Automate Blue Button Initiative Payer Content Workgroup Meeting

1. Automate Blue Button InitiativePayer Content Workgroup Meeting November 9, 2012

2. Meeting Reminders First…THANK YOU workgroup participants for sharing your valuable time & expertise. We are grateful. • Phone on MUTE – not hold • Meeting being recorded • Use WebEx “Chat” to queue questions & comments

3. Payer Content WG Current Status

4. Agenda

5. Synopsis & Charter Synopsis • The aim of the ABBI Payer Content workgroup is to identify a practical human-readable and machine-readable content standard for Blue Button data, capable of conveying both clinical and non-clinical health data offered by existing payers today, either by Blue Button or in EOB (Explanation of Benefits) documents today. The goal is to arrive at a data & interoperability platform, feasible for payers & PBMs and attractive to developers to innovative apps & to create personally-controlled solutions that target clinical quality, affordability, access and the experience of care itself. In Scope • Leverage existing elements defined by public & private payers • Leverage existing standards if possible e.g. MyMedicare.gov ASCII, X12, HL7, cCDA extension, HealthVault EOB data model • Produce implementation guidance • Payor-generated Health Financial data and Clinical Claims Data • Examples of relevant data : Explanations of Benefit (EOBs) -- with noted concern about proprietary network discounting information 10 Yes 0 No Abstain = 1

6. Voting Comments & Proposed Mods. Eligibility Data • Insurance approval or service provided or both? Financial Data • [We have some concerns about] expansion of the scope to replace EOB's/include financial data. Member Usability • Also, I don't believe we should consider the X12 format. We need to focus on formats that will be usable by members and I don't feel X12 will be useful in member settings.

7. Clarification: What’s the “Ask”? Proposed standard may be non-binding; probably will not actually require some fields be populated (especially if they are unavailable, e.g. Rx data for some payers). For organizations who do want to supply those fields, though, they will benefit from a common content format – especially to be interoperable with consumer-controlled applications. Example: For Sensitive Network Discount Information, some organizations may choose to share structured & interoperable data about PR (patient responsibility) amount only. Others may share the full set of data already available on the paper-based or PDF-based EOBs (explanations of benefit) sent to the beneficiaries. ASC X12 is being discussed in a non-traditional sense, as an existing standard that contains the typical fields found in payor-generated data. The Use Case is fundamentally different than what X12 is used for today, i.e. consumer-centric data, vs. payer-provider transactions.

8. Clarification: Dual Aim is related • Generalized Use Cases Human-Readable Machine-Interoperable Payer and PB Based Claims & Rx Databases Front-end Member & Patient Portals Original Claims & Other Data e.g. X12 Payer & PBM Supplied Individual Health Data Consumer-Centric Use Cases (Generalized) Aggregate & Reconcile Apps & Services View Share Human Readability needed Machine Interop. needed

9. Interoperability allows Payers & PBMS to • Benefit from Shared External Innovation No Interoperability for Consumer-Facing Uses Interoperabilityfor Consumer-Facing Uses A B C D A B C D PCHR* PCHR = Personally-Controlled Health Record, e.g. Microsoft HealthVault App Dev 2 App Dev 1 App Dev 3 App Dev 2 App Dev 1 App Dev 3 Consumer apps face an “n-hard” problem today – number of technical negotiations is exponential (handshakes = n * m, where n = # of suppliers and m = # of developers), in addition to probable HIPAA business associate agreements. SLOW, COMPLICATED, THWARTS INNOVATION. • Patient is in control of their data • Fewer handshakes needed for data • Risk of innovation shifts from data suppliers to developers, in exchange for larger accessible market for any given developer • FASTER, SIMPLER, DRIVES INNOVATION

10. Agenda

11. ABBI Payor WG: Data Fields of Interest 11/9 draft

12. Agenda

13. Guest Demo: EligibleAPI.com

14. EligibleAPI: Example of Bridge betweenModern JSON API developers & EDI Information you can call: Patients Active VS Inactive Status Coinsurance Copayment Deductible Health Spending Balance Speciality Specific Info (ie MRI, Diagnostic Labs)

