The Healthcare Payments Hub: A New Paradigm for Funds and Data Transfers in Healthcare
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The Healthcare Payments Hub: A New Paradigm for Funds and Data Transfers in Healthcare

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HIMSS World Bank Task Force January 2013

HIMSS World Bank Task Force January 2013

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The Healthcare Payments Hub: A New Paradigm for Funds and Data Transfers in Healthcare The Healthcare Payments Hub: A New Paradigm for Funds and Data Transfers in Healthcare Document Transcript

  • The Healthcare Payments Hub: A NewParadigm for Funds and Data Transfers inHealthcareHIMSS World Bank Task ForceJanuary 20131 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • CONTENTSEXECUTIVE SUMMARY ............................................................................................ 4 OPPORTUNITY ............................................................................................................... 4 BACKGROUND ............................................................................................................... 4 CURRENT SITUATION .................................................................................................. 5 RECOMMENDATION ..................................................................................................... 5OPPORTUNITY ............................................................................................................ 6 MARKET DRIVERS ........................................................................................................ 6 KEY SOLUTION PRINCIPLES ....................................................................................... 7 HEALTHCARE PAYMENTS HUB – CONCEPT............................................................ 8BACKGROUND ............................................................................................................. 9 COMPLEX CONNECTIVITY ......................................................................................... 10CURRENT SITUATION............................................................................................ 12 OVERVIEW OF CURRENT CLAIMS PROCESSES ...................................................... 12 ROLE OF NCVHS IN HEALTHCARE PAYMENTS.................................................... 14 OPERATING RULES..................................................................................................... 14 STRAIGHT THROUGH PROCESSING ......................................................................... 15 MARKET OPPORTUNITY............................................................................................ 15 PARADIGM SHIFT ....................................................................................................... 172 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • RECOMMENDATION ............................................................................................... 19 A DEMONSTRATION DESIGN .................................................................................... 19 STP EXAMPLE............................................................................................................. 20 PILOT PROGRAM ........................................................................................................ 20 Vision Statement for a Pilot Program ................................................................................................... 20 Examples of Functions within the Healthcare Payments Hub ................................................... 21 Use Case Summary ....................................................................................................................................... 22 Approach .......................................................................................................................................................... 23 Milestones ........................................................................................................................................................ 25CONCLUSION .............................................................................................................. 26APPENDIX .................................................................................................................... 28 GLOSSARY .................................................................................................................... 28 HIMSS WORLD BANK TASK FORCE WHITE PAPER CONTRIBUTORS ............. 31 ENDNOTES ................................................................................................................... 323 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • EXECUTIVE SUMMARY OPPORTUNITYThis HIMSS White Paper describes an opportunity for providers, payers, banks, financialnetworks, and healthcare clearinghouses to establish an interoperable healthcarepayments “hub” that enables Straight Through Processing (STP) of healthcare financialtransactions (or, as is the emerging parlance today, “medical banking” transactions). Thishub is intended to demonstrate bottom line financial advantage to each of thecounterparties and/or stakeholders involved by creating a prototype for Electronic FundTransfers (EFT)/Electronic Remittance Advice (ERA) management using the STP model.We believe that this new hub can be demonstrated in a limited fashion at the HIMSSInteroperability ShowcaseTM and could spawn innovations that optimize the use ofhealthcare financial data that is flowing through payment channels. We encourage thehealthcare community to embark upon this path in order to optimize business value that iswaiting to be unlocked within our healthcare payment system.Understanding the magnitude of this value has been a key focus of HIMSS Medical BankingProject, which in 2001 estimated that healthcare providers could save $35 billion annuallyby extracting business value from an STP model.1 In 2009, US Healthcare released a reportestimating that $160 billion can be saved over the next 10 years by integrating paymentand remittance transactions.2 Others suggest $11 billion in annual savings can be realized,3while NACHA-The Electronic Payments Association, pegs potential savings at up to $4.5billion over ten years.4 However calculated, this value remains largely untapped withoutnew technology that can evolve the current paradigm to a future state.Toward this end, the paper concludes with a recommendation to form a pilot program.While we acknowledge that federal operating rules coupled with new technologies cansupport re-association of data and dollars in the healthcare payment system that couldinevitably achieve the same goal, the pilot articulated in this paper envisions using an STPmodel. This approach would enable existing stakeholders to enhance value and improveoperational efficiencies. BACKGROUNDSince 2001, HIMSS Medical Banking Project has focused on increasing technological linksbetween financial and healthcare systems. They have sought to work with the financial andhealthcare stakeholders to envision new approaches for streamlining payments and4 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • settlements while assuring a secure platform that is compliant with all regulatoryrequirements. This streamlining includes the concept of “straight-through processing” (orSTP) that financial organizations employ to optimize transactions in such a manner thatmanual intervention is avoided or completely eliminated. In fact, many now believe there isa broad and compelling opportunity to use banking platforms, already scaled with strongannual investments, to expand healthcare financial technologies that bring new value ashealthcare payments transform from paper to electronic transactions.For this reason, and many others, we believe there is a broad and compelling opportunityto use banking platforms, already scaled with strong annual investments, to expandhealthcare financial technologies that bring new value as healthcare payments transformfrom paper to electronic transactions. CURRENT SITUATIONIn healthcare today, health plans issue payments via Electronic Fund Transfers (EFTs) andcorresponding