Pilot for End-to-End Testing of Compliance with Administrative

SimplificationPresented By:

National Government ServicesDecember 20, 2012

10:00 am to 11:00 am EST

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Welcome

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Agenda Welcome/Opening Remarks Julie McBee 5 minutes ICP Attendance David Carrier 5 minutes Ground Rules Julie McBee 5 minutes Goals, Intended Outcomes & Overview Definitions David Carrier

Readiness Open Floor 20 minutes

Compliance Open Floor 20 minutes

Readiness Specific (Provider, Payer, Vendor) Tentative Questions Team Closing Remarks Team How to contact us Julie McBee

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Industry Collaborative Partners Introductions

• Aetna• American Health Insurance Plans (AHIP)• American Hospital Association (AHA)• American Medical Association (AMA)• CMS Medicare FFS• Emdeon• Healthcare Billing & Management Association (HBMA)• IVANS• Medicaid – CSG Government Solutions• Medical Group Management Association (MGMA)• Nachimson Advisors, LLC• Providence Health and Services• TIBCO Foresight• TRICARE• UNC Health Care• Walgreens• WellPoint • Veteran’s Affairs

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Ground Rules All participants will be muted upon log in for the start of the webinar. Once the opening presentation is done, we will open it up for questions. Please provide your name when asking a question so that we know who is

speaking. Additionally, we ask that only the primary and back-up points of contact

be your designated speakers on the webinar. With the number of participants we expect to participate on our webinars, we want to give each Industry Leader ample time to contribute.

Listen to and value all contributions equally. We are trying to make sure this is a collaborative effort where all Industry leaders can be heard.

We value your time so please keep your discussion focused. Specifically for today’s call, we will be opening the floor for each

contributor up to 3 minutes to speak. We will let you know when you are at 2 and 2:30 minutes to finalize your comments.

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GoalsThe goals of the pilot are:

• To develop and implement a process and methodology for End-To-End testing of the transaction standards, operating rules, code sets, identifiers, and other Administrative Simplification requirements adopted by the Secretary of Health and Human Services (HHS) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Patient Protection and Affordable Care Act of 2010 (ACA) based on industry feedback and participation.

• To develop an industry wide “Best Practice” for End-to-End Testing that lays the ground work for a more efficient and less time consuming method for health care provider testing of future standards, leading to more rapid adoption of the future standards.

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Intended OutcomesThe intended outcomes of the pilot are:

• To provide documents and artifacts to all industry segments outlining the critical check-points needed to ensure compliance with the current mandates

• To provide documents and artifacts to all industry segments outlining the critical check-points which can be used as foundations with future mandates

• To provide a universal testing process and methodology that can be adopted by all industry segments

• To provide a framework and common understanding around the End-To-End testing process and definitions

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Overview• Phase I – Business and Gap Analysis started on September 24, 2012 and

will run through December 21, 2012

• Phase II - Development of Pilot Testing started on December 10, 2012 and will run through June 27, 2013 (approximately six months)*

• The planned start date for Phase III - Implementation and Quality Assurance is July 1, 2013, and will run through September 23, 2013 (approximately three months)*

*Actual dates are subject to change during detailed schedule development

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ReadinessReadiness is a state of preparedness that includes defining needs, identifying risk and implementing a planned sequence of actions to successfully operate and maintain a new/upgraded system, and or processes, with each published standard by the regulatory implementation date.

*Our revised definition is as follows:

Readiness is a state of preparedness in which an Entity has completed internal testing of applicable policies, procedures, guidelines, laws, regulations, and contractual arrangements with expected results. Additionally, entities will need to test with a (%) of external trading partners, complete internal documentation, complete internal and external training, complete scheduled deployments, and complete software migration for each published standard prior to the regulatory implementation date.

*This is a catalyst for our initial discussions with our Industry Collaborative Partners for establishing a clearly refined definition of readiness based on Industry feedback and participation on December 11 th & 13th, 2012 webinars.

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Readiness Webinar Feedback #1Godwin Odia – what is the % of testing? The group should decide on that.

Julie McBee – we don’t have any set %, do you wish to suggest any %?

Shawn Turner – defining your success area, more than just the %, needs to know and demonstrate your success criteria, have you demonstrated your IT, UAT, etc… Know what you want to achieve, what makes us successful or ready? For example, if you sent 1000 claims, an 80% pass rate would indicate readiness.

Jeffrey Collier - Agree with previous statement, it will vary with what the changes are, we don’t need to specify in the definition, eliminate the sentence that mention %, but can include in the checklist. Percentage will vary depending on the checklists.

Elizabeth Reed – it’s important to note you would want to test w/ 100% of your vendors, TP, Clearinghouses. The success criteria is the right way to go.

Godwin Odia – agree with taking out the %, how many Trading Partners (10 or 20) do you have to test with, do you need to test with the ones problematic?

Dean Cook – we don’t want to dictate mission critical, as it will be different for each entity, we leave it up for discussion today, since we couldn’t decide.

