AMA Testimony/Presentations to NCVHS on Administrative Simplification
The National Committee on Vital and Health Statistics (NCVHS) is the federal agency with responsibility for the electronic health care transaction standards and other administrative simplification provisions contained within the Patient Protection and Affordable Care Act (ACA). AMA has provided extensive testimony to NCVHS to ensure physicians’ interests in fully automating their practices are represented. Elimination of the manual processes and administrative hassles endured today can only occur if NCVHS adopts standards that meet the needs of all stakeholders, rather than just the interests of health plans.
AMA has testified on all of the following issues:
- Claim edit and payment rules
- Workers compensation
- Audit forms and process
- Provider enrollment forms
- Transaction claims attachment
- Health plan ID
- Virtual credit cards
- Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)
- Transaction acknowledgements
- Maintenance and Modifications to Standards and Operating Rules
Standards and Operating Rules for Claims Attachments
The AMA participated in the NCVHS Subcommittee on Standards Review Committee meeting focusing on the currently adopted standards used in the claims revenue cycle. The AMA offerred written testimony on numerous potential improvements in current standards and operating rules. Additionally, the AMA participated in a panel review of prior authorization and the electronic remittance advice/electronic funds transfer transactions.
The AMA, the Medical Group Management Association (MGMA), and the American Hospital Association (AHA) submitted joint testimony to the NCVHS Subcommittee on Standards regarding the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) operating rules and the rule development process. The testimony calls for enhancements to the draft operating rules for the claim and prior authorization electronic transactions, including seeking the addition of data content requirements. In addition, the AMA and the other provider organizations urged the Subcommittee to use this opportunity to fully address the multiple process deficiencies that are hindering true automation and simplification of the current burdensome prior authorization system.
The AMA partnered with the American Hospital Association (AHA), the Medical Group Management Association (MGMA), and the American Dental Association (ADA) in testimony regarding the role of the Review Committee, a body established under the Affordable Care Act to review existing administrative health care electronic transactions. The provider organizations' testimony advocated for the Review Committee to take on major administrative simplification challenges facing the industry, including oversight of the electronic standards development process, responsiveness of the current standards and operating rules to emerging business needs, and industry compliance.
At this meeting, the AMA provided an update on health plan usage of virtual credit cards. The AMA believes: (a) that payment by virtual credit cards should be by mutual agreement of payers and providers; (b) that payers should be required to be completely transparent on all applicable card processing fees for virtual credit cards; (c) that payment options should be clearly communicated to physicians; and (d) that payers should not receive incentives to use virtual credit cards.
At this meeting, the AMA gave a presentation on health plan usage of virtual credit cards. The AMA believes: (a) that payment by virtual credit cards should be by mutual agreement of payers and providers; (b) that payers should be required to be completely transparent on all applicable card processing fees for virtual credit cards; (c) that payment options should be clearly communicated to physicians; and (d) that payers should not receive incentives to use virtual credit cards.
At this meeting, the AMA gave a presentation on pharmacy prior authorization. The AMA believes thatadministrative burdens and costs associated with PA should be reduced through simplification and standardization. The AMA supports a uniform, electronic prior authorization process that is available to physicians at no or minimal cost.
AMA Advocates for HIPAA Standard for Attachments
The AMA has long advocated for an attachment standard to be named under the Health Insurance Portability and Accountability Act (HIPAA) to streamline the process physicians use to send payers additional information requested to pay a claim. A complete solution for handling attachments is also expected to significantly reduce costs for physicians by automating the prior authorization process. In joint testimony to HHS’ National Committee on Vital and Health Statistics (NCVHS), the AMA and the Medical Group Management Association (MGMA) recommended HHS adopt the transaction standard for claims attachments (known as the X12 275). The AMA and MGMA also called for HHS to improve use of the existing named HIPAA standard which lets payers communicate with providers about the status of their claim (known as the X12 277), by allowing it to also be used by payers to request additional information needed from a provider. Together, the robust use of these two transactions could remove the largely manual, time consuming and expensive process for physicians when responding to payers’ varying attachment requests. In addition, the joint testimony urged NCVHS to find a way to ensure that innovative solutions to handling claims attachments could be allowed, should physicians elect to use them.