15. X12 EDI 270/271 SampleEligibility Transaction ***N~MSG*Genetic Testing~EB*H*IND*82***23******N~MSG*Genetic Testing~EB*F*IND*42***23***DY*120**Y~EB*F*IND*42***23***DY*120**N~EB*A*IND*75*****0*S7*17**Y~MSG*Hearing Aid~EB*A*IND*75*****0*S7*17**N~MSG*Hearing Aid~EB*A*IND*80^68*****0****Y~EB*A*IND*62*****.2****Y~III*ZZ*23~EB*B*IND*62***26*0*****Y~III*ZZ*23~EB*C*IND*62***26*0*****N~III*ZZ*23~EB*A*IND*81*****0****Y~MSG*Adult Preventative Care~EB*A*IND*81*****.4****N~MSG*Adult Preventative Care~EB*A*IND*A9*****.2****Y~MSG*All Therapies~EB*H*IND*A9***23******Y~MSG*All Therapies~EB*A*IND*A9*****.4****N~MSG*All Therapies~EB*H*IND*A9***23******N~MSG*All Therapies~EB*A*IND*3*****.2****Y~MSG*Specialist Services~EB*A*IND*75*****

16. EligibleAPI JSON (Javascript Object Notation) { "health_coverage": { "current_status": "active", "description": [ "Choice Fund HRA Open Access Plus", "Carelink" ], "limitations": { "remaining": "$751", "limitations_comment": "HRA Balance" }, "deductible": { "ind_yearly": "1500", "ind_remaining": "1321", "fam_yearly": "3000", "fam_remaining": 3000 }, "coinsurance": { "ind_percentage": ".2", "fam_percentage": ".4" }, "out_of_pocket": { "ind_yearly": "2500", "ind_remaining": "2321", "fam_yearly": "7500", "fam_remaining": "7500" } } }

17. Resource URL https://eligibleapi.net/eligibility.asp ?APIkey=***************** &SearchID=1 &PayerName=CIGNA&PayerID=00001 &ProviderLastName=Austen&ProviderFirstName=Jane&ProviderNPI=DFJJDLJAFJD &PatientLastName=Pooh&PatientFirstName=Winnie&PatientDOB=10/17/1911&PatientMemberID=FRDJLS999 (ServiceTypeCode and Version are optional)

18. ABBI Workgroup Meetings, Site & Contacts Fridays 1-2p ET: Payor Content Workgroup Meetings Wednesdays: All-Hands Community Meetings Web Site with meeting details, materials, discussions and recordings: http://wiki.siframework.org/Automate+Blue+Button+Initiative Contacts: • Initiative Coordinator: Pierce Graham-Jones (pierce.graham-jones@hhs.gov) • Presidential Innovation Fellows: • Henry Wei MD (henry.wei@va.gov) for Payer Content WG • Ryan Panchadsaram (ryan.panchadsaram@hhs.gov) • Project Manager: Jennifer Brush (jennifer.brush@esacinc.com) • S&I Admin: ApurvaDharia (apurva.dharia@esacinc.com) 18

19. Appendix

20. Health Financial Data: Issues Raised So Far Health Financial Data • Is Financial data in-scope? • Unlike “traditional” clinical health data • Patient advocate organization represented in broader ABBI community meetings have expressed it as a priority, however • Could be a “home run” for the ABBI Community if it enables more affordable care. But if not us, who else will tackle this? • Solutions are out-of-scope; data standards & interoperability in-scope, and pre-requisite for 3rd-parties to create solutions. • How are patients getting it today? • Explanations of Benefit (EOBs)  concern about proprietary network discounting information, may need QH Policy-like stipulations! • Limited electronic access today (mostly PDF and/or “scraping” aggregators like Simplee & Cake Health)

