Office of ehealth Standards and Services Update: An Overview of 2010-2011 Priorities and Key initiatives Lorraine Tunis Doo Senior Policy Advisor, OESS March 11, 2011
AREAS OF FOCUS Our Ever Changing World and the Triple Aim Affordable Care Act HITECH Act Implementation and Stage 2 5010/ICD-10 Other Initiatives 2
A FEW THOUGHTS ABOUT CHANGE 3
OUR (SHARED) EVER CHANGING WORLD November 2009 November 2010 Health Care Reform Legislation HITECH Vision CCHIT 5010/ICD-10 Reality Affordable Care Act HITECH Implementation ONC ATCBs * 5010/ICD-10 REALITY Authorized Testing & Certification Bodies 2011. oregulatory Reform oreduction in FOIA requests ofuture of Health Reform o 4
THE TRIPLE AIM CMS ADMINISTRATOR S VISION Better Health for the Population Risk Factors Vitality Safe Effective Patient- Centered Timely Efficient Equitable Better Care for Individuals Government All Payers Lower Cost through Improvement 5
AFFORDABLE CARE ACT- ADMINISTRATIVE SIMPLIFICATION
PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 Congress improve the effectiveness and efficiency of the Medicare and Medicaid programs as well as the entire health care system The Administrative Simplification provisions in the Affordable Care Act underscore the establishment of uniform standards and requirements for the electronic transmission of certain health information 7
PATIENT PROTECTION AND AFFORDABLE CARE ACT (ACA): ADMINISTRATIVE SIMPLIFICATION 1104 AND 10109 Unique Health Plan Identifier New Standards and Operating Rules Medicare EFT payment requirement Compliance certification Penalties Audits Review of existing standards and operating rules ICD-10 cross walk 8
PUBLICATION AND COMPLIANCE DATES Requirement under 1104 IFR Date Industry Compliance Date Operating rules for Eligibility and Claims status 7/2011 1/2013 Health Plan Identifier 8/2011 10/2012 Standard for EFT (and Medicare EFT payment policy) 1/2012 1/2014 Operating Rules for EFT and Remittance Advice Standard and operating rule for claims attachments Operating rules for claims, enrollment, premium payment, referrals and authorizations 7/2012 1/2014 1/2014 1/2016 7/2014 1/2016 9
HEALTH PLAN IDENTIFIER Supports original HIPAA legislation to establish a unique health plan identifier Take into account multiple uses for identifiers Not an easy task! Complexity stems from: Wide variety of health plans (ex: commercial group plans, HMOs, government, high risk pools) Variety of levels and entity types that could be enumerated (ex: contract, line of business, processor, TPA, repricers) Changes in the structure of the health care industry over time (e.g. use of business associates for plan functions) Current use of the identifier(s) within the standards 10
OPERATING RULES Are the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications Must be consensus-based and reflect needed business rules affecting health plans and providers Operating rule authors must be non-profit organizations that meet specific criteria The Secretary will adopt operating rules based on recommendations from NCVHS, and ensuring consultation with providers Greater, consistent industry ACTIVE engagement is crucial 11
OPERATING RULES TO BE ADOPTED o Eligibility and Claim Status Compliance by 1/2013 o Electronic Funds Transfer* and Remittance Advice Compliance by 1/2014 o Claims, Enrollment, Premium Payments, Referrals/Authorizations Compliance by 1/2016 o Claims Attachments* - Compliance by 1/2016 * Standards must be adopted for EFT and Claims Attachments as well 12
PROGRESS TO DATE NCVHS action on Health Plan Identifier (HPID) and Operating Rules for Eligibility Query and Claim Status Hearings July 19-21, 2010 Full Committee Deliberations September 15-16, 2010 Letter to Secretary September 30, 2010 Regulatory work underway at CMS NCVHS action on standard and operating rules for EFT and Remittance Advice Hearing December 3, 2010 Applications sent to potential authoring candidates for operating rules December 31, 2010 NCVHS letter to Secretary expected in March 2011 ICD-9 Coordination and Maintenance Committee Collected public input on General Equivalence Maps (aka crosswalks ) at September 15-16, 2010 public meeting; published revised cross walk January 1, 2011. 13
HIGHLIGHTS OF RECOMMENDATIONS FROM NCVHS HEALTH PLAN IDENTIFIER (HPID) Clarify the definition of health plan and specify other entities that will also be eligible for an identifier to be used in the standard transactions (e.g. third party administrators) Avoid having intelligence in the identifier Determine if operating rules can help smooth the process of using identifiers in the 5010 version of the standards Collaborate with stakeholders for the content of the directory/database to store the numbers Allow the use of the RxBIN number in pharmacy transactions, in addition to HPID Consider creative options for timing of implementation (10/1/2012 is very soon!) 14
HIGHLIGHTS OF RECOMMENDATIONS FROM NCVHS OPERATING RULES FOR ELIGIBILITY AND CLAIMS STATUS Select CAQH CORE as the authoring entity for operating rules for nonpharmacy eligibility and claims status transactions Select NCPDP as the authoring entity for operating rules for pharmacy eligibility transactions (claims status not used in rx) Adopt Phase I and Phase II of the CAQH CORE operating rules for eligibility and claims status Encourage authoring entities to collaborate with more stakeholders, including States and Medicaid agencies to identify key enhancements with ROI that could be included (through consensus) in Phase I or II by December 3, 2010. Update: some enhancements being voted upon first quarter 2011. Discourage plans from continuing to use companion guides that conflict with either the standards or the operating rules. Enforce only inclusion of the minimum information to enable business between trading partners. Make certification voluntary until the CMS mandatory certification compliance program is launched in 2013 (no federal requirement to obtain certification to use operating rules). 15
COMPLIANCE, CERTIFICATION, AND AUDIT UNDER THE AFFORDABLE CARE ACT Provisions specify certification for health plans All covered entities must comply with the rules Certification program: Health plans must certify compliance (through CMS) with applicable standards and operating rules: 12/31/2013 and 12/31/2015 Requires ongoing certification with revised standards and operating rules Secretary will conduct periodic audits to ensure compliance with the adopted standards and operating rules Penalty fees for failure to comply with certification and documentation requirements will be assessed beginning 4/1/2014 and annually thereafter $1 per covered life per day until certification complete Penalty fees double for misrepresentation Annual increase in penalty fees by the annual percentage increase in total national healthcare expenditures 16
NEXT STEPS FOR OESS Preparing Interim Final Rules for HPID and first set of operating rules Will consider NCVHS recommendations for EFT standard By May, 2011, complete review of applications from candidates to author operating rules for EFT and ERA and secure recommendation from NCVHS Begin work on proposed rule for compliance certification, audits and enhanced penalties 17
Medicare and Medicaid Electronic Health Record Incentive Program Implementation 18
OVERVIEW American Recovery & Reinvestment Act (Recovery Act) February 17, 2009 Medicare & Medicaid Electronic Health Record (EHR) Incentive Program Notice of Proposed Rulemaking (NPRM) published January 13, 2010 Final Rule Published July 28, 2010 19
MEANINGFUL USE STAGE 1 2011 AND 2012 Medicare eligible professionals and hospitals must use certified EHR technology, and successfully demonstrate meaningful use in order to receive incentive payments. Medicaid eligible professionals and hospitals have the option to adopt, implement or upgrade their certified EHR technology in their first year of participation in order to receive an incentive payment. 20
REQUIREMENTS FOR MEANINGFUL USE Stage 1 Objectives and Measures reporting Eligible Professionals must complete the following: 15 core objectives 5 objectives out of 10 from a menu set 6 total Clinical Quality Measures (CQM) 3 core or alternate core, and 3 out of 38 from the additional set 21
EHR INCENTIVE PROGRAM TIMELINE Registration for the EHR Incentive Programs began January 2011 For Medicare providers, attestation for the EHR Incentive Programs began in April 2011 Medicare EHR incentive payments will begin a month following the start of attestations For Medicaid providers, some States launched their programs in January 2011 November 30, 2011 Last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for FFY 2011 February 29, 2012 Last day for EPs to register and attest to receive an incentive payment for CY 2011 2015 Medicare payment adjustments begin for EPs and eligible hospitals that are not meaningful users of EHR technology** 2016 Last year to receive a Medicare EHR incentive payment; Last year to initiate participation in Medicaid EHR Incentive Program** 2021 Last year to receive Medicaid EHR incentive payment** **Statutory 22
STAGE 2 POSSIBLE CHANGES Final Rule Signaling: Optional objectives will become mandatory Administrative transactions will be added CPOE measurement will go to 60% Will reevaluate other measures possibly higher thresholds Other potential changes Legislative fixes Linkages to other initiatives Higher focus on certain priorities 23
ROAD TO STAGE 2 Critical Factors Input from the HIT Policy Committee Feedback from Stage 1 Regulation process Timeline Oct 2010 - April 2011- Identify issues and potential decisions May 2011- August 2011- Feedback from Stage I January 2012 - Develop and publish NPRM 24
RESOURCES CMS Website for Incentive Program - http://www.cms.gov/ehrincentiveprograms Path to payment Frequently Asked Questions Registration and attestation Upcoming events And much much more 25
5010/ICD-10
5010 AND ICD-10 IMPLEMENTATION Some key dates: Industry expected to have begun testing 5010 standards as of January 1, 2011 Compliance date for 5010 January 1, 2012 Compliance date for ICD-10 October 1, 2013 CMS status: Some FFS Medicare contractors have begun external testing 27