remittance advice transactions or Electronic Remittance Advices (ERAs).These transactions are distinct and may flow through two completely different paths. EFTsare processed through financial networks, while ERAs are transferred through healthcarenetworks. This information is received by the provider and their bank at different times,and they are not inherently easy to match.In July 2012, the U.S. Department of Health and Human Services (HHS) published OperatingRules for healthcare payments that include requirements for re-association, timing, anddelivery.5 NACHA-The Electronic Payments Association, in its HHS-appointed role as anoperating rules author for EFTs under the Patient Protection and Affordable Care Act(PPACA),6 has developed new operating rules for healthcare payments, that, together withoperating rules for ERAs created by CAQH-CORE,7 (another operating rules author underPPACA), will enable these benefits for the healthcare stakeholders. Yet, while theserequirements can certainly serve as a catalyst for enhancing healthcare payment needs, theplethora of healthcare transaction delivery mechanisms may continue to be a challenge asthe healthcare payments “infrastructure” adopts new federal operating rules. RECOMMENDATIONThe objective of this white paper is to identify some of the key problem areas that existwith current payment processing schemes and to create a framework for industry action inthe form of a "healthcare payments hub” pilot design. The “hub,” essentially a platform thatenables the transfer of electronic funds with its associated remittance data, could addressmany of the stakeholder challenges in payment processing and enable a streamlinedapproach for cash posting, reconciliation, workflow automation and ultimately, businessintelligence.5 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • The objectives of the hub, specific goals, operating requirements, and the high levelsolution architecture and design are all part of the discussion that is outlined in thisdocument. Implementing a pilot is not within scope; however, it is anticipated that anyinterest generated by this paper can influence the creation of such a program among thestakeholders. OPPORTUNITYThis paper describes an opportunity to establish an interoperable “Healthcare PaymentsHub” that enables Straight Through Processing (STP) of medical banking transactions. STPis used by companies in the financial world to optimize the speed at which transactions areprocessed. This is performed by allowing information that has been electronically enteredto be transferred from one party to another in the settlement process without having tomanually re-enter the same pieces of information repeatedly over the entire sequence ofevents.8 Moreover, electronic access to this data helps to drive and transform redundant,manual-intensive workflow routines and fuel business intelligence for the enterpriseand/or healthcare practice.Administrative efficiency is driving the need for a new healthcare financial network.Because this network is central to all stakeholders, each with varying technology andbusiness objectives, there is a need to frame the scope of what is being proposed and why itis needed. Vendors and suppliers will then be able to add value based on their strategicobjectives.This paper includes a recommendation to form a pilot program. This pilot program wouldinvolve existing, not new, stakeholders. The pilot would seek to prove out operational costsavings and improved efficiencies by the stakeholders, including but not limited to,healthcare providers, banks who deliver payment services, and health plans who maybenefit indirectly via reduced customer service calls and other potential benefits. MARKET DRIVERSKey market drivers necessitating such a solution include:  The emergence of electronic payment systems that are replacing paper payment processing in healthcare  The annual volume of healthcare payments in the U.S. is approximately $2.8 trillion; gaining the attention and arousing competition among financial institutions to attract this market6 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  •  ARRA (American Recovery and Reinvestment Act of 2009), including HITECH (Healthcare Information Technology for Economic and Clinical Health) federal funding for health IT, is a high priority issue with funding of approximately $36 billion,9 fueling both clinical and electronic business transformation in healthcare. Securing ARRA funding requires facilities and providers to demonstrate Meaningful Use on a yearly basis, driving change through financial incentives and later, driving change through penalties for non-compliance; thus, there is a government-based market driver in place for implementing electronic health record technology in the U.S..  Robust exchange of clinical and payment data affects an entire spectrum of business-to-business stakeholders and ultimately, the consumer of healthcare services as well. These stakeholders include: o Providers o Insurance/Claims o Employers o Banks/Financial Institutions o Federal Entities (HHS, Federal Reserve System, Centers for Disease Control, etc.,) o State Level Administration & Regulation o Consumers o Value added Vendors (HIEs, /RHIOs, Health Vaults, Software Vendors, etc.) KEY SOLUTION PRINCIPLESIn order to be successful, the “hub” should adhere to several key principles:  Foster organic adoption based on a compelling ROI  Be supported at the federal, state, and commercial banking levels  Protect data via a security framework that also lowers liability barriers and enables adoption  Increase payload capacity and/or facilitate reconciliation of payments data  Allow for phased implementation(s)  Flexibly adapt to multiple payment message standards  Allow counterparties in the network to create bi-lateral agreements for service differentiation  Create financial incentives for participants (highest value/lowest cost)  Avoid single large capital concentration or bottleneck projects  Guarantee delivery and provide non-repudiation  Create common addressing, billing and delivery standards without prescribing or reading the internal content between the counterparties7 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  •  Meet regulatory, audit, and compliance hurdles for HIPAA, SOX (Sarbanes- Oxley Act), FACTA (Fair and Accurate Credit Transactions Act), etc.  Have specific and measurable metrics of success HEALTHCARE PAYMENTS HUB – CONCEPTBanks with an interest in forwarding or moving files containing protected healthinformation (PHI), as defined primarily under HIPAA, need a payments hub that complieswith relevant banking and healthcare regulations. These regulations ultimately seek to,among other things, mitigate exposure to and protect individually identifiable healthinformation.Using open standard technologies that support mandated security protocols, such asVirtual Private Networks (VPN), Secure File Transfer Protocol (SFTP) and others that areimplemented within the SWIFT network (Society for Worldwide Interbank FinancialTelecommunication), could gain appeal within the banking community. Features of SWIFTthat are responsive to regulatory and market needs include:  Many banks across the globe already rely and use SWIFT for financial processing  SWIFT is flexible and readily adaptable to the needs of the healthcare payment marketplace in that it publishes procedures and transactions that permit users to prescribe the container, with a guarantee of its secure delivery, without dictating the payload  Users can track settlement of transactions via a website  Connectivity solutions for end users are readily available  SWIFT has reportedly never been compromised  SWIFT connects to many of the settlement systems and exchanges, including: o SEPA – Single European Payments Area o NACHA – The Electronic Payments Association – manages the ACH or “automated clearinghouse network” as well as the International ACH. NACHA oversees rules development for the world’s largest network of clearing and settlement operators: 60% settled by Federal Reserve banks, 40% settled by the Electronic Payments Network (EPN) o FedWire – U.S. Federal Reserve managed wire payment