X12 Clearinghouse Caucus. January 31, :00-6:30 pm Sheraton Seattle Hotel / Metropolitan B

Transcription

1 X12 Clearinghouse Caucus January 31, :00-6:30 pm Sheraton Seattle Hotel / Metropolitan B

2 Clearinghouse Caucus Sponsors

3 Clearinghouse Caucus - ASC X12 Standing Meeting January 31, :00-6:15pm Sheraton Seattle Hotel / Metropolitan B Welcome and Introduction -Sherry Wilson, Board Chair, Cooperative Exchange and EVP/ CCO, Jopari Solutions ASC X12 Update - Stacey Barber, ASC X12N Chair BCBSA Member ID Update - Gail Kocher, BCBSA Value Based Payment Implementation - Preparing for Change - Open forum stakeholder exchange - Implementation considerations for success Presenter: Crystal Ewing, Board Member, Cooperative Exchange and Manager of Data Integrity, ZirMed Moderator: Debra Strickland, Education Chair, Cooperative Exchange and Project Manager, Conduent 7030 Clearinghouse Review Update Presenter - Betty Lengyel-Gomez, Co-Chair, Emerging Trends and Strategic Innovation Committee, Cooperative Exchange and Compliance Director, Government Healthcare Solutions, Conduent Moderator: Joe Bell, Vice Chair, Cooperative Exchange and Senior Program Manager, Product Strategy, esolutions Transaction Processing Top Cybersecurity Findings Presenter - Doreen Espinoza, Board Member, Cooperative Exchange and Vice President of Regulatory Affairs and Privacy Officer, UHIN Moderator: Debbi Meisner, Secretary, Cooperative Exchange and Vice President Regulatory Compliance, Change Healthcare

4 Overview of Cooperative Exchange (CE) 25 Clearinghouse Member Companies Represent over 90% of the clearinghouse industry Over 750,000 submitting provider organizations Maintain over 8,000 Payer connections 1000 plus HIT vendor connections Process over 4 plus billion claims annually Value of transactions over $1.1 Trillion Infrastructure framework supports BOTH administrative and clinical transactions

5 Our Members

6 ASC X12 Update Stacy Barber, Chair, ASC X12N

7 BCBSA Member ID Update Gail Kocher, BCBSA

8 Value Based Payment Implementation Discussion Moderator: Crystal Ewing, ZirMed Debra Strickland, Conduent

9 Value Based Payment it is a reality 50% of Medicare Payments will be tied to an Alternative Payment Model (ACO or Bundled Payment) by the end of % of traditional Medicare payments will be tied to quality of value by 2018 through programs such as Hospital Readmissions Reduction The coalition known as the Health Care Transformation Task which includes 20 health systems and insurers says it is committed to moving 75% of its contracts into alternate payment models by 2020 Source:

10 The Triple AIM

11 Value Based Program Examples MIPS and APMs Value Modifier, PQRS, Meaningful Use (Replaced by MIPS) Hospital Readmission Reduction Hospital Value Based Purchasing Program (HVBP) End Stage Renal Disease (ESRD) Quality Incentive Program Hospital-Acquired Condition (HAC) Reduction Program Skilled Nursing Facility Program (SNFVBP) Home Health Value Based Program (HHVBP)

12 Alternative Payment Model Framework

13 It s Complicated

14 How can we make this transition successful?

15 Payer Use Cases Few examples of payer use cases: Quality measures requests and responses (HEDIS data) Connecting to other orgs/networks (EHR data pull) Value based payments (future models for encounter /claims) Patient access their care plans (CCD) Notifications alerts (CDS Hooks) Transitions of Care (Admit, Discharge, Transfer, and care management) Prior Authorizations Gaps in care (population health analytics)

16 Payer Perspective What types of functionality are used in your current implementation of value based payment models? What type of training tools are available? What type of functionality and training tools are needed by payers to ensure the success of alternative payment models? What are the sources and format of your data? (X12, EMR, HL7, etc.) Is it meeting your business needs? Do you have any lessons learned so far?

17 Provider Perspective What types of functionality is used in your current implementations of value based payment models? What functionality do you as providers think you need to ensure success of alternative payment models? What are the sources and format of your data? (X12, EMR, HL7, etc.) Is it meeting your business needs? Do you have any Lessons Learned so far? What functionality do you need from your payers to ensure the success of alternative payments models? What type of training tools do you need from your payers to ensure the success of alternative payment models?

18 Clearinghouse Perspective What can clearinghouses do to ensure the industry succeeds in the transition to alternative payment models?