21. Implications for Healthcare Affordability Comments from Keith Boone • [Patients will not only] be able to track all of their clinical data, but they'll also be able to track costs of particular illnesses. • The apps this content will support will be able link EOB data back to clinical data, so that patients can understand the true cost of a given diagnosis. • Patients could also agree to share the content anonymously to third parties (in exchange for other services using that data).   • Thus, a patient could give access to anonymized data that links services, diagnoses and costs, to particular aggregators.   • The aggregators could agree (similar to the QH Policy Sandbox) to certain stipulations on use of the data, with the patient.  See http://wiki.siframework.org/Query+Health+Policy+Sandbox • The aggregator would then be able to analyze and generate cost information for illness, by provider, payer, policy and region.  Such data could be used to enable patients to obtain: • For a given diagnosis and plan, average costs for services and providers in their region. • For given diagnoses, the expected annual out-of-pocket costs for providers that the patient uses, based on historical data. • The upside for payers is that access to such data across payers will enable them to drive costs downward. Source: “What ABBI can do for Healthcare Cost Transparency”, 9/13/12, http://motorcycleguy.blogspot.com/2012/09/what-abbi-can-for-for-healthcare-cost.html

22. Implications for Personal Healthcare Quality Claims data-driven analytics focused on Clinical Decision Support & Quality are currently available to large self-insured employers, but not directly to consumers Through analysis of “rough” ICD-9, CPT, and NDC-coded data, these existing organizations can run “n-of-1” quality measures for individual patients & consumers.

23. Implications for Personal Health Affordability Claims data-driven cost prediction is currently available to insurers & large employers, but not yet directly to consumers Individuals may be able to help predict & budget for their health care spending needs, if they have a level-playing-field & access to the same data used by actuaries & underwriters.

24. Strawman 1: MyMedicare.gov Blue Button MyMedicare.gov Blue Button Data File Current footprint = ~35 million eligible lives • FIELDS SUPPORTED • Demographics • Name • DOB • Address • Phone • Email • Eligibility • Effective Date(s) • Plan Contract ID(s) • Plan Period(s) • Plan Name(s) • Claims Summary • Claim ID • Provider ID • Service Dates • Financial data by claim • Charged • Approved • Paid • Patient may be billed • Diagnosis Code(s) • NDC Drug Code(s) • CPT Codes • UB04 Codes • NPI Codes • COMMENTS • Include clinical quality data • A Codes – unbilled codes used for quality reporting

25. Example: Medicare Blue Button Mymedicare.gov 25

26. Strawman 2: X12 835 : Health Care Claim Payment/Advice X12 835 Version 5010 : required for nearly every insurance transaction • FIELDS SUPPORTED (TRANSACTION SET) • Header Level • Amount • Payee • Payer • Trace number • Payment method • Detail Level • EOB information • Adjudicated claims and services • Summary level • Provider adjustment • COMMENTS

27. Potential Standards • Standards for sharing claims information with beneficiaries • ASC X12 835 (Electronic Admittance Advice) - Health plan that contains multiple patient information to one provider • NCPDP D.0 telecommunication for pharmacy claims and remittance • ASC X12 837 (Health Care Claim Transaction Set) - File of 837 claims from a healthcare provider will contain multiple claims destined to either one payer or clearinghouse for multiple payers • Claim Submission • Post Adjudicated Claims • No EOB standard identified other than above • Typically a proprietary format exchanged • Minnesota print standard format • Other standards being considered for payer exchange of clinical information • Claims attachment to CCD • Payer data mapping to CCD • PHR to PHR standard being developed by HL7 / WEDI 27

28. Strawman 3: Create a new CDA EOB template Potential XML template for CDA Implementation Guide • FIELDS SUPPORTED (TRANSACTION SET) • Insurer Information • Payer ID • Name • Policy Info • Patient Info • Identifier • Name • Address • Provider Info • NPI • Identifier • Name • Address • Diagnosis Table • Diagnosis • Service Performed • Date(s) of service • Price billed • Negotiated Price • Amount Paid • Patient Responsibility • Notes • COMMENTS • See http://motorcycleguy.blogspot.com/2012/09/what-abbi-can-for-for-healthcare-cost.html

