Eligibility and Claim Status Operating Rules Update

January 1, 2013 is rapidly approaching. This is the date by which HIPAA covered entities must implement the Department of Health and Human Services (HHS) Eligibility and Claim Status Operating Rules mandated under the Affordable Care Act. The Eligibility and Claim Status Operating Rules that HHS adopted by regulation in 2011 comprise the majority of those required for CAQH CORE’s voluntary Phase I and II certification. Emdeon became CORE Phase II certified in 2010, so Emdeon was in a strong position of readiness when HHS adopted these operating rules.

Emdeon has completed a thorough gap analysis in order to be ready by the compliance date. We are now concluding our remediation of any identified gaps.

Trading Partner Support
Emdeon dedicated to help our clients complete this important transition successfully. We have already initiated testing with health plans that are ready to test their operating rule conformance.

In addition, we are actively engaging health plans who utilize our Eligibility and Claim Status Hosted Data Services (HDS). These health plans must:
• Migrate to version 3 of HDS if they are not on that version already; migration efforts for clients on prior versions are actively underway.
• Provide the proper data content in their eligibility files. (There are no data content requirements for the Claim Status transaction)

HIPAA Simplified
Our HIPAA Simplified website, www.hipaasimplified.com, remains the primary resource for information regarding the operating rules and other HIPAA and ACA regulations.

On the Operating Rules pages, you will find the newly updated Operating Rules Playbook. This publication is full of valuable information, including our operating rule program management structure, roles and responsibilities, educational material on the rules themselves, and a new section specific to the upcoming ERA/EFT Operating Rules.

HIPAA Simplified is updated regularly, so check back often!

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Setting the Stage for Stage 2. Where We Are Now & What You Need to Know.

(Part 1 of 4)

Stage 2 of the Meaningful Use (MU) incentive program is being billed by some as “a giant leap in data exchange1.” The overriding goal of the program is to advance the secure exchange of information within our health system between all of a patient’s providers as well as the patients themselves —and that is a giant leap from where the system is currently, indeed. Of course, with every giant leap comes the chance for big missteps. That’s why the time is now to prepare for Stage 2 objectives and requirements.

The Biggest Challenges Revealed in Stage 1
According to a recent study published in the Journal of the American Informatics Association, the biggest challenge for hospitals participating in the MU program is Computerized Provider Order Entry (CPOE). Out of 2,475 hospitals in the study that intended to participate in MU, only 313 received incentive payments in 2011 during Stage 1. Half of those hospitals that didn’t meet Stage 1 requirements cited CPOE criteria as a top challenge. As we move to Stage 2, issues related to CPOE will remain as many hospitals are only beginning to adopt EHRs and build infrastructure to meet MU criteria.

For hospitals that were awarded incentive payments, giving patients access to their data in electronic form and generating numerator and denominator data for quality reporting directly from the Electronic Health Record (EHR) were reported to be the most significant challenges. The difficulty of providing electronic data to patients is very important to note and prepare for, as Stage 2 focuses on electronic patient communications and assigns heightened requirements to achieve program incentives.

According to Stage 2 Meaningful Use requirements final rule by Centers for Medicare & Medicaid Services (CMS), providers must achieve meaningful use under Stage 1 criteria before advancing to Stage 2. CMS has announced certain changes to Stage 1 CPOE; details may be found by clicking here.

What is different in Stage 2 as compared to Stage 1
In Stage 2, there are more core objectives for Eligible Professionals, Eligible Hospitals and Critical Access Hospitals (CAHs). Many Stage 1 core objectives have been merged or folded into other requirements. Eligible Professionals have 20 total objectives, including 17 core objectives and 3 (of 6) menu objectives. For Eligible Hospitals and CAHs, there are 19 total objectives comprised of 16 core objectives and 3 (of 6) menu objectives.

Here’s a quick look at core objectives that Eligible Professionals must report on, as well as the six menu objectives they may choose from.

Core Objectives
1. Computerized Provider Order Entry (CPOE)
a. Use CPOE for more than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology.

2. ePrescribing (eRx)
a. Use eRx for more than 50 percent.