system (RTGS10) o Continuous Linked Settlement bank (CLS) – FX Netting Engine o Clearing House (CHIPS) Netting (non-RTGS) system for clearing domestic and international transactions – 47 members, privately held o CHAPS – UK version of FedWire (RTGS) o CHATS – Hong Kong version of FedWire (RTGS)8 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • In cases where SWIFT is used, the “container size” (size of the transaction) can be up to 250megabytes. In other cases, the CCD+ (Cash Concentration and Disbursement plusremittance re-association number) reconciliation process can be used if preferred whilestill delivering workflow status and tracking necessary for all counterparties. BACKGROUNDToday’s lack of a centrally accepted payment exchange and persistent use of non-standardmessage content (multiple versions of the X12 835) have worked against automation ofhealthcare administrative processes, resulting in duplicate procedures, higher costs, longercollection periods, unclear coverage application, and lack of accessible information that canbe used to support business intelligence. Healthcare stakeholders clearly need to haveconsistent and interoperable information exchange among all the components that supportthe financial value chain. This value chain includes commercial banks, healthcare andbanking IT vendors and service providers, healthcare providers, and health plans thatinclude self-funded employer groups.While the need is well defined, there are opposing forces at work between banks andsettlement institutions and healthcare payment and provider groups. On the one hand,providers have to continually revise the detailed data, procedure codes and supportingdetail provided to payers in order to meet the requirements of the adjudication processbased on the payer contract. The absence of enough data results in processing delaysand/or partial claims settlements. Meanwhile, providers wait for claims to be paid intotheir receivables bank account with sufficient detail to reconcile the claim in their patientaccounting system.On the other hand, the providers banks may not be interested in handling the supportingdetail for the claim (remittance data) and only provide payment data so that they are notexposed to HIPAA and/or HITECH requirements. Consequently, the separation of thedetailed EOB (Explanation of Benefits) from the payment stream can result in hardship forall participants in the financial reconciliation process.In response to this reality, HIMSS G7 met at the Vanderbilt Center for Better Health inNashville, Tennessee, in October 2010. This group consisted of leaders from healthcareproviders, payers, clearinghouses, employers, the banking sector, and technologyproviders. Through a creative brainstorming process, the concept of a "healthcarepayments hub" architecture was developed as a way to demonstrate a new best practice forhealthcare stakeholders to conduct payment and reconciliation processes nationally, andpossibly globally.119 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • COMPLEX CONNECTIVITYThe typical healthcare provider uses claims clearinghouses to assist in transporting healthdata transactions and to automate many of the manual processes that support the businessof healthcare. In fact, most healthcare organizations use several methods and multiplecounterparties for eligibility, claims, remittance, and payment.Major providers often use dedicated links to their major payer groups, such as Medicare,via dedicated FTP or other secure tunnels. Healthcare providers have made considerableinvestments in legacy-coded systems, internal hospital processes, and proprietarybiller/provider systems and procedures. Often, these systems require additionalinvestment to implement EFT/ERA re-association mechanisms and to support newprocesses around healthcare STP. The diagram below illustrates many typical largeprovider and payer network implementations.EDI connections between the clinical environment and the patient accounting system formost large providers are often manual and disjointed with reliance on batch processing(“data dumps”) and manual data entry and review. There is little true STP in the healthcareenvironment.The number of connected end points and average number of episodes per year thatgenerate claims is large and growing. For example, when we consider the total number ofphysical locations where back office systems may reside in provider networks and thenumber of physicians creating data for the patient accounting system, the numbers lookdaunting (see the table below). For this reason, in order to simplify the overall process10 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • similar to what has been done in banking, the creation of a payments hub is stronglyindicated. Sampling of End Points that Require Healthcare EDI12Rank Medical Group Offices Physicians 1 Kaiser Permanente Medical Group 301 7858 2 Greater Houston Anesthesiology 11 2278 3 Cleveland Clinic 104 1851 4 MEDNAX (f.k.a. Pediatrix/Obstetrix 275 1625 Med Grp Nat) 5 Advanced Radiology 19 1349 6 Mayo Clinic Jacksonville 37 1311 7 Fairview Physician Associates 194 1295 8 University Pittsburgh Phys 156 1215 9 Palo Alto Medical Foundation 47 905 10 Partners in Care ? 850 11 Henry Ford Medical Group 60 816 12 Radiology Imaging Associates 14 796 13 Aurora Medical Group 88 790 14 Austin Radiological Assoc. 12 754 15 Marshfield Clinic 37 699 16 UC Davis Medical Group 68 673 17 ENH Medical Group 133 664 18 Harvard Vanguard Medical Associates 23 650 19 Emory Clinic 76 636 20 Geisinger Medical Center 56 616 21 UW Health Clinics 80 612 22 Ochsner Clinic 27 554 23 Allina Medical Clinic Coon Rpds 41 552 24 Carolinas Physician Network 90 539 25 LSU Healthcare Network Rhu 55 53211 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • CURRENT SITUATION OVERVIEW OF CURRENT CLAIMS PROCESSESTo determine best practices for the future of remittance and settlement, it helps tounderstand the current state of claims processing. Today, the infrastructure for claims andremittance is highly variable by provider type. Most claim and remittance transactions arecommunicated electronically. Major providers often establish direct connections for largerentities such as Medicare but do not have direct connections for smaller payers. In thosecases, clearinghouses are typically used as a central aggregation hub. Smaller providersmay use clearinghouses for all of their claims submissions.A providers healthcare information management system captures charges and ultimatelycreates a claim that is processed in their patient accounting system. Providers are atdifferent stages of readiness for this process, which effectively creates an electronic bill andmoves it from the clinical or care environment into a patient accounting or financial systemenvironment. Of importance, the industry has migrated from version 4010 of the ASC X12health data transactions to version 5010.13 This will enable the provider to transfer thesignificant increase in coding as of October 2014, when the ICD-10 coding system14 will beimplemented nationally.The HIPAA-mandated version 5010, an ASC X12 transaction,15 provides the standard forthe structure of the healthcare transactions. This dictates, for example, where one needs tofind the required processing information in the claim (X12 837) or remittance (X12 835).ICD-9 (moving to ICD-10) describes the procedures that were done. In addition thesestandards include contextual information such as demographics (e.g., patient name,address, insurance provider, etc.). Finally, there are standards for supplementaryattachments such as surgical reports and images. Though not implemented broadly, withthe population shift to aging baby boomers, it is likely these standards will become morecommonly used.Another health data transaction that is integral to the patient visit is eligibility (X12270/271).16 Pre-qualification fields in this transaction may be used for full “pre-certification.” Pre-certification goes beyond basic eligibility of coverage and indicatesadditional criteria such as whether the patient has met his or her deductible or whether aparticular type of procedure is covered. Pre-certification could indicate what