Innovation Messaging Group
The Innovation Message group mission is to drive down healthcare costs by reducing the effort needed to implement complex message flows not yet addressed by any standards organization (for example, complex prior authorizations, claim attachments, DME orders, etc.) This group will oversee the development and adaptation of standardized, structured formats, data transport, and digital signature that support high value health care, improved quality, and enhanced efficiency.
Provider Survey Update (Rebecca Elhassid)
- Most providers report prior auth to be highly painful and time consuming
- Providers spend 16.4 hours/week on Prior Auths.
- 80% of chronic cases or ongoing meds require re-authorization
CAQH Index Report:
- Work on Prior Auths is manual, time consuming, and expensive.
- There is a projected 60 million in savings for plans.
- Very few providers/plans are engaged with the 278 transaction set.
The primary takeaway from these surveys is that there need to be better industry standards to help providers and payers. Having an industry wide standard would help drive the taskforce mission and assist both providers and payers with Prior Auths.
It is possible to fully automate (hands off) this process and there are already pilots out there that are reducing common problems often caused by human error and reducing processing time by up to 75%. A main concern for everyone is transparency.
Meta Data Team Update (Dave Cheli)
Dave, Boris Shur (SES), and Tony Laurie (Noridian) have been developing meta data sets. They have been simulating test scenarios based on the transactions sent from prescribers to specialty providers. This scenario is similar to other scenarios so is a good starting point to work from.
The testing has led to a need to define initial targeted transactions. This is still in the early phases and any who would like to join the technical testing teams are welcome.
Collecting and Distributing: Payer Requirements and Prior Auths (Michael Dale)
Dan discussed how one of the primary points to come out of the first taskforce meeting was that many providers didn’t know they needed additional information for Prior Auths. ACA required payers’ disclosure of this information on their respective websites.
Michael Dale discussed how TransUnion has been accumulating the required information for prior auths and disseminating the data to providers. CPT codes are used to give guidance based on the procedure being looked up.
Credentialing is not currently taking place as the information being provided is already publicly available. The end goal is to make it easier to both educate and automate the Prior Auth process.
From this conversation, a need to build in state requirements arose. The VA and community care were also brought up as some of the biggest users that will need authorizations and should be kept in mind as the taskforce develops strategies. Mary Kay McDaniel suggests that the taskforce needs a joint work group with HL7, especially as the goal of the taskforce is to have something across the board of both X12 and HL7.
White Paper Discussion (Kevin Yang)
Kevin Yang of Optimity Advisors was asked to join and discuss the objectives, target audience, and outline for a taskforce white paper. The title of the paper needs to reflect the key premise and solution to what the taskforce is trying to accomplish and will continue to be kept in mind as the group meets.
The group consensus on the white paper is that it needs to clearly define the goals of the taskforce and how it fits into the industry conversation. Defined use cases based on the different target audiences (providers, payers, vendors, advocacy groups, etc.) need to be considered for the success of the taskforce mission. For providers, use-case based materials are likely to be more valuable than a white paper.
Exploring the First Pilots (Lisa Savicki Basham)
Humana is currently sending 278 transactions to Athena Health. This flow works very well when additional information is not needed. As part of a pilot, Lisa displayed a diagram that walks through a flow for sending transactions between the two groups and details how the request for additional information could be handled.
The taskforce discussed the need to address administrative systems which do not communicate well with EMRs. The end goal must be a simple solution without too many steps. Since Athena is a larger EHR, smaller systems need to be considered in discussions.
Main discussion points that were brought up throughout the meeting were:
Action items are to develop:
- Specific Use Cases
- Simplicity of Process
- Diagrams for Easy Adoption
Taskforce members will talking to different larger EMR vendors (such as Epic) as well as payers to work on ideas for auto evaluating information and what steps are needed.
Follow up questions from the Humana 278 presentation:
- What percentage of 278 transactions are referrals vs Prior Auths?
- How many of the Prior Auths actually require additional information?
- Dan Kazzaz (SES)
- Rebecca Elhassid (SES)
- Isabella Beaton (SES)
- Kevin Yang (Optimity)
- Michael Dale (TransUnion)
- Tab Harris (BCBS Florida)
- Elizabeth Templeton (BCBS Florida)
- Rachel Foerster (RFA-EDI)
- Tammy Banks (Optum)
- Jeanie Smith (BCBS Florida)
- Sandra Stuart (Kaiser Permanente)
- Lisa Savicki Basham (Humana)
- Dave Cheli (Focus Script)
- Darlene Sutara (UPMC)
- Mary Kay McDaniel (Cognosante)
- Durwin Day (Health Care Service Corp)
- Daniel Wei (Athena Health)
- Michele Barry(Availity)
- Tony Laurie (Noridian)
- Teresa Autery (TIBCO)
- Sherry Wilson (Jopari)
- Walter Suarez (Kaiser Permanente)
- Leslie Elsarboukh (Surescripts)
- Jim Seidler (Noridian)
- Dave Delano (MAeHC)
- Nathan Apter (Medforce)
- Jonathan Wiik (TransUnion)
- John Bartley (SES)
- Luke Ellis (Optimity)
- Nathan Macomber (Athena Health)
- Shawn Wiese (MEDHOST)
- Catherine Graeff (Sonora Advisors)
- Jeff Salmon (SES)
- Tony Laurie, Noridian