Title: Arial 28pt'

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HTH974 - Whats Next after HIPAA Transactions -
Neighborhood Health Plan
Marilyn Daly, RN. MPH Director of Applications
e-Business mdaly_at_nhp.org August 15-19, 2004
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Overview

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

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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.

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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

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Problem Statement

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

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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

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Pre- HIPAA Environment
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 Credenti
alling
Claims from Web MD-EDI
Scanned Paper
Keyed manually
Manual loads
CLAIMS PROCESSING (CSC/TXEN) Premium
Billing Capitation Payment Claims
Processing Provider Payment
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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

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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

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Post HIPAA- Batch transaction flow
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Post HIPAA -Real Time Transaction flow
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Post HIPAA Results Institutional Claims
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Post HIPAA Results Institutional Claims
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Post HIPAA Results Professional Claims
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Post HIPAA Results Professional Claims
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Post HIPAA Results Eligibility Inquiries
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Post HIPAA Results Claims Status Inquiry
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Post HIPAA Results Referral Transactions
TODATE NO DIRECT EDI TRANSACTION VOLUME THROUGH
NHPnet
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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)

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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

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NEHEN Collaborative
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NEHEN Collaborative
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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 BCBSMA
Secure MA Medicaid

• 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
Develop post-HIPAA Data Exchange
All Payer, All Transaction Connectivity
(completing the txn matirx)
Data Mining Content (disease management)
New Features Direction
NEHEN Portal Services
Plan for Common Provider Portal
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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.

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HTS Transactions with HPHC
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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 Plan747,000 members
• Fallon Community Health Plan185,000
  members
• Neighborhood Health Plan120,000 members
• Pilot Hospitals
• Beth Israel Deaconess Medical Center534 beds,
  teaching, level 1 trauma
• Boston Medical Center.547 beds,
  teaching, level 1 trauma
• Emerson Hospital170 beds,
  community

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Meds Info Who?

• Project Management
• MA Health Data Consortium, Inc.
• MA-SHARE, LLC
• Technical Consultants
• ZixCorp
• Computer Sciences Corporation (CSC)

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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

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Meds Info Clinical Connectivity- Vision
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Meds Info Integrating into the ED workflow
A patient safety initiative to automate
communication of medication history
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Meds Info Approach
Phase 1 Health Plans authorize access to
dispensed (adjudicated) Medication History Phase
2 Add Pharmacies Hospitals as data sources
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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

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Meds Info Go Live Timeline
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Some said we would implement Regional Community
Connectivitywhen pigs fly
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Questions