condition thepatient has and what procedure is going to be performed. Authorization by the payer isgranted or the payer may decline the procedure as “not covered,” resulting in the need tocollect additional payments from the patient or necessitating an appeal to the payer. Thisinformation then enables collection of partial to full payment at point of service.12 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • As an example of how the process currently works, a major hospital surveyed for thisreport uses a partially outsourced model in which a third party assembles batches of claimsand remittances and coordinates the deposits to their financial institutions. The hospital isbound to the formats and “standards” of the third party and is required to maintain these attheir expense. This includes keeping them up to date any time there is a system change. Onthe other hand, when a hospital uses a claims clearinghouse, the clearinghouse implementsthe ongoing changes in data and formats as part of their routine maintenance. In bothcases, whether using a partially outsourced model or using a clearinghouse, the hospital isrelying on point-to-point electronic interfaces in the form of Internet tunnel VPN, VAN(Value-Added Network), or some other exchange protocol to exchange claims data. Thereare no standard information highway “on ramps,” “off ramps,” or "fast lanes" on which thedata travels.While we have articulated a very small fraction of the types of health data communicationsthat are routinely among the healthcare stakeholders, it should become evident that thenumber of connections across the entire healthcare payment landscape is significant. Notethat payers and their office locations, providers and their office locations, clearinghouses,lockboxes, associated counterparty banks, and their connected ACH network end-pointsshould also be included.Looking to the future, it is likely that more claims data will be required by payers. This willfurther increase the EDI traffic. Consider the explosion of diagnosis and procedure codes asthe industry moves from ICD-9 to ICD-10, (from approximately 16,000 to over 125,000codes),17 a change that will more precisely codify the patient episode. The need for a morerobust data transfer system begs the question of whether the right infrastructure is in placeto handle the increasing intensity of data exchange.For banks to play a more meaningful role in healthcare information management andpayments, they will require a highly secure transport network beyond the Internet forlimiting exposure under HIPAA. New requirements would include items such as:  release rules (defines what data can be released and processes for requesting data)  validation of required elements in the file  security and network exchange protocols  digital signature that consistently satisfies HIPAA requirementsAs claims become more detailed and as technology converges to optimize payment andremittance management among payers, providers, and banking organizations, there will beincreasing pressure for an STP solution. The solution will need to be highly secure as morerecords, and thus more data, is communicated.13 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • ROLE OF NCVHS IN HEALTHCARE PAYMENTSA recommendation by the NCVHS (The National Committee on Vital and HealthStatistics),18 acting as a statutory advisor to the U.S. Department of Health and HumanServices (HHS), suggested that the EFT and the ERA do not need to be submittedtogether;19 in fact, NCVHS recommended that the payment and remittance informationshould be submitted separately using the CCD+,20 a NACHA-governed paymenttransaction.21One option that has been considered to create better value in healthcare payments is toenvelope both the EFT and the ERA within a CTX (Corporate Trade Exchange) transaction(a NACHA format) and deliver them together through the ACH network. However, somehealthcare plans and healthcare providers have indicated concern around doing this due toa lack of trust that the ACH clearinghouse networks fully comply with HIPAA. Duringtestimony at NCVHS hearings on this topic, a large public provider network of hospitals,clinics, and other healthcare facilities made discrete recommendations to ban the CTX andto require stakeholder-wide use of the CCD+.22 OPERATING RULESIn July 2012, HHS published Operating Rules that include re-association, timing, anddelivery requirements for healthcare payments. These rules require that by January 1,2014, all health plans must support EFT, with various requirements including:  Requires EFTs to be delivered in CCD+ format, which means they must include linkage to their corresponding Electronic Remittance Advice (835)  Requires that 835s are sent by the health plan no longer than three days before or after issuing the EFT23With these new requirements, the potential use of the CCD+ will increase; however, thebenefits that come from STP would largely go unrealized. While re-association may becomethe standard industry practice – linking the EFT and ERA using the CCD+ format, there maystill be an opportunity to realize a more robust healthcare payment experience thatprovides compelling ROI for the stakeholders using a true STP approach.14 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • STRAIGHT THROUGH PROCESSINGThe advent of STP among business enterprises has yielded strong business value.According to Wikipedia, “Straight-through processing (STP) enables the entire tradeprocess for payment transactions to be conducted electronically without the need for re-keying or manual intervention, subject to legal and regulatory restrictions.”24Clearly, the business of healthcare is in need of streamlined systems and processes inseveral key areas. The adaptation of STP practices could provide strong business value forthe healthcare provider. In a growing number of cases, healthcare providers are alreadypiecing together the technology components that can advance this area through pointapplications that process electronic remittances into the patient accounting platforms.Dollars that are received, and their associated remittances, are being automaticallyreconciled with bank accounts, are posted, and are kicking off a wave of downstreamprocesses that traditionally required manual intervention.Moreover, banks and financial institutions are playing an increasing role in the healthcarefield by offering new data processing services that address healthcare STP and provideother value added services for the stakeholders that leverage their “first in line” positionfor receiving and processing electronic remittances when those remittances are sent to theprovider with the healthcare payment. These services are referred to as “medical banking”and have generated new thinking around best practices for revenue cycle managementaccording to a major hospital network.25Yet in many circumstances, the processing of claims payment and remittance advicerequires significant manual intervention at various points between the provider and thepayers, including clearinghouses, IT vendors, and banks. The current processes andsupporting infrastructure generally do not allow for even simple end-to-end reconciliation.Receivables outstanding may be adversely impacted as payers adjudicate claims, engage inQ&A with providers on coverage specifics, and ultimately, settle payments to the provider’sbank. MARKET OPPORTUNITYIn defining the requirements for a healthcare payments hub architecture, it is necessary toidentify all of the impacted stakeholders in the processing environment. The diagrambelow outlines the full landscape.15 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • Within this ecosystem, the market transaction size is robust and growing:  Claims market size: 6 billion+ (claims processed to third party payers, not patient pay)  Third party payer remittance market size: 12 billion (conservative estimate based on receiving a small number of partial payments for each claim)The estimated remittance breakdown is:  Commercial: 5 billion (includes all commercial payers, BC/BS)  Government: 7 billion (includes Medicare, Medicaid, TRICARE and other government plans)  Self-pay remittances: 18 billion (based on an average of 3 additional payments for each claim)The estimated number of EDI connection points for just hospitals, payers and physicians is:  Hospitals: 6,000  Payers: 2,000 (note that the number of health plans is different; Aetna alone offers hundreds of health plans)  Active physicians: 750,000Collectively, this data26 exemplifies the market opportunity and the scope of impact for anew healthcare payments hub. This type of innovation could provide an efficient payment16 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • and remittance channel between the stakeholders that dramatically increasesadministrative efficiency in healthcare. PARADIGM SHIFTA Healthcare Payments Hub could instigate a “sea change” in the use of financial data forworkflow automation and business intelligence. Among the factors that are fueling aparadigm shift are:Demand – There is increasing technological convergence between healthcare and bankingthat could be leveraged to drive systemic efficiency in the infrastructure of our healthcaresystems. This technological intersection encompasses a healthcare marketplace valued at$2.8 trillion in 2012, yet today’s component parts are disconnected point solutions andproprietary technologies. There is a heavy reliance on manual processing. Through theapplied use of a payments and remittance platform, it is possible to enjoy high value dataexchanges that offer “near real time” transaction management. As more groups find thevalue, the demand for efficiency will evolve the platform.27Leverage Existing Connections – A payments hub efficiently consolidates multiplecounterparty connections, economizes on-boarding of new connections, and reducesmaintenance costs. This type of system would allow much more rapid adding and changingof counterparty relationships between payers, providers, clearinghouses, and theirprocessing financial institutions. The more members that join, the more likelihood theirdesired counterparty is already connected, resulting in minimum connection cost formembers.28 The benefit of standardized connections would save considerable time andeffort and result in optimum management of this redundant cost center.Neutrality – Banks are the end-point for virtually all payment settlements. As a result, thebanking community is noted for creating a neutral, trusted financial platform for dataexchange.29Value Added Services – Since the payments hub would be a "traffic cop" of sorts betweenhealthcare providers, payers, clearinghouses, and their banks, it could leverage its positionto offer value added services. This would help clearinghouses build their businessconnection model and provide web-based reporting for transaction research, archiving,and other services.Security – Data security concerns relating to medical data in the form of remittance detail,lack of standard Personal Health Records (PHRs), and the inherent risk of disclosingpersonal medical details across the Internet, have plagued any interoperable cross-business exchange. Meaningful adoption requires addressing the security concerns across17 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • the healthcare stakeholders. Secure FTP, Digital Certificates and other methods can be usedto facilitate secure provider and other connections to the hub.Within the context of financial settlements, and the types of security safeguards that areroutinely used, the U.S. banking system is fairly mature. External to the U.S., the securitycontrols implemented in the SWIFT network are well understood. However, regardless ofthe platform, a comprehensive HIPAA/HITECH assessment is required. While SWIFT hasreportedly never been comprised, it would need to, as with any financial platform, provideevidence that its use is satisfactory to the healthcare stakeholders. It will need todemonstrate that it meets, at a minimum, the HIPAA-specified standards around securityand data delivery. This will help to speed adoption of STP business practices in healthcare.Financial institutions will naturally have different risk tolerances and therefore differingbusiness offerings to healthcare. Their risk tolerance will drive whether they want to beinvolved in strict financial settlement or in other value added services to healthcare thatmay deem them “Business Associates” and “Covered Entities” that are subject to the HIPAAand HITECH regulations.Standards That Do Not Over-prescribe – The global banking industry has spent yearslaying the groundwork for global standard messages. Connected counterparties canprocess global standard payments, detailed bank statements, and many other financialmessages on a trusted and secure information highway. The evolving ISO standards forXML tagging (and XBRL or extensible business reporting language are useful in taking thedocuments that describe relationships between business counterparties and allowingtechnology to apply them dynamically in settlement of a claim use case.In healthcare, evolving standards and complexity is a larger problem. Consider that withinthe area of electronic health records, there are a number of emerging standards such asConsolidated CDA (C-CDA) and ISO 13606. Furthermore, payer-specific variations remainwithin the 837 and 835 standards. Given this reality, it may be that there are tradingpartner nuances that need to be “baked” into the healthcare transactional ecosystem (i.e.,for example, note the large amount of companion guides in the claim process). Whilehaving a standard is clearly in the best interest of the healthcare stakeholders, there aresome exchanges of information that may benefit from transfers of payments and datawithout a standard message type, in a format that the correspondents agree to, while stilloffering the security, audit, guaranteed delivery, and banking system integration benefits.In proposing a healthcare payments hub that offers a standard and reusable transportmechanism, robust security, and routing and delivery, we envision the first-ever platformfor universal healthcare payments exchange. This effort would be analogous to defining aninternational shipping and payment process. So for the payments hub, we would suggestnot prescribing everything inside the “shipping container” but rather leave that to18 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • competitive market forces and bi-lateral agreements between trading partners, and/orlegislative fiat (as in the U.S. with version 5010 of the health data transactions)The next section provides a recommendation for a pilot project. This pilot project woulddesign the equivalent of standard data tags and container sizes for loading exportcommodities onto ships through their ports of call. The container shape, size, construction,loading and unloading hooks, and secure transport regulations around them would bestandardized while the content within them could still vary. In this way, the tradingpartners (e.g., provider and payer) could use their own business relationship agreementsand settlement networks to drive the format requirements they require. RECOMMENDATIONA recommendation based on the current opportunity is provided in this section, followedby the description of a pilot program that can demonstrate a stakeholder-wide valueproposition. A DEMONSTRATION DESIGNSince the main efficiency problems in the healthcare payments value chain have yet to besolved, there may be a place for a “payments hub” that can support both separatedEFT/ERA transactions as well as an alternate larger and secure payload package thatcontains both EFT/ERA in one bundle. In this paper, we examine the use of the SWIFTmessaging platform for this purpose.SWIFT is an international financial messaging platform that is used for wiring funds. Inrecent years, however, the organization has expanded its scope into other types oftransactions. This includes the “FileAct”30 transaction which allows secure and reliabletransfer of files and is typically used to exchange batches of structured financial messagesand large reports. FileAct supports tailored solutions for market infrastructurecommunities, closed user groups and financial institutions. FileAct is particularly suitablefor bulk payments, securities value-added