May 23, 2018
Director of the Office of Strategic Operations and Regulatory Affairs
Centers for Medicare & Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development
7500 Security Boulevard
Baltimore, MD 21244-1850
Attention: Document Identifier CMS-10148
Dear Director Cantwell:
The following comments for the Medical Group Management Association (MGMA) is in response to the Information Collection Request for the Centers for Medicare & Medicaid Services (CMS) “HIPAA Administrative Simplification (Non-Privacy/Security) Complaint Form.” We will provide comments specifically on the complaint form itself and more generally on the overall CMS administrative simplification enforcement process.
MGMA is the premier association for professionals who lead medical practices. Since 1926, through data, advocacy and education, MGMA empowers medical group practices to create meaningful change in healthcare. With a membership of more than 40,000 medical practice administrators, executives, and leaders, MGMA represents more than 12,500 organizations of all sizes, types, structures, and specialties that deliver almost half of the healthcare in the United States.
MGMA appreciates the opportunity to provide comment of the complaint form and on the broad issue of enforcement of the electronic transactions, operating rules, national identifiers, and code sets mandated in HIPAA and the Patient Protection and Affordable Care Act of 2010 (ACA). While we are supportive of a process that permits physician practices to formally lodge a complaint against a health plan or clearinghouse, notifying CMS of a potential violation, the low adoption rate for many of the electronic transactions signals that this process should be augmented with a more aggressive enforcement approach. The most current figures from the CAQH Index report show significant stagnation in several of the critical administrative transactions and actually a decreased utilization rate for some.
For example, use of the X12 270/271 (Eligibility & Benefit Verification) continues to be less than 80% and the X12 835 (Remittance Advice) remains stagnant at 56% adoption. Disconcertingly, use of the Electronic Funds Transfer transaction for payments declined from 62% to 60% while use of the X12 278 (Prior Authorization) transaction went from 18% to just 8%. At the same time, health plans have increasingly been driving providers away from using the HIPAA standards transactions and toward use of online portals. While online portal use benefits the plans by reducing faxes and phone calls, proprietary portals create a manual workflow process for providers and decreased revenue cycle automation.