HTH974 - What’s Next after HIPAA Transactions - Neighborhood Health Plan

1. HTH974 - What’s Next after HIPAA Transactions - Neighborhood Health Plan Marilyn Daly, RN. MPH Director of Applications & e-Business mdaly@nhp.org August 15-19, 2004

2. Overview • About Neighborhood Health Plan • The Problem • Objective • Pre HIPAA • Post HIPAA • NEHEN • HTS Transactions with HPHC • Meds Info • Questions

3. About Neighborhood Health Plan • Neighborhood Health Plan is a not-for-profit health maintenance organization serving over 120,000 members throughout Massachusetts. • Approximately 300 employees • Information technology has approx 30 employees • Our network of providers include: • 1,900 primary care physicians at more that 250 primary care sites • 9000 specialist • 41 teaching, community and specialty hospitals • 26 community health centers.

4. Problem Statement • NHP struggled for a number of years with a fragmented Edi environment • Current infrastructure did not support future business requirements • Fragmented architecture – no true automation • Each health care visit estimated to produce 5 administrative transactions per visit • Clearing house cost expected to increase from .40cents to $2.00 per health care visit

5. Problem Statement • Needed a long term information technology plan to reduce paper and be HIPAA compliant • Many competing priorities • Limited resources • Competitive market place

6. Objectives • Be A Strategic partner in NEHEN Network • Develop an EDI infrastructure to support direct submissions of • Real time transactions • Batch Transactions • Reduce transaction cost • Leverage HIPAA to achieve administrative simplification • Streamline business operations through the use of technology • Improve provider relations • Position NHP to be a competitive player in the Massachusetts market place

7. Pre- HIPAA Environment PrInSys CS2000 TXEN Onyx Data Warehouse Referral and Eligibility transactions WWW.NHPnet MEMBERS Member Enrollment Member Education Member Service Member Appeals REFERRAL/ AUTHS / CASE MGMT. Concurrent Review Referral Management Authorization Management Health Needs Assessment Case Management Disease Management PROVIDER Directory Enrollment Contracting Credentialling Claims from Web MD-EDI Scanned Paper Keyed manually Manual loads CLAIMS PROCESSING (CSC/TXEN) Premium Billing Capitation Payment Claims Processing Provider Payment

8. Developing the Infrastructure - Batch • Leveraged Sybase BPI Suite for Health Care • Developed a mail box structure in the DMZ • EDI server in the DMZ • Set-up trading partners • Batch transaction files dropped in the trading partners mailbox • Process listener move the files into the network • Providers receive transaction reports • 997- File acknowledgement • 278- Unsolicited –detailed claims submission report • 835- Electronic remittance

9. Developing the Infrastructure – Real Time Transactions • Asynchronous socket-to-socket connection • Real time request/response • 50/100 concurrent sessions • Established Near Real Time member and provider database • Reduced source variation • Provided up to date real time eligibility • Supports both the batch and real time transactions • Migrated all in bound electronic eligibility requests to one standard source • NEHEN • NHPnet • Direct EDI

10. Post HIPAA- Batch transaction flow

11. Post HIPAA -RealTime – Transaction flow

12. Post HIPAA Results: Institutional Claims

13. Post HIPAA Results: Institutional Claims

14. Post HIPAA Results: Professional Claims

15. Post HIPAA Results: Professional Claims

16. Post HIPAA Results: Eligibility Inquiries

17. Post HIPAA Results: Claims Status Inquiry

18. Post HIPAA Results: Referral Transactions TODATE NO DIRECT EDI TRANSACTION VOLUME THROUGH NHPnet

19. NEHEN Collaborative • The New England Health Care EDI Network (NEHEN) is a consortium of regional payers and providers who have designed and implemented a secure and innovative electronic commerce solution for reducing administrative costs in Health care. • Use of private network rather than the internet • Each Member connects by private frame relay or VPN • No central server or data base- all patient identifiable data is transitory in nature • Standards based • HIPAA (ANSI X.12)

20. NEHEN Collaborative • Collaborative • Shared development • Shared intellectual property • Integrated with enterprise applications • Avoids double data entry • Integrated into existing workflows and processes • Minimal intrusion into enterprise strategies and architecture

21. NEHEN Collaborative

22. NEHEN Collaborative

23. NEHEN Collaborative 2004 2005 2006 2nd Qtr 3rd Qtr 4th Qtr Implement Highly Reliable eGateway Infrastructure Improvements Develop & Document “new” Technology Standards Develop Data Mining Transaction Stats Develop and Implement Better Performance Monitoring Tools Secure MA Medicaid Secure BCBSMA • Analyze Market Segments • Community Hospitals, PHOs, Ancillary/Allied Providers, Practice Groups (small provider message), Small Payers • Develop Market Segment Strategies & Solutions • Community Hospitals, PHOs, Ancillary/Allied Providers, Practice Groups (small provider message), Small payers Develop Small Provider Solution (if feasible) Market Expansion Secure Aetna, Cigna, United Develop Strategy for Vendors (Meditech, etc.) Process Improvements Define Process Standards Low Cost/Minimized Administrative Overhead Optimize Utilization by Providers All Payer, All Transaction Connectivity (completing the txn matirx) Develop post-HIPAA Data Exchange Data Mining Content (disease management) New Features & Direction Plan for Common Provider Portal NEHEN Portal Services

24. HTS Transactions with HPHC • Exchanging information between payers and providers in a distributed environment, leveraging SOAP as the mechanism for transporting the messages and XML Schema syntax for describing the data elements and structure of the XML Soap message. • SOAP can exchange messages over multiple Internet protocols, but we are currently sending and receiving messages over HTTPS and HTTP. • SMTP and/or RPC services will be added at a later time, when there is a business need to do so.

25. HTS Transactions with HPHC

26. Meds Info: Who? • Sponsors: • Alliance for Health Care Improvement: Medical Directors of 5 local Health Plans • Blue Cross Blue Shield of MA……………………..2.6 million members • Harvard Pilgrim Health Care……………………….790,000 members • Tufts Health Plan………………………………………747,000 members • Fallon Community Health Plan……………………185,000 members • Neighborhood Health Plan…………………………120,000 members • Pilot Hospitals: • Beth Israel Deaconess Medical Center…………534 beds, teaching, level 1 trauma • Boston Medical Center……………………………….547 beds, teaching, level 1 trauma • Emerson Hospital………………………………………170 beds, community

27. Meds Info: Who? • Project Management: • MA Health Data Consortium, Inc. • MA-SHARE, LLC • Technical Consultants: • ZixCorp • Computer Sciences Corporation (CSC)

28. Meds Info: Why? The GOALS • Real-time clinical information for ALL patients to their treating providers: what they need, when & where they need it to assure patient safety • A clinical application to comply with The Leapfrog Group/National Quality Forum Safety Practices… information transfer, communication, safe medication use • Address JCAHO Patient Safety Goals: “Improve the Effectiveness of Communication Among Caregivers” • Collaborate with MA Coalition for the Prevention of Medical Errors- Reconciling Medications project

29. Meds Info – Clinical Connectivity- Vision

30. 5 6 1 2 ED Registration 3 4 • Patient Presents at ED • Patient: • Provides demographic information • Discusses/provides Notice and Agreement to patient • ED Registrar, RN, or MD, inputs information to MedsInfo Solution, initiates inquiry • MedsInfo System returns Rx history • Clinician: • Validates patient identified by MedsInfo Solution • Uses Rx Information as appropriate in care of patient • 6) Clinician treats patient accordingly and communicates as needed Proof of Concept Solution Set Meds Info – Integrating into the ED workflow A patient safety initiative to automate communication of medication history

31. Meds Info Approach Phase 1: Health Plans authorize access to dispensed (adjudicated) Medication History Phase 2: Add Pharmacies & Hospitals as data sources

32. Meds Info – Patient Privacy Privacy Officers agreed: • HIPAA permits release of RX history to ED for treatment without consent, BUT • Application design will include “Yes/No” to capture patient notification of query capability and opportunity to participate or not • Pilot will screen-out “sensitive” classes of medications for treatment of HIV/AIDs, Mental Health, Substance Abuse for Mass. Law compliance • Reviewing acceptable community practice to eventually release all Rx history Security Officers agreed: • Access – unique individual user level sign-on with password • Audit– requires capture of user & patient level data, no clinical PHI • Demographic PHI maintained in MPI, must be secured, protected, contractually defined

33. Meds Info – Go Live Timeline

34. “Some said we would implement Regional Community Connectivity…when pigs fly”

35. Questions