information and reporting, and for otherpurposes, such as central-bank reporting and intra-institution reporting.Using the SWIFT messaging platform, the healthcare payment transaction wouldessentially envelope the CCD+ (to comply with the new federal operating rulerequirements) but then additionally offer the required space for the related remittancedata in the same package – thus supporting a straight-through process. A demonstrationproject using a FileAct transaction could showcase a financial infrastructure that reducescosts across the healthcare ecosystem.19 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • One large healthcare system suggests that an STP-enabled approach could serve theirnational footprint extremely well and listed the following design features:  Connectivity with the majority of existing banks, clearinghouses, and vendor partners  Pre-built services that include a number of workflow functions, such as payer- specific edits, eligibility verification, EDI transactions reporting and analytics, payment and remittance reconciliation, standard remittance, and denial code management  Security controls including encrypting and separating enterprise information in storage and transit, ensuring services are not mingled with other customers, etc.  The ability to benefit from financial incentives such as volume discounts unavailable through a single vendor solution STP EXAMPLEFor an example of STP in action, consider the following: 1. John Doe is treated by a provider; his claim is processed through ABC clearinghouse which sends an edited version (X12 837) to ABC Insurance Corp. 2. ABC Insurance Corp adjudicates the claim and processes a payment that is loaded into a batch payment file. The file is submitted to ABC Vendor that prepares it into a CCD+ transaction (EFT plus ERA re-association information) and an EDI835 (ERA with re- association information). They then send these to “First Medical Bank” for execution. 3. First Medical Bank sends the CCD+ and the 835 over SWIFT (banking network) for secure transport and guaranteed delivery. 4. SWIFT processes the CCD+ through the ACH Network all the way to the RDFI (provider’s bank) and sends the 835 directly to the provider. 5. Provider picks up the 835 and reconciles with their bank account (which may also be reported via SWIFT), and then processes the ERA into their patient accounting system. PILOT PROGRAMThis section outlines the specific recommendation for the creation of a healthcarepayments hub pilot program. VISION STATEMENT FOR A PILOT PROGRAMA successful pilot program requires a common vision among all the healthcarestakeholders. The payments hub could support multiple useful functions. The followingvision statement could be used to appropriately scope a pilot program.20 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • We envision a new healthcare network solution beginning in pilot and growing into a common standard where healthcare stakeholders and their service providers enjoy robust and standardized B2B remittance and payment exchange. As a result, healthcare and related service organizations and exchanges will optimize the business value of payment and remittance transaction and fuel new forms of business intelligence that enable better enterprise and/or practice management.The benefits of a payments hub would:  Improve overall revenue cycle management across the industry  Improve cash flows and accounts receivables for all counterparties  Decrease the cost and complexity of transaction processing  Promote unprecedented interoperability of banking and healthcare financial systems, and enable the evolution of new uses of bank-based technologies for healthcare  Increase healthcare STP and offer near real-time data exchange between the stakeholders  Increase acceptance rates of electronic healthcare payment transactions  Offer an innovation platform for vendors and financial institutions to expand services  Increase visibility into healthcare payment transactions EXAMPLES OF FUNCTIONS WITHIN THE HEALTHCARE PAYMENTS HUB  Provide secure connections to payers, providers, and clearinghouses via SFTP, VPN, Digital Certificate etc., while connecting to banks via SWIFT  Offer server-side web-based technology setup so no client application installation required  Support CCD+ for transaction trace identification and send individually and/or inside of the File Act-based bulk remittance via SWIFTThis type of pilot platform could be implemented as a fully functioning demonstrationwithin the HIMSS Interoperability Showcase.TM In addition, the demonstration couldinclude workflow status and associated dashboards for tracking transactions via a webbrowser, with export to CSV or Excel formats that enable STP integration with patientaccounting systems.21 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • USE CASE SUMMARY Use Case: Healthcare Payments Hub and Value-Added Vendors Today’s Process Actor What to potentially demonstrate around this processHUB: Payment batch file Payer’s third party and/or Show how the file is “spliced” andreleased bank that provides payments are executed via electronic accounts payable services process, paper process or other. Of particular note: what happens to the payment and the associated remittanceHUB: Payment is processed For EFT, NACHA and/or Show the movement of EFT/ERAby financial institutions SWIFT could play a role linked together, or show their here movement separate but with the bank having the ability to link (or a third party)HUB: Payment is reconciled Commercial Bank: RDFI or Show the process of reconciliation – ato the provider’s bank Lockbox, Lockbox Vendor, major sore point for providersaccount Third party application service providersValue Added Vendor: HIS, specialized application Show the benefit of moving all thePayment is posted to patient vendor (claims paper EOBs through a digitizedaccounting platform – clearinghouses with this process for remittance managementcomprehensive posting: cash capability, etc.)posted, contractuals, rejectnotes, financial class updatesValue-Added Vendor: Denial Denial management Show automated denial managementmanagement vendors routines versus paper-basedValue-Added Vendor: Contract management (same as above except for contractContract Management vendors management)22 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • Today’s Process Actor What to potentially demonstrate around this processValue-Added Vendor: Analytic IT vendors that use Show the relative value of enterpriseBusiness Intelligence the remittance data to decisioning using automatedAnalytics for enterprise or assist in enterprise processes versus manual/paperpractice management decisioning processes (including mitigation of paper-based errors that propagate through revenue cycle and the making of bad decisions). APPROACHThe diagram below shows a sample approach for architecting a hub that could be used inthe healthcare industry.23 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • The components of a project plan for the pilot could be: 1. Define criteria for success of pilot 2. Define and document key requirements 3. Define business case showing tangible and intangible costs and benefits for counterparties 4. Define use cases for the pilot encompassing the top potential uses of the network 5. Recruit pilot participants 6. Secure resources a. Funding b. Knowledge/Expertise24 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • c. Infrastructure 7. Establish steering team 8. Determine implementation process 9. Execute pilot (operationalize demonstration) 10. Report pilot findings against success criteria 11. Document best practices on production implementations for counterparties MILESTONESMilestone Due By 1. Create/articulate business case and use Go-ahead decision + 2 weeks cases to sponsors and participant 2. Define/document functional, technical + 3 weeks and legal requirements 3. Gain participant agreements and + 3 weeks resource commitments 4. Design/develop solution pilot + 6 weeks 5. Implement and test + 6 weeks 6. Go live 7. Report output/findings + 2 weeks 8. Publish draft standard for trial use + 3 weeks Time to complete ~ 25 weeks25 