19 7030 Clearinghouse Review Update Betty Lengyel-Gomez, Co-Chair, Emerging Trends and Strategic Innovation Committee, Cooperative Exchange and Compliance Director, Government Healthcare Solutions, Conduent Moderator: Joe Bell, Vice Chair, Cooperative Exchange and Senior Program Manager, Product Strategy, esolutions

20 7030 Clearinghouse Review The 7030 Workgroup is comprised of Cooperative Exchange members who want to be involved in the review of X12 s proposed changes for Version 7030, all affected transaction sets, all cycles. The workgroup provides: Discussion and collaboration of all proposed changes as well as a means for clarification of these changes if needed. Opportunity to have a positive impact on the proposed changes while addressing clearinghouses business needs for version Opportunity to educate our stakeholders on impactful changes.

21 Highlights since timeline release Workgroup has completed 2 cycles 277CA - removal of STC12 Workgroup agreed that to remove this segment would result in a slow-down of claim correction and adjudication Increase the number of calls to the payer for clarification of non-codified messages Providers would be forced to obtain additional information from payer portals Clearinghouses provide a more efficient path for getting information to the provider Surveyed members on usage application reviewing results will share with X12 Will work with WEDI, X12 and Cooperative Exchange on education, efficiency and solution initiatives

22 Highlights since timeline release Workgroup has completed 2 cycles 835 proposed changes discussed - Credit Card information within the 835 transaction. This poses a security risk and needs to be revised to use a token number instead of an actual card number. The HPID should not be used as an identifier for the payer within the 835 transaction, the payer id should be the standard. CAS/RAS changes that occurred in 6020 that moved forward in 7030 code values deleted or added where there was a CAS will now change to RAS 835 DTM segment of the 2100 Loop Clean Claim Date Need for a clear and concise definition of clean claim.

23 CE V7030 upcoming review meetings

24 How can you participate? Join the Work Group meet twice a month co-chairs Betty.Lengyel-Gomez@conduent.com Joan.Kossow@ssigroup.com Lisa Beard - lisa@m3solutionsllc.com

25 Transaction Processing 2016 Top Cybersecurity Findings Doreen Espinoza, Board Member, Cooperative Exchange and Vice President of Regulatory Affairs and Privacy Officer, UHIN Moderator: Debbi Meisner, Secretary, Cooperative Exchange and Vice President Regulatory Compliance, Change Healthcare

26 CE proactive preparation for Cyber War: Economic war is here

27 We are not prepared for Cyber War and it is Economic war now 2017 Prediction - Top Target Healthcare Data

28 Key Trends for Healthcare Data

29 2016 Healthcare Industry Top Target for Cybersecurity Attacks* Healthcare Payments and Medical Records yield more value on the black market than credit card information 90% Breaches - Targeted Spear Phishing - Average 187 days to detect beach - Average global organization containment cost $ 3.7 million Increase in targeted Hacktivist Intent to harm organization reputation Inadequate authentication and verification controls ranks high on breach incidents *

30 Attacks are focusing on higher value data targets ,000,000+ records breached, with no signs of decreasing in the future ,000,000,000 records breached, while CISOs cite increasing risks from external threats Healthcare mega-breaches set the trend for high value targets of sensitive information Source: IBM X-Force Threat Intelligence Report

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32 Highly regulated industries have the highest per-record data breach costs $359 $294 $227 $206 Healthcare Education Pharmaceutical Financial $155 $141 $122 $105 Consumer Energy Hospitality Retail *Currencies converted to US dollars Source: 2014 Cost of Data Breach Study: Global Analysis, Ponemon Institute,

33 Community Health Systems Breach Data from 5.4M patients, including social security numbers Cost: $75-$150M Class action filed immediately Hackers used the Heartbleed bug to access VPN credentials CHS used a lot of open source or free security software Bug reported in April records still being stolen in June

34 CE Cyber Security 2017 Initiatives In addition To : Clearinghouse HIPAA /OCR Audit Certification Engaged with Top Cybersecurity Industry Leaders- Resources National Institute Standard Technology SP Update on Digital Authentication Guideline Homeland Cybersecurity Participating in ONC and HIT Security Committees Engaged with International CCM3 Cloud Security Alliance Clearinghouse Security Best Practices for Cloud Tool Kit: Clearinghouse Cyber Security Certification

35 Clearinghouse Caucus Sponsors

36 Thank You Cooperative Exchange Contact Information Lisa Beard, Executive Director, Cooperative Exchange Sherry Wilson, Board Chair Cooperative Exchange EVP and Chief Compliance Officer Jopari Solutions