The Healthcare Imperative Lowering Costs and Improving Outcomes: Workshop Series Summary (2010) / Chapter Skim
Currently Skimming:
19 Administrative Simplification
19 Administrative Simplification
Pages 547-568
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 547... ...
. Information needed for provider credentialing is requested repeatedly by differing institutions, consuming time and resources that would otherwise be spent on patient care (Healthcare Administration Simplification Coalition, 2009b)
|
From page 548... ...
Discussing the specific challenges and potential opportunities demonstrated through two initiatives -- the Universal Provider Datasource and the Committee on Operating Rules for Information Exchange -- he emphasizes the critical need to ensure that these efforts continue to be aligned with federal health information technology policies, the necessity of multistakeholder support, and the barriers posed by the inevitable changes to current business practices. ADMINISTRATIVE SIMPLIFICATION AND PAYER HARMONIZATION Lewis G
|
From page 549... ...
. This paper describes a policy framework that would promote realization of these opportunities and outlines three areas for policy development: first, policies that promote "spread" of existing standards and capabilities; second, policies promoting electronic connectivity and transaction automation; and third, policies promoting multipayer capability development.
|
From page 550... ...
, a multistakeholder coalition (of which UnitedHealth Group was an early member) , has also advocated for full deployment of existing capabilities in this area (Healthcare Administration Simplification Coalition, 2009a)
|
From page 551... ...
Rather, the administrative simplification agenda can be advanced in these domains through emphasis on interoperability. For example, advanced notification requirements for coverage verification and/or medical management may vary across payers as a result of differences in covered populations or other factors, but the notification process itself could be "engineered" into PMIS and health plan clinical management platforms using current and emerging standards for clinical data exchange, rather than the manual processes used by both practices and payers at present.
|
From page 552... ...
-- which is made up of some 54,000 health information management professionals sharing the vision that quality information will create quality health -- joined with the American Academy of Family Physicians and the Medical Group Management Association in 2005 to form the Healthcare Administrative Simplification Coalition (HASC) to spotlight and advance opportunities to reduce administrative complexity, including but not limited to the complexity of payment systems.
|
From page 553... ...
Health Insurance Eligibility Process The Health Insurance Portability and Accountability Act of 1996 called for adoption and use of standardized electronic transactions associated with payment processes, including those for eligibility verification and notification of processed claims. A decade later, the standards have yet to be widely implemented, and these processes remain highly manual, contentious, and costly.
|
From page 554... ...
The vehicle for adoption should be the Health Information Technology Standards Panel and HIT Standards Committee, which are managed by the HHS Office of the National Coordinator. The standard should be reflected in conformance criteria used by HIT certifying bodies.
|
From page 555... ...
However, policy, governance, standards, technology, and education resources related to terminologies and classifications in the United States remain inadequate to support an interoperable health information system. In 2007, the American Health Information Management Association and the American Medical Informatics Association (AMIA)
|
From page 556... ...
healthcare spending is estimated to be $2.3 trillion per year (Center for Health Transformation, 2009) with about 25 percent attributed to administrative functions (Healthcare Administration Simplification Coalition, 2009b)
|
From page 557... ...
CAQH, a nonprofit healthcare industry alliance that is helping drive payer collaboration through national, multistakeholder efforts, has spearheaded two initiatives that are producing real results in the marketplace today: CORE and UPD. These initiatives have been widely adopted regionally and nationally, but have yet to realize their full potential for savings and interoperability in the healthcare industry.
|
From page 558... ...
. With industry-wide adoption of CORE Phase I, Phase II, and Phase III rules, the potential savings in the industry increases to $14 billion in 3 years (IBM Global Business Services, 2009)
|
From page 559... ...
Upon finalization in April 2006, the CORE Phase I rules required health plans responding to an eligibility request from a provider to include patient financial responsibility. This requirement was made well ahead of the HIPAA 5010 recommendation (see Table 19-1)
|
From page 560... ...
This effort embraces existing priorities and, because of the multiphase approach of CORE, enables updates to the CORE rules as new priorities are established. Align Efforts with Federal Health Information Technology Policies One of CORE's guiding principles is to complement federal efforts that contribute to a national solution.
|
From page 561... ...
The draft specifications that HITSP's "Tiger Teams" have issued to support meaningful use include previously recognized specifications, including the CORE rules. Gaining Multistakeholder Support Generating multistakeholder support, including those that affect policy outcomes, is essential to industry coordination and adoption of the CAQH initiatives.
|
From page 562... ...
The best example of leadership is actual implementation. Early adopters of both CORE and UPD were CAQH member health plans that showed support for administrative simplification and challenged other stakeholders to learn more about the changes being delivered by these streamlined administrative data exchange solutions.
|
From page 563... ...
Further, by providing recommendations for policy-directed approaches, the industry can consider setting very specific goals such as deadlines for adoption of existing solutions that have been shown to enhance marketplace operations. For example, the multistakeholder committee led by the State of Colorado recently issued recommendations to create policy requirements for the use of CORE rules, as well as deadlines for adopting the rules (State of Colorado Department of Regulatory Agencies, 2009)
|
From page 564... ...
THE HEALTHCARE IMPERATIVE TABLE 19-2 Policy-Related Approaches -- CAQH Examples Policy-Related Approach and Example Approach Tactics Benefit Phase in efforts CORE CORE Phase I and II rules related Entities becoming with existing builds on to eligibility data content (YTD CORE Phase I priorities existing deductibles, copays, service- and II certified are Example: CORE standards level financials) were developed assured CORE and 5010 (e.g., with the 5010 regulation in certification HIPAA, mind; although at the time, the testing aligns HTTP)
|
From page 565... ...
providers can use effort had a goal to collaborate administrative with CORE simplification • As HITECH unfolded, CAQH savings to further communicated regarding clinical efforts the need for providers to use HITECH dollars for administrative simplification efforts and clinical or administrative interoperability. CAQH also participated in HITSP Tiger Team efforts; CORE rules -- data content and connectivity -- are incorporated into draft meaningful-use technical requirements Gain Both Direct leadership involvement (e.g., Through multistakeholder CORE and UPD scope)
|
From page 566... ...
In September Without such 2009, a meeting will be held openness, a with key stakeholders to discuss lasting industry the opportunity as well as the change could not challenges be identified as a potential short term industry goal NOTE: BCBSA = Blue Cross and Blue Shield Association; CAQH = Council for Affordable Quality Healthcare; CEO = Chief Executive Officer; CMS = Centers for Medicare & Medicaid Services; CORE = Committee on Operative Rules for Information Exchange; HIE = health information exchange; HIMMS = Healthcare Information and Management Systems Society; HIPAA = Health Insurance Portability and Accountability Act; HIT = health information technology; HITECH = Health Information Technology for Economic and Clinical Health; HITSP = Healthcare Information Technology Standards Panel; HTTP = hypertext transfer protocol; PSV = primary source verification; UPD = Universal Provider Datasource; YTD = year-to-date. relevant stakeholders, including those entities in the state healthcare system that might not otherwise implement such proven approaches.
|
From page 567... ...
REFERENCES American Health Information Management Association.
|
From page 568... ...
2007. Health Identification Card Implementation Guide.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.