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • CONCLUSIONThis paper has covered a number of issues related to healthcare payment and remittanceprocessing, outlining key benefits of “straight-through processing” for the stakeholders, inparticular, the health plans, providers and consumers; and providing key factors in thedevelopment of a pilot program that could be used to demonstrate return on investment.The HIMSS World Bank Task Force believes that the healthcare payments hub concept canbe demonstrated in a limited fashion at the HIMSS Interoperability ShowcaseTM and thatthis demonstration could spawn an impressive array of innovations that evolve fromoptimum use of data that is flowing through payment channels. The Task Force encouragesthe healthcare community to embark upon this path in order to provide strong value andremarkable process efficiency for the stakeholders engaged in the healthcare businessprocess.The healthcare payments hub design pilot project is intended to demonstrate bottom lineimproved efficiency and financial advantage to each of the involved parties tocounterparties involved by creating a functional prototype for EFT/ERA management usingthe STP model. Importantly, comments in the Final Rule for Electronic Funds Transfer,recently passed by the U.S. Department of Health and Human Services (HHS), exhort theindustry to continue to innovate and explore potentially new solutions that create greaterefficiency in payments and remittance management. Should the stakeholders seek toimplement the program, the HIMSS World Bank Task Force will seek to publish andhighlight the benefits in cost, quality, or customer service across the counterparties viaHIMSS communications venues.It is likely that the issue of STP will continue to surface until a viable solution is developed.The benefits of STP in healthcare are substantial and have been well documented. This costefficiency will drive the marketplace in search of a solution. Notably, while largerhealthcare providers and health plans have developed work around solutions with theirclearinghouses and other vendors, the vast majority of providers have yet to takeadvantage of these solutions. Implementing a healthcare payments hub could facilitatestronger use of clearinghouses that provide the critical end point value that can drive fargreater efficiency in our healthcare complex.In order to make this happen, however, the banking community must step up to thechallenge and create credible solutions where ROI can be demonstrated and case studiescan be socialized throughout the healthcare stakeholders. There is a growingacknowledgement that convergence of banking and financial technologies via point ofservice processing, implementation of PHRs that are interoperable with electronic healthrecords, HSA management, claim liquidity mechanisms (A/R financing), and other areas areplacing more protected health information into banking systems and thus, placing26 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • increased pressure on core banking and healthcare service organizations to work togetherin more synergistic ways.27 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • APPENDIX GLOSSARYTerm DefinitionACH Automated Clearing HouseARRA The American Recovery and Reinvestment Act of 2009. Abbreviated ARRA and commonly referred to as the Stimulus or The Recovery Act, this is an economic stimulus package enacted by the 111th United States Congress in February 2009 and signed into law on February 17, 2009 by President Barack Obama. This act made supplemental appropriations for job preservation and creation, infrastructure investment, energy efficiency and science, assistance to the unemployed, and State and local fiscal stabilization. As part of ARRA, Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH) addresses the privacy and security concerns associated with the electronic transmission of health information. Source: http://www.gpo.gov/fdsys/pkg/PLAW-111publ5/content-detail.htmlB2B/B2C Business to Business/ Business to ConsumerCCD+ Cash Concentration and Disbursement plus remittance re-association numberC-CDA The Consolidated Templated implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from Health Level Seven (HL7), Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It represents harmonization of the HL7 Health Story guides, HITSP C32, related components of IHE Patient Care Coordination (IHE PCC), and Continuity of Care (CCD), and it includes all required CDA templates in Final Rules for Stage 1 Meaningful Use and 45 CFR Part 170 – Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology; Final Rule. Source: http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258CHAPS Clearinghouse Automated Payment System (U.K.)CHATS Clearinghouse Automated Transfer System (Hong Kong)ChIPS Clearinghouse Interbank Payment System. See: http://www.chips.org/home.phpCLS Continuous Linked Settlement. See: http://www.cls-group.com/Pages/default.aspxCTX Corporate Trade ExchangeEFT Electronic Funds Transfer. Transfer of funds electronically rather than by check or cash. The Federal Reserves Fedwire and automated clearinghouse services are EFT systems. Source: http://financial-dictionary.thefreedictionary.com/Electronic+Funds+TransferEOB Explanation of BenefitsEPN e-Payment Network (One of the nation’s oldest payment networks)ERA Electronic Remittance AdviceFedWire Federal Reserve Wire Network. Fedwire is the primary U.S. network for large-value or time-critical domestic and international payments. See: http://www.federalreserve.gov/paymentsystems/coreprinciples/default.htmFileAct FileAct allows secure and reliable transfer of files and is typically used to exchange batches of structured financial messages and large reports. It supports tailored solutions for market infrastructure communities, closed user groups and financial institutions. FileAct is particularly suitable for bulk payments, securities value-added information and reporting, and for other purposes, such as central-bank reporting and intra-institution reporting.HHS The U.S. Department of Health and Human Services28 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • Term DefinitionHIE Health Information Exchange. Used as a noun: An organization that enables the exchange of health information, typically clinical information, across diverse stakeholders, that governs the exchange of health information for the purpose of bringing greater efficiencies to the exchange of clinical data and improving the quality of healthcare in that community. This organization might also be referred to as a Health Information Organization (HIO). - HIE participants include hospitals, providers, labs, imaging centers, RHIOs, HIEs, nursing facilities, payers, state public health entities, etc. - Data shared may include lab results, discharge summaries, medication histories, e-prescriptions, allergies, immunizations, advanced directives, etc. - HIE services typically include results delivery, record locator services, consent management, and e- prescribing. Used as a verb: Health information exchange (HIE) is defined as the mobilization of healthcare information electronically across organizations. Source: http://www.ehnac.org/files/PDF/Glossary_of_Terms_092811.pdfHIMSS HIMSS Interoperability Showcases™ held during HIMSS conferences at locations across the globe, areInteropera- unique events where healthcare stakeholders come together to demonstrate the benefits of usingbility standards-based interoperable health IT solutions for effective and secure health data informationShowcase™ exchange. Educational opportunities at the Showcase connect thousands of health IT buyers and end- users to answer the most complex health IT questions.HIPAA The Health Insurance Portability and Accountability Act of 1996.HITECH The Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. Subtitle D of the HITECH Act addresses the privacy and security concerns associated with the electronic transmission of health information, in part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules. Source: http://www.ehnac.org/files/PDF/Glossary_of_Terms_092811.pdfHSA Health Savings AccountICD-9/ International Classification of DiseaseICD-10ISO International Standards OrganizationNACHA/ACH National Automated ClearingHouse Association/Automated Clearing HouseNCVHS National Center for Vital Health and StatisticsPHI Protected Health Information. PHI is individually identifiable health information: 1. Except as provided in paragraph two (2.) of this definition, that is: - Transmitted by electronic media; - Maintained in electronic media; or - Transmitted or maintained in any other form or medium. 