ERRATA FOR 5010 AND NCPDP D.0 Technical issues identified by user community in the course of implementation Changes to the standards determined necessary for effective implementation Change proposals reviewed by both SDOs based on impact to the industry Packages of change pages identified and balloted Same implementation dates as base standards Errata notice published October 12, 2010 28
CMS OVERALL ICD-10 GOALS Enable a successful industry and CMS program transition to ICD-10 by 10/1/13 ICD-10 is not just a CMS mandate. CMS will collaborate with other government agencies and industry partners to use the power of the ICD-10 codes to improve healthcare and support reform including: Better quality measurement Improved research Decreased fraud Better public health data sharing 29
CMS DUAL ROLE IN ICD-10/5010 IMPLEMENTATION Internal As HIPAA covered entity, Medicare must ensure that its business processes, systems, policies and those of its contractors, providers, health plans, etc. are compliant with HIPAA Ensure that state Medicaid programs, as covered entities, are compliant with HIPAA Maintain and update the ICD-9 procedure codes; will do the same for ICD-10 (CDC is responsible for diagnosis codes.) 30
INTERNAL IMPACT IF CMS AND MEDICARE ARE NOT READY FOR ICD-10 Risk Adjustment Very High Impact Incorrect MA and Part D Plan Payments Beneficiary Call Center Low Impact Beneficiaries could receive incorrect information Medicare FFS Claims for Risk Adjustment Models Medicare FFS Claims for Customer Services Reps Input for Medicare FFS payment methodology updates Medicare Integrity High Impact CMS may not be able to prevent or recover incorrect payments Medicare FFS Claims Very High Impact Incorrect provider payments Quality High Impact Medicare FFS Claims for Medical Review & Benefit Integrity (FWA) Medicare FFS Claims for PQRI & Quality Improvement Incorrect adjustments to Medicare FFS payments methodologies, limit to analysis of healthcare quality, inaccurate quality incentive payments Medi-Medi Medicare Claims for Research d Medicaid Impact (CMS Internal impact only) Challenges in monitoring/approving proper expenditures, managing Medicaid Integrity Program, value- based purchasing Medicaid Claims for Research Research & Demos, Moderate Impact Incorrect Medicare & Medicaid Supplement, limited effectiveness of medical research 31
CMS DUAL ROLE IN ICD-10/5010 IMPLEMENTATION External Establish and maintain liaison with all external industry segments Share lessons learned to inform industry efforts to achieve ICD-10/5010 compliance by respective deadlines Raise awareness, extend collaboration to achieve industry-wide compliance Provide audience appropriate educational materials/resources 32
CMS ICD-10 IMPLEMENTATION ACTIVITIES Industry Awareness, Outreach and Education Goal: To ensure that every affected entity successfully transitions to Versions 5010, D.0, 3.0 and ICD-10 by deadlines Objectives: Create national awareness; targeted educational products; leverage existing partnerships; monitor and assess outreach results. Progress Developed and have begun implementing plan Working with key stakeholders especially those associated with state Medicaid and small and rural providers Industry Compliance Monitoring-5010/ICD-10 need to have early compliance monitoring to gauge accurate picture of industry readiness and flag problems early on Baseline survey completed early 2010 Future survey work will be done on a regular basis coordinated with outreach efforts to ensure a timely and focused approach
ICD-10 AND HEALTH CARE REFORM ICD codes are critical to supporting a variety of payment reform and quality activities Congress signaled their support for ICD-10 and the current implementation date Affordable Care Act (ACA) provision to adopt HHS crosswalk as part of ICD-10 standard Convened a crosswalk stakeholders meeting in September 2010 to gain input, reviewed feedback, and posted revised crosswalk to CMS website in January 2011 5010/D.0 and ICD-10 tie to other administrative simplification ACA provisions 34
RESOURCES CMS Website - http://www.cms.gov/icd10/ Extensive resources with specific sections tailored to various industry segments Listserv that provides weekly updates and news to subscribers Contains all of CMS internal analyses including the overall impact analysis. 35
OTHER KEY OESS ACTIVITIES Data Governance HIPAA Transactions Compliance Reviews Random audits of TCS compliance to begin soon CMS urges industry to submit valid complaints about non-compliant transactions, companion guides and/or policies. Industry to advise on how to mitigate fears of retaliation, increase complaints and increase effective use of the standards! Associations urged to do more to secure complaint information and submit to OESS Personal Health Records Status of pilots MyMedicare.gov and the Blue Button 36
SUMMING IT UP Tremendous changes Multiple priorities Limited resources BUT Already have done a lot We continue to move ahead We will collaborate 37