December 6, 2018
Nicholas L. Coussoule, Co-Chair, Subcommittee on Standards
Alexandra Goss, Co-Chair, Subcommittee on Standards
National Committee on Vital and Health Statistics
CDC/National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782-2002
RE: Draft Recommendations for the Predictability Roadmap
Dear Mr. Coussoule and Ms. Goss:
The Medical Group Management Association (MGMA) is pleased to submit the following letter in response to the request for comments on the National Committee on Vital and Health Statistics (NCVHS) “Draft Recommendations for the Predictability Roadmap,” published on August 24, 2018. We believe this roadmap is an important initial step toward improving the identification and implementation of administrative standards that will streamline communications between providers and health plans.
MGMA is the premier association for professionals who lead medical practice. Since 1926, through data, people, insights, and advocacy, MGMA empowers medical group practices to innovate and create meaningful change in healthcare. With a membership of more than 45,000 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.
The current process for developing and adopting new and revised administrative simplification standards, encouraging wide-spread use of the standards, and enforcing compliance with the standards is defective. Transitioning from one version of the X12 standards (4010 to 5010, 5010 to 7030) has been needlessly protracted with some federally-mandated standards still waiting to be promulgated. For example, the X12 275 electronic transaction has yet to be published, despite two statutory requirements and four separate letters sent by the NCVHS calling for its release. Many of the currently-mandated standards are being underutilized and health plans are increasingly driving physician practices to proprietary web portals and away from the efficient use of electronic data interchange.
Adding to these challenges, the Centers for Medicare & Medicaid Services (CMS) has abdicated its leadership role by failing to issue or in fact rescinded guidance protecting physician practices from unfair business practices and by taking a hands-off approach to enforcement of health plan noncompliance. Recent results from the CAQH Index, measuring use and costs of the HIPAA electronic transactions and operating rules, suggest administrative transactions are underutilized and billions of dollars in saving are unrealized.
Further, physician practices are currently underrepresented in the current Standards Development Organization (SDO) process and, to date, little effort has been made to engage with this critical stakeholder group. Moreover, standards are implemented nationally prior to adequate testing of these new and revised standards, and with virtually no exploration of business need or return on investment for physician group practices and other industry stakeholders.
With this as the backdrop we were pleased to see NCVHS begin consideration of a revised process for the development and adoption of new and revised standards. The following are our high-level recommendations:
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- NCVHS should urge CMS to more aggressively enforce health plan compliance with mandatory electronic transaction standards and operating rules.
- The current process for developing and adopting electronic transaction standards and operating rules is broken and must be repaired. The process is overly protracted and significant streamlining is necessary if physician practices are to achieve the benefits of administrative simplification in a timely manner.
- The physician practice perspective in the standards developing process is underrepresented and we encourage the SDOs to create new opportunities to solicit input from this sector.
- Prior to NCVHS recommending a new or revised standard, the clear business need must be established and a comprehensive return on investment study conducted.
- New standards can be tested by willing trading partners, but these tests should be limited in scope and approved by HHS.
- While we support expedited review of potential new or revised standards, we oppose setting a defined time limit for the Department of Health and Human Services (HHS) to review and publish new or revised standards