X12 Clearinghouse Caucus

January 31, 2017 - 5:00 - 6:30 pm

Sheraton Seattle Hotel / Metropolitan B

Clearinghouse Caucus Sponsors

Clearinghouse Caucus - ASC X12 Standing Meeting

January 31, 2017 - 5:00 - 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 - 2016 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

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

Our Members

ASC X12 Update

Stacy Barber, Chair, ASC X12N

BCBSA Member ID Update

Gail Kocher, BCBSA

Value Based Payment

Implementation Discussion –

Moderator:

Crystal Ewing, ZirMed

Debra Strickland, Conduent

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 2018

90% 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: http://hcttf.org/

The Triple AIM

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)

Alternative Payment Model Framework

It’s Complicated…

How can we make this transition

successful?

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)

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?

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?

Clearinghouse Perspective

• What can clearinghouses do to ensure the industry

succeeds in the transition to alternative payment

models?

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

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 7030.

• Opportunity to educate our stakeholders on impactful changes.

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

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.

CE V7030 upcoming review meetings

How can you participate?

• Join the Work Group – meet twice a month

• Email co-chairs

• Betty.Lengyel-Gomez@conduent.com

• Joan.Kossow@ssigroup.com

• Email Lisa Beard - lisa@m3solutionsllc.com

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

CE proactive preparation for Cyber War:

Economic war is here

We are not prepared for Cyber War –

and it is Economic war now

2017 Prediction - Top Target

Healthcare Data

Key Trends for

Healthcare Data

2

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

• *https://cdn2.esetstatic.com/eset/US/resources/docs/white-papers/State_of_Healthcare_Cybersecurity_Study.pdf

•

Attacks are focusing on higher

value data targets2013

800,000,000+ records

breached, with no signs

of decreasing in the

future

2014

1,000,000,000 records

breached, while CISOs cite

increasing risks from

external threats

2015- 2016

Healthcare mega-breaches

set the trend for high value

targets of sensitive

information

Source: IBM X-Force Threat Intelligence Report - 2016

Highly regulated industries have the

highest per-record data breach costs

Healthcare Education Pharmaceutical Financial

Consumer Energy RetailHospitality

$359 $294 $227 $206

$155 $141 $105$122

*Currencies converted to US dollars

Source: 2014 Cost of Data Breach Study: Global Analysis, Ponemon Institute,

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

CE Cyber Security 2017 Initiatives

• In addition To : Clearinghouse HIPAA /OCR Audit Certification

• Engaged with Top Cybersecurity Industry Leaders- Resources

National Institute Standard Technology SP800- 63 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

•

Clearinghouse Caucus Sponsors

Thank You

Cooperative Exchange Contact Information

Lisa Beard, Executive Director, Cooperative Exchange

lisa@cooperativeexchange.org

http://www.cooperativeexchange.org/

Sherry Wilson, Board Chair Cooperative Exchange

EVP and Chief Compliance Officer

Jopari Solutions

sherry_wilson@jopari.com