29. Generic components of an EOB • Payer’s Name & Address • Provider of services • Dates of service • Services or procedure code numbers • Diagnosis codes and/or Rx codes • Amounts billed by the provider • Reductions or denial codes • Claim control number • Subscriber’s and patient’s name and policy numbers • Analysis of the patient’s total payment responsibility • Amount not covered • Co-payment • Deductibles • Coinsurance • Other insurance payment • Patient’s total responsibility • Total amount paid by the payer

30. Draft Use Cases as of 10/19 Emerging Blue Button App & Service Categories • Patient education • Care Coordination & PCMH activities & services • Quality-related applications & services for Accountable Care Organizations • Clinical decision-making, for both evidence-based decisions as well as preference-sensitive care • Finding and understanding more affordable care options (e.g. brand vs. generic medication) • Forecasting and planning a personal healthcare budget • Chronic disease management, including personal health tracking (e.g. diabetes) • Medication reconciliation & adherence tools • Integrity (errors, fraud & abuse) detection and assistance services • Patient-provider communication and scheduling (e.g. automatic pre-population of initial visit forms, triage of health issues, and scheduling & transportation support)

31. Microsoft Healthvault EOB Specification Main Information http://developer.healthvault.com/types/type.aspx?id=356fbba9-e0c9-4f4f-b0d9-4594f2490d2f XML Schema http://developer.healthvault.com/types/schema.aspx?id=356fbba9-e0c9-4f4f-b0d9-4594f2490d2f

32. HealthVault EOB Specification

33. HealthVault EOB Specification

34. 3rd-Party Developer Recommended Financial Data Fields Rationale: • Consistent with info already provided to members in EOBs • Key payment items enable individuals to see past health care spend & budget for future • Aims to lower healthcare costs, protects interest of payors Recommended Fields Paid amount Deductible amount Coinsurance amount Copay amount COB amount Employee member paid Explanatory codes Billed amount Allowed amount

35. Appendix: WEDI 10/22 Meeting Recap & Feeedback

36. Draft Scope Presented at WEDI 10/22 Draft Charter for S&I Community Review on the Wiki Identify, define, and harmonize implementation standards, tools and services that facilitate the automated PUSH and automated PULL of patient information via the Blue Button Identify, define and harmonize content structures and specifications for the Blue Button so that information downloaded is machine readable and human readable Identify, define, and harmonize protocols around identification and credentialing, and protocols around access and authorization, that facilitate the automated PUSH and automated PULL of patient information via the Blue Button Presented at WEDI 2012 Fall Conference, Health IT Business & Policy Impact http://www.wedi.org/forms/meeting/MeetingFormPublic/view?id=1C37D00000210 36 #ABBI

37. Schematic presented at WEDI 10/22Updated 10/26 Container Transport • Content • Capable • Recommended • Required “Automate” “Blue Button” For payors = Standardized EOB, or Standard Claims Info but.. ideally Consolidated CDA + financial data? Contacts:Pierce.Graham-Jones@hhs.gov& Henry.Wei@va.gov

38. Feedback, Comments & Discussionfrom WEDI Fall Conference 2012 (1/2) Plan-to-Plan PHR Standard is worth looking at, was ASC, developed by BCBS and AHIP. HL7 component was based on CCD. Did not contain financial data though. (commenter) ASC X12 835 satisfies what this needs (commenter) Family History may be an interesting use case (commenter) Timestamping is important. Time, place – design it NOW. Lesson learned from data warehouses, can’t go back and timestamp things. Long-term members are interested in narratives that fit into the narratives of their lives. If you want to portray a narrative, these info points will need underlying structure. (Max ___, commenter) What about making this available/accessible to patients? Need clear messaging – lousy today. E-mail also not a good thing. (commenter) Have you considered Dental Data (Kathryn Jonzzon) Need some way to correct the data (commenter) Maybe could include a VOID list, to actually convey not only the data, but what we knew to be corrected (Henry Wei)