3. Demographics
a. Record demographics for more than 80 percent.

4. Vital Signs
a. Record vital signs for more than 80 percent.

5. Smoking Status
a. Record smoking status for more than 80 percent.

6. Interventions
a. Implement 5 clinical decision support interventions + drug/drug and drug/allergy.

7. Labs
a. Incorporate lab results for more than 55 percent.

8. Patient List
a. Generate patient list by specific condition.

9. Preventive Reminders
a. Use Electronic Health Record (EHR) to identify and provide reminders for preventive/follow-up care for more than 10 percent of patients with two or more office visits in the last 2 years.

10. Patient Access
a. Provide online access to health information for more than 50 percent with more than five percent actually accessing.

11. Visit Summaries
a. Provide office visit summaries for more than 50 percent of office visits.

12. Education Resources
a. Use EHR to identify and provide education resources more than 10 percent.

13. Secure Messages
a. More than five percent of patients send secure messages to their Eligible Professionals (EP).

14. Prescription Reconciliation
a. Medication reconciliation at more than 50 percent of transitions of care.

15. Summary of Care
a. Provide summary of care document for more than 50 percent of transitions of care and referrals with 10 percent sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR.

16. Immunizations
a. Successful ongoing transmission of immunization data.

17. Security Analysis
a. Conduct or review security analysis and incorporate in risk management process.

Menu Objectives (select 3 of 6)
1. Imaging Results
a. More than 10 percent of imaging results are accessible through Certified EHR Technology.

2. Family History
a. Record family health history for more than 20 percent.

3. Syndromic Surveillance
a. Maintain successful ongoing transmission of syndromic surveillance data.

4. Cancer
a. Maintain successful ongoing transmission of cancer case information.

5. Specialized Registry
a. Maintain successful ongoing transmission of data to a specialized registry.

6. Progress Notes
a. Enter an electronic progress note for more than 30 percent of unique patients.

For even more details, view the CMS' Stage 2 Tipsheet by clicking here.

The Five Percent+ Factor: Focusing on Patient Engagement in Stage 2
Patient engagement—reciprocal communication between patients and providers—is a significant focus that everyone must be prepared for in Stage 2. To be eligible for incentives, providers must achieve the following patient action.

- More than five percent of patients must send secure messages to their eligible providers.

- More than five percent of patients must access their health information online.

For many Eligible Professionals, it may be quite daunting to evoke such engagement from over five percent of patients, as so many factors affect the transition to electronic information sharing. Technological, cultural and organizational barriers exist across communities nationwide. For example, CMS is introducing exclusions based on broadband availability by county, as some areas simply don’t have the Internet access necessary for five percent to take action even if they are willing to do so.

Timing for Stage 2
The final rule has been out since August 2012 and though there is an urgency for Stage 2, there is not the mad rush that surrounded Stage 1. Stage 2 test scripts have not yet been released in full from certification bodies and at this writing only three are out. Test scripts from vendors will be released in phases, with the launch of testing anticipated for December 2012 or January 2013.

For a complete look at Stage 2, visit CMS’ website by clicking here. There you’ll find tables, tipsheets and updates directly from CMS. In addition, continue to follow Emdeon for targeted announcements and interpretation of latest updates as it relates to your business. Emdeon will continuously guide you through Stage 2 so that you are prepared to offer expertise to your customers every step of the way.

Stay tuned for our next article in series, Planning for Certification and Strategies in Testing.

1. http://www.healthit.gov/buzz-blog/meaningful-use/meaningful-use-stage-2/
2. http://www.fierceemr.com/story/cpoe-huge-stumbling-block-meaningful-use/2012-10-02?utm_source=rss&utm_medium=rss
3. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforEP.pdf

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From Politics to Practice

What we learned at MGMA. By Gene Boerger, V.P. of Professional Product Management at Emdeon

On the surface, the agenda for the 2012 MGMA Annual Conference (San Antonio, Oct. 21-24) contained few surprises: Education sessions focusing on ICD-10, ARRA, administrative simplification, Meaningful Use and ACOs.

