CMS Compliance Review Program

CMS, WEDI and CAQH CORE Webinar Series: Part 2

LogisticsPresentation Slides and How to Participate in Today’s Session

▪ You can download the presentation slides at www.caqh.org/core/events or at www.wedi.org after the webinar.

▪ A copy of the slides and the webinar recording will be emailed to all attendees and registrants in the next 1-2 business days.

▪ Questions can be submitted at any time using the Questions panel on the GoToWebinar dashboard.

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Session Outline

▪ Speaker Introduction

▪ Featured Presentation: Administrative Simplification Enforcement – Compliance Review Program

▪ Q&A

▪ Closing Comments

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Thank You to Our Speakers

Paul AndersonHealth Insurance Specialist

CMS Division of National Standards

Charles StellarPresident and CEO

WEDI

April ToddSenior Vice President

CAQH CORE

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Gladys WheelerLead Health Insurance Specialist

for Compliance EnforcementCMS Division of National Standards

Administrative Simplification Enforcement

Compliance Review Program

July 18, 2019

Compliance Review Program

» Created to ensure compliance amongst covered entities with HIPAA Administrative Simplification rules for electronic health care transactions.

» The Compliance Review Program will conduct periodic reviews with randomly selected entities to assess compliance with HIPAA Administrative Simplification rules.

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Compliance Review Program Cont’d

» HHS will review the following administrative transactions for compliance:

1) Transaction formats

2) Code Sets

3) Unique Identifiers

» Participants will attest to compliance with operating rules.

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Non-compliance

» Covered entities found to be noncompliant will be allowed to undertake corrective actions.

» Covered entities who do not achieve compliance may be subjected to escalated enforcement actions.

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Compliance Review Process

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Optimization Pilot Program

» In 2018, ten organizations were selected to participate in the pilot program. Four clearinghouses and one health plan completed the pilot.

» Participating organizations assisted HHS with optimizing the review process, including review tracking, coordinating and communicating with participating entities, and assessing violations.

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Optimization Pilot Program Results Violations

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57%

20%

19%

4%

Transactions Code Sets Unique ID Operating Rules

Audience Q&A

Enter your question into the “Questions” pane in the lower right hand corner of your screen.

Please submit your questions

▪ The slides and webinar recording will be emailed to attendees and registrants in the next 1-2 business days.

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Thank you for joining us!

Website: www.CAQH.org/CORE

Email: CORE@CAQH.org

@CAQH@WEDIonline

Website: www.wedi.org

Email: wedi@wedi.org

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Additional Resources

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• go.cms.gov/adminsimp website

• Administrative Simplification Email Updates

• Compliance Review video at https://youtu.be/iRF8TvaW4DU

• ASETT to test transactions or file complaints at asett.cms.gov

• AdministrativeSimplification@cms.gov for questions and comments

• CAQH 2017 Index and savings calculator at CAQH.org

• DNS Regional Office Engagement SharePoint site

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Resources

Madhu Annadata – Madhusudhan.Annadata@cms.hhs.gov

Chris Gerhardt- Christine.Gerhardt@cms.hhs.gov

Gladys Wheeler – Gladys.Wheeler@cms.hhs.gov

Geanelle Herring – Geanelle.Herring@cms.hhs.gov

Cecily Austin – Cecily.Austin@cms.hhs.gov

Rosali Topper – Rosali.Topper@cms.hhs.gov

Paul Anderson – Paul.Anderson@cms.hhs.gov

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Contacts –Enforcement Team

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ASETT: Administrative Simplification Enforcement and Testing Tool

CDT: Code on Dental Procedures and Nomenclature

CPT: Current Procedural Terminology

DNS: Division of National Standards

EHRs: electronic health records

EIN: Employer Identification Number

HCPCS: Healthcare Common Procedure Coding System

HIPAA: Health Insurance Portability and Accountability Act of 1996

ICD-10: 10th revision of the International Statistical Classification of Diseases and Related Health

Problems

NDC: National Drug Code

NPI: National Provider Identifier Standard

Acronym Glossary