                  

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Readiness Webinar Feedback #2Tammy Banks – agree with all the comments, do we need to talk about the ability to test w/ external TP? Since it’s in the definition, clearly defined with the %, we may be just jumping the gun.

Julie McBee – in general, we’re trying to make it broad. Once we get into details, we’ll get more specific

Shawn Turner – training, document, deployment, testing is complete – don’t know what ready means yet? The readiness definition needs to be high level definition, more than just the components.

Holly Louie – can’t get down to the minutia that is unworkable, unfeasible, we should consider, what ready means whatever you are ready for, needs to have some kind of structure. During 5010 Lessons Learned, nobody had the same definition, everyone had a different meaning of what it meant to be compliant.

Jeffrey Collier – If we go to a high level definition of readiness, can we have a phrase for reference to a specific place to get detail on what to do to get ready, the criteria for this testing.

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Readiness Webinar Feedback #3Dean Cook – we want to get a broad definition, then once we get into checklist, we will have specifics, then get into details. What type of industry you’re with – will determine the details of specifics.

Jeffrey Collier – that’s exactly what he’s thinking.

Dean Cook – will like to get collaborated definition to present for the 1st week of Jan. for the Listening Session.

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Readiness FeedbackReadiness Feedback –looked at both Strengths & Opportunities

Addressed in Revised Definition: • What is considered ready? What do we mean by successful? • *Readiness applies to different entities in real world.• We need to be realistic in what and how we define readiness.• *Testing helps define readiness• *Readiness will be different for each industry segment.• *End-to-End testing should be the testing of the process to ensure readiness.• Accuracy of the process needs to be looked at as a whole.

*also embedded in our future checklists

Will be addressed in future checklists:• Determine if your payer is going with a crosswalk approach

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Compliance**Our revised definition is as follows:

Compliance is considered adherence to the conditions described in *Readiness along with the ability to produce the associated test results. *Readiness is a state of preparedness in which an Entity has completed internal testing of applicable policies, procedures, guidelines, laws, regulations, and contractual arrangements with expected results. Additionally, entities will need to test with a (%) of external trading partners, complete internal documentation, complete internal and external training, complete scheduled deployments, and complete software migration for each published standard prior to the regulatory implementation date.

**This is a catalyst for our initial discussions with our Industry Collaborative Partners for establishing a clearly refined definition of readiness based on Industry feedback and participation on December 11th & 13th, 2012 webinars.

HIMSS Definition:

HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations (Second Edition):

Compliance – Adherence to those policies, procedures, guidelines, laws, regulations, and contractual arrangements to which the business process is subject.

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Compliance Webinar FeedbackMichele Davidson – likes to use the word “Adherence”, she likes the definition of HIMSS, including policies, procedures, guidelines, etc…

Holly Louie – She likes Adherence also. She prefers NGS definition better than the HIMSS definition, theirs is too high level and non-specific. Too high level is not helpful.

Shawn Turner – instead of just Adherence, to add the word demonstrated Adherence, not just generic definition.

Elizabeth Reed – can we add a mention of “by the Implementation date set forth” at the end of the definition to HIMSS, she likes the HIMSS definition.

Julie McBee – stress on giving us a feedback on the definitions, would like to finalize that before we get into the Listening Session webinar the 1st week of January.

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Compliance FeedbackCompliance Feedback –looked at both Strengths & Opportunities

Addressed in Revised Definition: • Needs clarification on compliance with the standard transactions related

to upgrades.• Compliance means adhering, one can exchange and not be compliant. • Compliance equals a mandate, may not be an End-to-End delivery.• What are you complying with? • Uncomfortable with the term Compliance. It is generally a legal term in

complying with a regulation, not sure this is what we want to come up with here.

• Do we want an overall compliance term as health plans will be different? • We may need to be individualized for different types of questions. There

needs to be something more generic with regulations that come out. • Adherence may need to be more individualized for each End-to-End

Testing.

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Provider Readiness

A Provider is considered ready when they have completed internal testing and tested with a (%) of mission critical external trading partners including vendors, clearinghouses and payers. Additionally, they will have completed internal documentation, completed internal and external training, completed scheduled deployments and/or software migration for each published standard prior to the regulatory implementation date.

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Provider ReadinessDependent on the regulation, one or more of the following will apply:• All analytics, clinical, Electronic Healthcare Records

(EHR’s), Electronic Medical Records (EMR’s) and practice management system upgrades have been completed

• Confirmation of successful testing with submission payers• Confirmation of successful testing with vendors• Confirmation of successful testing with clearinghouses• Confirmation of successful production submission of claims (837) and receive

TA1, 824, 999, 277CA responses.• Confirmation of successful retrieval of the claims’ associated remittance (835)• Confirmation of successful acceptance of claim status inquiry submission (276)• Confirmation of successful return of claim status inquiry response (277)• Confirmation of successful receipt of claims eligibility status request(270)• Confirmation of successful return of claims eligibility status (271)• Confirmation of successful submission of services review inquiry (278)• Confirmation of successful receipt of services review response (278)

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Payer Readiness

A Payer is considered ready when they have completed all internal testing and tested with a (%) of mission critical external trading partners including vendors, clearinghouses and providers. Additionally, they will have completed internal documentation, completed internal and external training, completed scheduled deployments and/or software migration for each published standard prior to the regulatory implementation date.