What was unexpected, however, was the energy invested by the more than 3,000 people in attendance in transforming the politics of these issues into actionable strategies. Attendees and vendors alike were eager to convert the principles of reform into practice. We strategized with numerous provider groups to share how our expertise in care management, clinical information exchange and revenue optimization can transform industry concepts into real, workable scenarios. From our viewpoint, attendee interests fell into four major categories:

1. Solution engineering. We spoke with leaders at medical groups who recognize they need new solutions and new processes to achieve their objectives. Educational sessions, hallway discussions and vendor meetings centered on best practices and lessons learned. Attendees seemed to have a grasp of what they need and were tuned in to asking questions about how to get from here to there. Vendors were on the same wavelength. Countless meetings were held outside of exhibitor hours, where discussions about how to collaborate and integrate technologies to provide a more comprehensive whole abounded.

2. Care Management. Discussions about new care and reimbursement models, such as accountable care organizations (ACOs) and other pay-for-performance arrangements, have progressed from the abstract (“these approaches will help us control costs and improve care”) to the concrete (“who needs to be involved and what precisely will they be doing?”). Attendees explored the structures needed for greater focus on care management, for example, and heightened levels of coordination among providers. These conversations also dug deep into alignments—particularly as they affect community physicians—with hospitals.

3. Data drivers. As quality measures become engrained in emerging reimbursement models, medical groups increasingly need advanced data collection, analysis and reporting capabilities to successfully participate in a pay-for-performance or ACO-type model. Attendees recognized that their EHRs must work harder and that health information exchange (lowercase) is crucial. With a traditional focus only on delivering care—and not necessarily measuring it—providers are now taking a crash course in what tools are available, how they need to be configured and what they can do with the data that’s produced.

4. Business success. Billing professional fees. Proper coding and revenue optimization. Preparing for (and passing) audits. Contract negotiations. Use of outsourcing and technology. Patient collections. All activities that impact the bottom line—with a plethora of “practice proven and time tested” solutions for the challenges many medical groups face—were widely discussed. To arm our providers with information to improve business success, Emdeon held several educational presentations aimed at increasing revenue while effectively managing operations. Attendees agreed these considerations were more important in 2012 than ever before because of the incentive and payment reduction programs payers have adopted.

Emdeon made its presence felt throughout the conference, joining more than 350 other companies on the trade show floor with a dynamic booth that hosted long-time customers and new prospects. Emdeon was joined by the American Academy of Family Physicians for a speaking engagement in the MGMA Innovation Center on Care Management, and Emdeon representatives also delivered a number of in-booth educational sessions on topics ranging from how to remove barriers to submitting clean electronic orders to revving up cash flow by accepting online payments.

Overall, the mood of MGMA seemed to be of anticipation, partly fueled by the impending presidential election. Many attendees seemed to be of the opinion that the trends spurred by healthcare reform legislation would continue—and that they are embracing and preparing for new directions.

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Preparing Your Practice for the Future: A Look Ahead to 2013

You don’t need to be told that the speed of change in healthcare continues to accelerate. From healthcare reform to Medicare reimbursements to technology deployments, you must be ready to move with a quick and effective response to any and all challenges that come your way. The reward? Clinical and financial viability, now and well into the future. Here’s a peek at some market and regulatory forces that you will likely confront in 2013:

The Way is Paved for PPACA
The Patient Protection and Affordable Care Act (PPACA) was passed, the U.S. Supreme Court ruled to uphold the law and the potential Republican reversal to healthcare reform legislation came up short in a bid for the White House. If they haven’t already, physicians should gear up big for changes. PPACA will increase access to care for the millions of Americans who have previously been unable to obtain medical insurance; the expansion of Medicaid alone is estimated to result in up to 15 million new enrollees during 2014i. It’s important for practices to routinely verify information for its Medicaid patients, and with the impending, significant growth in this population, it will be increasingly vital to confirm that patient information is accurate. Whether coverage is obtained through private companies or government programs such as Medicaid, small practices better be ready.

An Adjustment in Income?
As it stands now, physicians may face an adjustment of 27 percent or more in Medicare reimbursements in 2013ii. Congress did implement a temporary patch last year to keep 2012 rates stable, but has yet to apply a permanent fix and replace the current sustainable growth rate (SGR) reimbursement system with a more stable and predictable payment mechanism.

Increasing Quality Reporting Demands
With the release of the new Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) announced that providers who do not successfully participate in the Physician Quality Reporting System (PQRS) during the 2013 program year will be subject to a one and a half percent payment adjustment in 2015, and a two percent adjustment in subsequent yearsiii. On the flip side, eligible professionals (EPs) who satisfactorily report quality measure data will qualify for a half percent bonus in 2013. To help you avoid reimbursement adjustments, CMS has proposed two additional reporting options. The first is to satisfactorily report at least one PQRS measure or measures group via a claims, registry or EHR-based reporting mechanism. The second option allows you to utilize administrative claims-based reporting for related measures. Be aware, however, that if you elect one of these reporting options, you will not qualify for an incentive payment.

ePrescribing Actions
CMS continues to aggressively push ePrescribing. The goal of CMS’ ePrescribing Program is ultimately to increase patient safety through the reduction of medication errors and adverse drug events. Besides the improvement in efficiency that physicians gain through this program, there is also a financial benefit for being an early adopter. In 2013, the last year of the Medicare ePrescribing incentive system, you can receive a half percent financial bonus for conducting a portion of prescription orders electronically. Considering that you will be subject to a one and a half percent payment adjustment for noncompliance, those easy to use ePrescribing platforms are beginning to look pretty attractive.

EHR Deployment Progress
Better known as “Meaningful Use,” the EHR Incentive Program continues in 2013, with many physicians preparing for their 90-day reporting period that will enable them to prove they are meaningful users of the technology under Stage 1 requirements. While the reporting period for Stage 2 compliance has been pushed back until October 2014, you should take advantage of the additional time and prepare for rising Stage 2 qualification thresholds, including demonstrating that at least 50 percent of your prescriptions are completed through ePrescribing, up from the 40 percent required in Stage 1.

Requirement to Accept Electronic Payments
Expect 2013 to be a watershed year for participation in emerging Medicare payment initiatives that are driving the formation of accountable care organizations (ACOs), shared savings programs, bundled payment pilot projects and value-based payment modifiers. And if Meaningful Use is not enough of an incentive for you to ramp up your EHR deployment efforts, these new initiatives surely demand that you look closely at enabling solutions to access and utilize the data you need to improve care and reduce costs. Additionally, January 1, 2014, is the deadline by which all payments under Medicare must be conducted via electronic funds transfer (EFT). And, while providers will not be required to accept electronic payments from commercial health plans, all payers will be required to have the ability to facilitate these transactions.

To help small practices navigate healthcare reform, Emdeon Office Suite provides many tools to increase accuracy and efficiency while reducing interruptions in the revenue cycle. Online pre-registration, real-time eligibility and benefits verification, and claims and payment management, including the facilitation of electronic funds transfer, are some of the key services this technology offers. Emdeon also provides a convenient and cost-effective way for providers and pharmacies to exchange ePrescribing transactions through its Emdeon Clinical Exchange EHR Lite, an ONC-Certified EHRiv.


iiMedicare Physician Fee Schedule; http://www.beckersasc.com/media/CMSFinalRule2013MPFS.pdf; Page 15

iiiMedicare Physician Fee Schedule; http://www.beckersasc.com/media/CMSFinalRule2013MPFS.pdf; Page 1195

ivThis Complete EHR is 2011/2012 compliant and has been certified by an ONC-ATCB in accordance with the applicable certification criteria adopted by the Secretary of Health and Human Services. This certification does not represent an endorsement by the U.S. Department of Health and Human Services or guarantee the receipt of incentive payments. Emdeon Inc, 01/19/12, Emdeon Clinician 7.6, 0119201230701, NQF0064/PQRI128, NQF0041/PQRI110, NQF0024, NQF0028, NQF0038, NQF0059/PQRI1, NQF0064/PQRI2, NQF0061/PQRI3.

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Make it easy and convenient for patients to pay their healthcare bills

Part 2 of a 4-part series designed to offer small practice providers tips on improving their administrative and clinical operations.

Few people enjoy paying their bills—it’s just no fun to watch hard-earned money end up in someone else’s bank account.

No matter how well you take care of your patients, they’re just as hesitant to open their wallets. It stands to reason, then, that you need to make the process as painless and convenient as possible. Online portals can be the perfect solution. Consumers have grown accustomed to managing their affairs via the Web and expect this level of service in all areas of their lives—including healthcare.

The healthcare industry, however, has yet to make patient-facing, Web-based payment tools a universal option. Small practices must pay especially close attention to cash flow, so encouraging timely and accurate payment by bringing the process online is crucial.

Optimizing the online advantage begins well before a patient encounter. Web-based registrations tools, for example, allow patients to sign in prior to their arrival and the practice to capture important information. Patients are free to register at their convenience days before their appointment, instead of arriving at the doctor’s office early just to fill out paper forms. The practice benefits, as well, because it has access to legible, accurate information to streamline the claims and billing process.

Then, after the visit, patients can conveniently—and promptly—settle their accounts via the secure portal. Not only is cash flow improved, practices can reduce administrative expenses by removing some of the burden of collections from their office staff.

When introducing online capabilities to their patients, practices must promote the portal to ensure it’s used. A “multi-touch” campaign offers the best approach. Posters in the lobby, hallways and exam rooms can announce the new payment option. Registration and check-out staff should mention the availability of the portal and maybe even hand out postcards, refrigerator magnets or other tchotchkes. An additional reminder can be printed on billing statements still being mailed.

It’s important to promote the portal on the practice’s website, as well, preferably on the home page. This serves as a constant reminder for current patients and might attract individuals looking for a new doctor.

Other ways to encourage use of an online payment option include:
• ensuring the portal features easy-to-use instructions and simple navigation;
• making sure the portal displays contact information prominently in case patients need help; and
• assuring patients that the portal is secure and all private information is protected.

One final note: Keep in mind that patients of all ages might use online tools. They should include the full-bodied features the younger generation has come to expect, but be simple enough so those less technology-savvy can navigate the process easily as well.

Emdeon’s Patient Pay Online Express is a patient-facing application designed to help small providers enjoy success with Web-based portals. As an example, Concord Integrated Health, a chiropractic medicine practice located in Concord, Massachusetts, was increasingly burdened by the conventional process for generating and sending patient statements. At the time, it was generating between 250 and 300 statements per month. Along with implementing an automated billing service, Concord Integrated Health began using the Emdeon Patient Pay Online Express solution to answer patient demand for Web-based payments. With individuals able to view billing amounts and pay their accounts online, at anytime, the amount and promptness of payments greatly increased. Dr. Jeff Robichaud, Chief of Concord Integrated Heath’s Chiropractic Medicine Department, summarizes that “by allowing patients to pay their bills online, we are seen as a practice that is providing the most up-to-date solution for them. Patient Pay Online drives patients to our website as well, so we can have a presence with them beyond the in-person office visit.”i

With a secure system accessible to patients 24 hours a day, seven days a week, the Emdeon Patient Pay Online Express solution improves collections and data accuracy, while offering patients greater convenience. Emdeon helps speed up the billing and payment cycle, improving finances, reducing staff time invested in administrative tasks and giving you more time to spend with patients.

Nothing will remove the sting of paying a medical bill completely, of course. But by reducing the hassle and offering an option that fits into the patient’s lifestyle, practices eliminate some resistance—resulting in timely payments and improved cash flow.

For more information on how Concord Integrated Health has experienced increased payments and patient satisfaction through the use of Emdeon’s Patient Pay Online Express, please click here.

(Note: Stay tuned for an in-depth look at other ways to improve customer relations to enhance patient billing and collections in the next issue of this newsletter.)

i “Emdeon Patient Billing & Payment Solutions: Efficient technology for reducing costs and accelerating patient payments,” Emdeon Business Services LLC, July 2011

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New Payer Transactions Added Recently

New payers on board with Emdeon. Take a look at the new list
We have recently added the following payers:

• Health Alliance Medical Plans (HAMP), ERA
• Mediture, Claims
• Medico Insurance Company, Claims
• Wellcare, Claims
• North American Benefits Network (Cleveland, OH), Claims
• Trellis Health Partners, Claims
• CNIC Health Solutions Inc., Claims
• AmeriChoice of New Jersey, Inc. (Medicaid NJ), Claims
• CareOregon, Inc., Claims
• Blue Cross of Arkansas, ERA
• MED3000 CMS TITLE 19 REFORM, Claims
• Hawaii Medical Service Association (HMSA), ERA
• Merchants Benefit Administration, Claims
• Cook Children STAR Plan, Claims

For a complete list of the payers in our network, visit our website at www.emdeon.com/payerlists/

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See the full list >>