39. Feedback, Comments & Discussionfrom WEDI Fall Conference 2012 (2/2) Claims data not perfect – but errors were in the data already. Blue Button doesn’t cause those errors – but DOES allows patients & consumers to finally at last see all their data. Still need to allow some 2-way communication & process to handle that error correction (Martin Jensen) When people download their ASCII files today, they start emailing their own PHR around. Potential abuse seems pretty hi; EMR seems more secure (Matt Warner) How many people really use this? Provider & payor % utilization is extremely low, PHR, EHRs, and payor portals do this already. Are we premature? We don’t have standards. We should let the industry work its way out. (commenter; ed. – may need clarification that this is a standard & brand for those PHRs, EHRs & portals) Personal story: my Medicare file had almost all the medical history incorrect, and also received an e-mail from Medicare in the clear with prevent service reminders. Very worried about security, privacy, and encryption. (commenter) Concern that EOB-type data has lower credibility, e.g. EOB has wrong date – couldn’t tell what was included – different name of other doctor who had billed for MD – not sure what it meant, e.g. negotiated rate (commenter) Feel “victimized” by Healthplan with “rule-out” diagnosis codes, as the health plan kept reaching out and contacting for a condition that I didn’t have; drugs were reclassified as COPD disease, and anurse wanted to help manage. Be careful with the data! (commenter)

40. Appendix: Options Review

41. Emerging Options as of 10/26As organized by C. Officer (thanks Chuck!) More Feasible More Useful Consolidated CDA, no financial info Option 1 + Financial Appendix as EDI 835 (either EDI or XML), separate file from CDA Option 1 + Financial Appendix, but map EDI 835 to HL7 C62 standard (like a “Misc.” section of CDA). One file, but could take a long time to map, and more like free form text. Go to HL7 and ask to create another section (like CCD) in CDA specifically for EOBs based on 835 Go to HL7 and ask to create another section with EOB + more (e.g. health savings account balances etc.)

42. Minnesota Uniform EOB Standard Source & Standard: http://www.health.state.mn.us/auc/eobremitmanual2007.pdf Stems from Minnesota HealthCare Administrative Simplification Act (ASA) of 1994 Payers can raise consumer awareness and strengthen customer satisfaction Set of administrative standards and simplified procedures throughout the industry Consistent industry guidelines

43. Comments from 10/26 Payer Content WG • Empower patient, get them the data, then let them figure out what to do with it • Potentially high complexity for payers • “may get very complex with all the proprietary information & algorithms used to display the EOB” • Payor-generated clinical content moving into Consolidated CDA • Many payors doing this today or soon (e.g. Humana, UnitedHealth, BCBS, Aetna) • Includes diagnosis info also, e.g. ICD-9 (or ICD-10) going in. (MU requires SNOMED for EMRs.) • Clearly caveated as payor data, based on billing information; has been discussed with providers, and they are aware – but what about patients without that prior knowledge? • CPT4 is proprietary to the American Medical Association (but CMS uses CPT4, HCPCS, ICD9s) • Discussion on ASC X12 835 • 835 provides a good conceptual framework – maybe a different final format, will help us • Patient really wants to know what their personal financial impact is… ultimate financial responsibility. Often EOBs will say “you don’t owe the provider anything.” • Adjustmentstake place later; e.g. contracted amounts, covered amounts etc. • Concern: “Uneasy” to look to 835 as source for meaningful information to the patient. 835 itself may not be appropriate…ultimately involves a proprietary data model at the carrier. • 837: Maybe patients really what to know what was submitted, versus what was paid. • What patients see today vs. what is in ASC X12 835 • 835 contains more info than EOB, e.g. code for procedure vs generic description • What patient really want is the current situation, or summarized status