AMA conveys to NCVHS Subcommittee: Compliance must be audited and certified
Physician practices need one workflow for all payers and all lines of business, and will adopt electronic health care transactions when they add value and are incorporated into practice management systems. These were the messages the AMA conveyed to the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards last week. The AMA emphasized to NCVHS that administrative simplification is a team sport and recommended an audit process for all partners within the claims process to ensure functional compliance with all the transactions to allow physicians and payers to begin realizing the cost savings that may be as high as $210 billion annually. AMA asked the Subcommittee to consider that while infrastructure investments and claim stoppages in the claims revenue cycle are investments or costs of business for payers and intermediaries, for most physicians, claim stoppages cause a loss of revenue that cannot be recouped and there is no money for infrastructure investment that cannot immediately be recouped from reduced administrative costs.
The AMA recommends: 1) that the Health Insurance Portability and Accountability Act’s (HIPAA) Transaction and Code Set (TCS) rule and other HIPAA Administrative Simplification provisions be revised as necessary to ensure the simplification and timely disclosure of all information necessary for determining patient and payer financial responsibilities at the point of care; 2) that the Medicare National Correct Coding Initiative (NCCI) should be the starting point for the development of a national claims edit standard; and 3) that the Medicare payment rules should be the starting point for the development of a national pricing rule standard.
The AMA conveyed that it is time to extend the HIPAA transactions to property and casualty insurance covering health care claims. The current ASC X12 standard health care transactions, such as claims and electronic remittance advice, are able to send appropriate property and casualty claims information to payers. Solutions have also been created to allow the attachment of additional information, typically required by workers’ compensation claims, in the absence of an available HIPAA electronic health care standard transaction.
The AMA believes that the ground work has now been laid for the development of a HIPAA standard provider enrollment transaction which would be used by all payers. By comparing the fields included in the National Plan & Provider Enumeration System (NPPES) registry, the Council for Affordable Quality Healthcare (CAQH) Universal Provider DataSource (UPD), the National Committee for Quality Assurance (NCQA) credentialing standards and the various state mandated forms, it should be possible to come up with a comprehensive set of data elements that would meet the credentialing needs of all payers.
The AMA encourages the development of standardized audit forms and processes, which would greatly benefit all stakeholders. In order for payers to realize the full benefits of audits, physicians must be able to determine and accept the accuracy of an audit request. This understanding can lead to the desired long term improvement in the practice operations. Helping physicians understand and rectify billing errors is perhaps the most important goal of legitimate audit activity.
The AMA encourages the adoption of the Accredited Standards Committee (ASC) X12 275 (X12N/005010X210), Additional Information to Support a Healthcare Claim or Encounter, as a HIPAA electronic health care standard transaction that will make significant additional inroads to the goal of administrative simplification.NCVHS Testimony on Claims Attachment Transaction
AMA provided testimony reinforcing the importance of the ASC X12N acknowledgment healthcare standard transactions and the need for physician practices be able to track the progress of their electronic claims and other transactions - to know if and when the transaction was received, where the transaction is and where it has been. The AMA asked for the adoption of the ASC X12 acknowledgment health care transactions as additional HIPAA-mandated standards, and strongly believes that they will further promote the administrative simplification goals of HIPAA.
The ACA administrative simplification provisions provide tremendous opportunities to address the lack of use of the majority of the electronic health care standards. The addition of an operating rule entity in the current standard-setting process requires clear communication and delineation of responsibilities between all parties. The AMA requests thoughtful consideration by all parties to ensure successful harmonious collaboration throughout the maintenance and modifications process of the standards and operating rules.
The opportunities contained in the ACA are accompanied by very tight timeframes. ”AMA Timeline Standards and Operating Rules” conveys these timeframes for the development and adoption of new versions of the electronic health care standard transactions and operating rules.
The AMA urges prioritization and adoption of a National Health Plan Identifier for each payer and other entity involved in the health care billing and payment process. The National Health Plan Identifier should clearly specify:
- the entity with primary financial responsibility for paying the claim;
- the entity responsible for administering the claim;
- the entity that has the direct contract with the health care provider;
- the specific fee schedule that applies to the claim;
- the specific plan/product type;
- the location where the claim is to be sent; and
- any secondary or tertiary payers.
Specific Requirements for Standards & Operating Rules for Electronic Funds Transfer (EFT) & Claims Payment/Electronic Remittance Advice (ERA)
The AMA would like to see all stakeholders in the claims billing and payment process recoup the estimated $11 billion that would be saved if EFT was adopted across the health care industry. However, the complete elimination of paper checks and paper remittance advice in favor of EFT and ERA would require complete automation of the entire claims management cycle.
The full economic benefit of the EFT transaction will not be realized until:
- all the EFT issues identified in the accompanying white paper have been resolved;
- the electronic standard transactions are thoroughly examined to ensure the appropriate information can be transferred; and
- consistent, widespread use of the standard transaction occurs.