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Payer ReadinessDependent on the regulation, one or more of the following will apply:• All system upgrades – front end translation and back end adjudication system –

have been loaded• Confirmation of successful testing with submitting providers• Confirmation of successful testing with submitting vendors• Confirmation of successful testing with clearinghouses• Confirmation of successful acceptance of production like claims (837) submission• Confirmation of successful return of the claims’ associated remittance (835)• Confirmation of successful acceptance of claim status inquiry submission (276)• Confirmation of successful return of claim status inquiry response (277)• Confirmation of successful receipt of claims eligibility status request (270)• Confirmation of successful return of claims eligibility status (271)• Confirmation of successful receipt of services review inquiry (278)• Confirmation of successful return of services review response (278)• Confirmation of successful receipt benefit enrollment (834)• Confirmation of successful return of benefit maintenance (834)

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Vendor ReadinessA Vendor is considered ready when they have completed internal testing and tested with a (%) of mission critical external trading partners including providers, clearinghouses/vendors and payers. Additionally, they will have completed internal documentation, completed internal and external training, completed new/change processes, completed scheduled deployments and/or software migration for each published standard prior to the regulatory implementation date.

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Vendor ReadinessDepending on the type of vendor your organization is and the regulation change, one or more of the following will apply:

• All system upgrades – front end translation and back end adjudication system – have been loaded

• Confirmation of successful testing with submitting providers• Confirmation of successful testing with submitting payers and/or vendors• Confirmation of successful testing with clearinghouses• Confirmation of successful acceptance of production claims submission (837) • Confirmation of successful return of the claims’ associated remittance (835)• Confirmation of successful acceptance of claim status inquiry submission (276)• Confirmation of successful return of claim status response (277)• Confirmation of successful acceptance of eligibility status (270)• Confirmation of successful return of eligibility status (271)• Confirmation of successful receipt of services review inquiry (278)• Confirmation of successful return of services review response (278)• Confirmation of successful receipt benefit enrollment (834)• Confirmation of successful return of benefit maintenance (834)

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Suggested Audience for Listening Session Definitions

Small providers will include small/medium sized organizations comprised of 99 or less physicians/staff, independent practices, dentists, durable medical suppliers, pharmacy, home health agencies/hospices and specialty practices.

Large providers will include organizations comprised of 100 or more physicians/staff, clinical labs, hospitals, critical access hospitals, nursing homes, rehab centers, skilled nursing facilities, ambulatory surgical centers, pharmacy and Federally Qualified Health Centers (FQHC).

Payers will include organizations comprised of Commercial, Medicaid, Medicare, Pharmacy Benefit Management (PBM) and Workers Compensation Government Contractors.

Vendors will include organizations comprised of Billing Services, Clearinghouses, Electronic Health Record/Electronic Medical Record Systems, Network Service Vendors, Practice Management Systems and Value Added Networks.

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Questions ?

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Closing Remarks• Hope to finalize the End-To-End Definition soon. If you have any feedback

on the definition, we need it no later than Friday, December 21st. • Next ICP webinar session is Thursday, January 3, 2013 from 10am to

11am EST• First Listening Sessions start on Thursday, January 3, 2013

– Participants can join via a CMS website link. Below is the link to register for those sessions. http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/index.html 

Thursday, January 03, 2013 1:00 pm - 2:00 pm Welcome, Intro, Definitions Small Provider Group 1Thursday, January 03, 2013 3:00 pm - 4:00 pm Welcome, Intro, Definitions Small Provider Group 2

       Tuesday, January 08, 2013 1:00 pm - 2:00 pm Welcome, Intro, Definitions Large Provider Group 1Tuesday, January 08, 2013 3:00 pm - 4:00 pm Welcome, Intro, Definitions Large Provider Group 2

       Thursday, January 10, 2013 1:00 pm - 2:00 pm Welcome, Intro, Definitions Vendor Group 1Thursday, January 10, 2013 3:00 pm - 4:00 pm Welcome, Intro, Definitions Vendor Group 2

       Tuesday, January 15, 2013 1:00 pm - 2:00 pm Welcome, Intro, Definitions Payer Group 1Tuesday, January 15, 2013 3:00 pm - 4:00 pm Welcome, Intro, Definitions Payer Group 2

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How to contact us• All questions may be sent to ngs.compliancetesting@wellpoint.com• Our expected level of service is to acknowledge all e-mails within 24

hours• Additional Contact Resources: