is manual and requires human intervention, e.g., telephone, fax, etc. Parts of the PA process are automated and do not require human intervention. Typically includes manual submission on behalf of provider which is received by health plan via an automated tool, e.g., health plan portals, IVR, ASC X etc. Entire PA process is at its most effective and efficient by eliminating unnecessary human intervention and other waste. Optimized PA process would likely include automating internal provider/health plan workflows. 26

27 Support & Alignment Across the Industry CAQH CORE Board Endorses Consensus Statement The Consensus Statement on Improving the Prior Authorization Process was released by six associations in January 2018 and outlines five areas that offer opportunity for improvement in prior authorization programs. The CAQH CORE Board sent a Letter of Support for the Consensus Statement and endorses the statement and urges ongoing cooperation to reduce healthcare costs, ease administrative burdens and improve continuity of care and the patient experience. There are specific areas where CAQH CORE and the organizations that authored the Consensus Statement have clear, shared goals: 1. Improved transparency and communications. 2. Continuity of patient care. 3. Greater automation and efficiency. 27

28 CAQH CORE Scope and Draft Phase V Operating Rules

29 CAQH CORE Rule Research, Development & Maintenance Group Structure CAQH CORE Participating Organizations play a critical role in all aspects of the rules lifecycle. All Groups are open to and chaired by CAQH CORE Participants. Identify Opportunities Develop Rules Maintain & Enhance Rules Rules Work Group (RWG) Technical Work Group (TWG) Advisory Groups Subgroups Subgroups Task Groups e.g., Attachments (Additional Documentation) Advisory Group. e.g., Prior Authorization Subgroup, Claim Status Subgroup, etc. e.g., Connectivity & Security Subgroup, Certification/Testing Subgroup, etc. e.g., CORE Code Combinations Task Group, EFT/ERA Enrollment Data Sets Maintenance Task Group. 29

30 Scoping the Prior Authorization Rule Opportunities From Fall 2016 through Summer 2017, a multi-stakeholder CAQH CORE PA Advisory Group vetted potential PA operating rule opportunity areas against agreed-upon evaluation criteria. The initial PA opportunities list was developed via thorough review and analysis of a variety of sources, including: NCVHS testimonies, ACA Review Committee, industry forums and discussions, CAQH CORE industry surveys and prior rule development efforts, X12 v5010x TR3, etc. The PA Advisory Group conducted an environmental scan to hone in on pain points and understand the potential benefit of the various opportunity areas. The resulting opportunities list was used by the CAQH CORE PA Subgroup, which represents more than 50 multi-stakeholder organizations, to further prioritize operating rule development. Over the past six months, the PA Subgroup held nine calls and provided input via multiple feedback forms and straw polls to develop draft requirements to drive further automation of PA. 30

31 DRAFT Requirements DRAFT Requirements Draft Phase V CAQH CORE Prior Authorization Operating Rules The Draft Phase V Prior Authorization Rules reduce unnecessary back and forth between providers and health plans. These efficiencies enable shorter time to final adjudication and more timely delivery of patient care. DRAFT RULE X Request / Response Data Content Consistent provider and patient identification to reduce common errors and associated denials. Consistent submission of diagnosis, procedure and revenue codes to allow for full health plan review/adjudication. Consistent use of codes to indicate errors/next steps for the provider, including need for additional documentation. Detection and display of code descriptions to reduce burden of interpretation. DRAFT RULE Prior Authorization Web Portals Application of standard X12 data field labels to web portals to reduce variation and ease submission burden. Confirmation of receipt and acknowledgment of prior authorization submission to reduce manual follow-up for providers. System availability requirements for a health plan to receive a prior authorization request, to enable predictability for providers. NOTE: The CAQH CORE Prior Authorization Subgroup is currently reviewing and refining these draft rule requirements. Review will continue until the Subgroup sends to the CAQH CORE Rules Work Group. While in the review process, draft rule requirements are subject to change. 31

32 Value of Prior Authorization Draft Rules Draft Phase V CAQH CORE Operating Rules build on the Phase IV Rules by requiring more robust information in the prior authorization transaction and streamlining provider data submission, reducing the amount of manual follow-up between providers and health plans. Addressing fundamental uniformity for data field labels, ensuring confirmation and acknowledgement of the submission/receipt of a PA request, and providing for system availability are foundational for creating a pathway to more robust automation. An incremental phased approach that addresses defined pain points now, while encouraging the industry to move to adoption of the standard allows for the systems and applications that need to be built to support auto adjudication to be better defined. Automation Spectrum Manual Partially Automated Optimized 32

33 Next Steps

34 Phase V Rule Development From Fall 2016 through Summer 2017, the CAQH CORE PA Advisory Group researched PA operating rule opportunity areas. Timeline is subject to change based on feedback from CAQH CORE Participants. We are here 34

35 CAQH CORE Group Information Join Today Why join a CORE group? Contribute to the development of implementable operating rules for targeted industry change, resulting in meaningful improvements for providers, health plans and patients. CAQH CORE Group Name Group Focus Current Group Objectives Target Launch & Meeting Cadence (Tentative) Phase V Rules Work Group Rule Review Review the Draft Phase V Operating Rules developed by the Prior Authorization Subgroup; participate in ballot to approve the draft rules to move on to an All CORE Participant Vote. Target Launch: August/September Cadence: Once monthly; targeted for the August/September-November 2018 period. Phase V Certification & Testing Subgroup Test Suite Development Develop the Certification Test Suite for the Phase V CAQH CORE Operating Rules. Target Launch: Q Cadence: Once monthly; targeted for the October 2018-January 2019 period. Phase V Technical Work Group Test Suite / Technical Specification Review Review technical rules (when applicable); review the Certification Test Suite for Phase V CAQH CORE Operating Rules (developed by the Certification & Testing Subgroup). Target Launch: Q / Q Cadence: Once monthly; targeted for the December- February 2019 period. CORE Certification and CORE Endorsement Organizations can ensure they are following the CAQH CORE operating rules and demonstrate to trading partners adherence to industry standards for HIPAA-covered electronic transactions, including prior authorization. 35