44. Comments from 10/26 Payer Content WG • Eligibility Data • May want to consider also what would come back in an eligibility transaction, • Coverage info, responsibility, co-pays, deductibles, insurance, in/out network. • Could this be initial set of data to look at to begin with? • Hl7 did put in financial/insurance modules in C32. That might be a starting point. • Data source could first be what is required to be returned in the X12 271 eligibility/verification response transaction. • Then could consider additional data, e.g. here are currently claims submitted and status of the claim. • Keith Boone: Where do they go? Insurance ID Cards and CCD & CCDA • http://motorcycleguy.blogspot.com/2012/10/where-do-they-go-insurance-id-cards-and.html • CCD and cCDA template: Coverage Activity, with Policy Activity (list of policies, with policy or program activities) • Issue identified by Lloyd McKenzie: not every insurer has an HL7 OID (though payer IDs will become available soon)

45. Comment related to HIPAA & Privacy “HIPAA says you have to sign consent to send information, provider has to be able to share that with a payer.” – workgroup comment 10/26/12 Sources: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/righttoaccessmemo.pdf http://www.govhealthit.com/news/ocr-tells-patients-use-legal-right-health-data-access http://www.youtube.com/watch?v=JY1l5s8ED5c Note: Memorandum Leon Rodriguez -- director of the Office of Civil Rights Director noted that some health care orgs mistakenly think HIPAA privacy and security rules restrict their ability to give patients their own medical records "We're hearing more and more about widespread issues, patients being denied or obstructed in their access to their records.” “HIPAA is a valve not a blockage, and it needs to be understood that way.” Patients also have a right to correct health record, to submit a written statement of disagreement

46. Value Proposition of Blue Button for InsurersDeveloper Perspective 11/2/12 Value of making EDI-type Codified Financial Data available to consumers Reduced call volume & operational costs -- other entities can participate in reconciling and closing the claim quickly and correctly Patient satisfaction: direct and painless access to all relevant data; clarity on what to pay and why Provider network satisfaction: more patients pay their bills - reduction of bad debt (esp. with high-deductible CDHP) Competitive advantage: allows integration (“mashup”) of other consumer driven products/services to further reduce claim cost (healthier patients) Employer segment will begin to make member self-service access to their own data a factor in selecting health plans “Price transparency is also important because the current system favors bad quality providers. Once it becomes clear that for example [Hospital A] is cheaper and a lot better quality than [Hospital B], it will apply the right pressure on providers to improve quality.”

47. Preferred Payer Content FormatDeveloper Perspective 11/2/12 • “Anything is good as long as it’s electronic – better than mail!” • “There is no other standard besides ASC X12 835 & 837 [for the type of data we are dealing with]...” • “[We] would prefer Quicken banking-type format, too, e.g. XML format, represents everything.” • Patient-controlled ASC X12 835 data would be “awesome”, solves for 80% of the needs, but still has some needs • “Deductible, co-pay, and nitty-gritty details” especially those that are important to TPAs • Employer wrap-arounds • Reimbursements paid to the patient vs. the provider • “The first question I have [as a patient/member] is: how much do I owe? How do I know this is the correct amount?” • Highly preferred if this can be done via pull-model OAuth-style server-to-server transport (although content standard useful) – should reduce operational costs for insurer as well vs. EDI feeds

48. Developer Needs (proposed as Goals)Developer Perspective 11/2/12 Key Needs from the Developer/Solutions Community “Get the technical details done fast and correctly” “Clear, standard, working code and SDKs” Insurers & other data suppliers (PBMs) to signal their intent & commitment to make the data available, e.g. via the Blue Button Pledge Community (healthit.gov/pledge) Automation standards (see Push & Pull workgroups)

49. Payer Content Standards Options for Blue Button to Review (as of 11/2)

50. Potential Blue Button Download Delivery Patterns for Patient/Member Portals Payer Claims Database Patient / Member Portal ASCII .XLS ? .PDF .XML ? Self-Displaying Embedded Data?