2. Protected health information excludes individually identifiable health information in: - Education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g; - Records described at 20 U.S.C. 1232g(a)(4)(B)(iv); and - Employment records held by a covered entity in its role as employer.PHR Personal Health Records. A personal health record permits you to securely gather, store, manage and share your own and your familys health information - when you want, where you want, and with whom you choose. Source: www.webmd.com/phrRHIO Organized cross-organizational healthcare data-sharing organizations are referred to as RHIOs. These organizations are also referred to as health information exchanges (HIEs). Source: http://www.ehnac.org/files/PDF/Glossary_of_Terms_092811.pdfRTGS Real Time Gross Settlement. RTGS networks such as the FedWire system differ from ACH networks in that they are real time and non-reversible. ACH is reversible and not final, plus has a delay minimum posting of 1 day domestically and >1 day in global scenarios. Each country has some form of RTGS system available as part of their interbank processing and clearing functions.29 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • Term DefinitionSEPA Single European Payments Area. See: http://en.wikipedia.org/wiki/Single_Euro_Payments_AreaSTP Straight Through Processing. An initiative used by companies in the financial world to optimize the speed at which transactions are processed. This is performed by allowing information that has been electronically entered to be transferred from one party to another in the settlement process without manually re-entering the same pieces of information repeatedly over the entire sequence of events. Source: www.investopedia.com/terms/s/straightthroughprocessing.asp#axzz2F8NEYBgwSWIFT Society for Worldwide Interbank Financial TelecommunicationVPN Virtual Private NetworkXML/XBRL eXtensible Markup Language/eXtensible Business Rules Language30 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • HIMSS WORLD BANK TASK FORCE WHITE PAPER CONTRIBUTORS Peter Lang, Chair, FY2013 HIMSS World Bank Task Force Managing Partner/President, Trellis Integration PartnersEric Cohen Hamilton Todd, MSMXBRL Global Technical Leader Senior Revenue Analyst, Revenue CyclePriceWaterhouse Coopers Mayo ClinicEd Dodds John CasillasCollaboration Strategist Senior Vice PresidentCommergence Business Centered Systems, HIMSSVlad Kaminsky Joyce Sensmeier, MS, RN-BC, CPHIMS, FHIMSSSolutions Consultant Vice PresidentRevenue Cycle Technology Informatics, HIMSSKaiser Permanente31 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • END NOTES1 http://www.himss.org/content/files/medicalBankingProject/MBP_Toolkit_ProviderROI.pdf2 See: http://www.digitaltransactions.net/news/story/30043 http://www.ushealthcareindex.org4 https://healthcare.nacha.org/node/399#_ftnref15 See: http://www.gpo.gov/fdsys/pkg/FR-2012-08-10/html/2012-19557.htm6 See: https://healthcare.nacha.org/HealthcareEFTStandard7 http://www.caqh.org/ORMandate_EFT.php#Rules8 Source: www.investopedia.com/terms/s/straightthroughprocessing.asp#axzz2F8NEYBgw9 See: http://www.himss.org/content/files/12_04_09_ARRAHITECHHIE_FactSheet.pdf10 RTGS stands for Real Time Gross Settlement. RTGS networks such as the FedWire system differ from ACHnetworks in that they are real time and non-reversible. ACH is reversible and not final, plus has a delayminimum of posting of 1 day domestically and >1 day in global scenarios. Each country has some form ofRTGS system available as part of their interbank processing and clearing functions.11See:http://www.himss.org/content/files/MedicalBankingProject/HIMSS_G7_AdvisoryReportElectronicBusinessTransformationNovember2011.pdf; Also see: HIMSS G7 Advisory Report: The Intersection BetweenAccountable Care Organizations and the Financial Network of the Future, page 3 (see “Three KeyIntersections: (1) Integrator; (2) Data Analysis; (3) Payments Hub)12http://en.wikipedia.org/wiki/Group_medical_practice_in_the_United_States13 See: http://www.x12.org/x12org/subcommittees/dev/index.cfm14 See the ICD10 PlayBook: http://www.himss.org/asp/topics_FocusDynamic.asp?faid=47115 See: http://www.x12.org/x12org/subcommittees/dev/index.cfm16 ibid17 See HIMSS G7 Advisory Report:http://www.himss.org/content/files/medicalBankingProject/ICD10PlayBookAdvisoryReportHIMSSG7.pdf18 See: http://www.ncvhs.hhs.gov/19 45 CFR Part 162 Administrative Simplification: Adoption of Operating Rules for Health Care ElectronicFunds Transfer (EFT) and Remittance Advice Transactions; Final Rule, Table 6 – EFT and ERA Usage forMedicare, Medicaid and Other Government Health Plans, and Commercial Health Plans Between 2013 and202320 CCD stands for Corporate Cash Disbursement, and the “+” represents a part of the transaction that canhouse a trace number that links the EFT and ERA back together. This process is called “re-association” and isperformed by the recipient of funds, the recipient’s bank, or the health IT service provider. In this process, thefunds (EFT) may travel separately from the data (ERA) but are then re-associated at the destination. Whileappearing to simplify the reconciliation process, it is not clear if this practice facilitates STP, which assumesthat all of the remittance data is submitted with a payment.21 For a brief discussion of value, see: http://www.digitaltransactions.net/news/story/3004 – the articlerefers to a report by US Healthcare, released in 2009, that suggests $160 billion can be saved over the next tenyears in healthcare by integrating payments and remittances. Earlier estimates by the Medical BankingProject, in 2001, estimated that healthcare providers alone could save $35 billion annually (see:http://www.himss.org/content/files/medicalBankingProject/MBP_Toolkit_ProviderROI.pdf). Others suggest$11 billion in annual savings could be realized (see: http://www.ushealthcareindex.org/), while NACHA pegspotential savings at up to $4.5 billion over ten years (see: https://healthcare.nacha.org/node/399#_ftnref1).22 See VA Healthcare testimony at: http://hhs.granicus.com/MediaPlayer.php?publish_id=1123 See: http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/OperatingRulesforHIPAATransactions.html24 http://en.wikipedia.org/wiki/Straight_through_processing25 Interview with Hamilton Todd, senior director of revenue cycle, Mayo Clinic, 201226 All figures are estimates only, and are derived from data collected from HHS, CMS, CDC and other websites.32 © 2013 Healthcare Information and Management Systems Society (HIMSS)
  • 27http://www.himss.org/content/files/20110519_UnveilingTruthBehind_RTA.pdf28 For an academic discussion of network effects, please see:http://www.utdallas.edu/~liebowit/palgrave/network.html29 For example, for the settlement side of transactions, SWIFT offers a viable option. SWIFT is a non-profitconsortium owned by the global banks and already connects to more than 9,000 institutions around theworld. Core issues with proprietary exchange technologies could largely disappear without stifling businessopportunity and creating bottlenecks for value added services across healthcare and banking alike. SWIFT isalready at the center of the ISO20022 XML global financial exchange standards and is accepted as the globalfinancial backbone for financial messaging across banks and other financial and corporate members (sinceopening a corporate adoption model “SCORE” in 2006…SCORE stands for “SWIFT for CORPORATEs” andrepresents a specific SWIFT community of connections designed for corporate access).30 See the SWIFT FileAct implementation guide at:http://www.swift.com/solutions/by_business_area/trade_services/sfc_snfa_July08_ig.pdf33 © 2013 Healthcare Information and Management Systems Society (HIMSS)