Colorado Clean Claims Task Force

Friday, March 01, 2013 12:23 PM

Citing unprecedented progress, task force seeks extension to finish developing standardized set of claims edits and payment rules

Marilyn Rissmiller, Senior Director, Health Care Finance

A Colorado task force has made unprecedented progress toward developing a standardized set of health care claims edits and payment rules, and is recommending lawmakers approve an extension to allow the group to finish its work.

The Colorado Clean Claims Task Force presented a report to legislators and the executive director of the state’s Department of Health Care Policy and Financing late last year. In it, the group noted it has had more success getting and keeping key stakeholders at the table and achieving consensus on difficult issues than any other state or national initiative of its kind.

Walter Suarez, co-chair of the National Commission on Vital Health Statistics’ committee on administrative simplification and health reform, agreed.

“Colorado’s effort remains the only significant work in this area,” Suarez said.

The task force was formed in 2010 through legislation supported by the Colorado Medical Society. Its goal is to help ensure claims are coded, submitted and processed “cleanly” the first time – a critical element of the state’s strategy to reduce health care administrative costs. The group estimates its work could save Coloradans $80 million each year in costs related to claims processing.

“By creating uniform medical claim edits and payment rules to be shared among all payers in Colorado, both payers and providers will be unburdened of tens of millions of dollars of administrative redundancy and outright waste, which can be redirected toward reducing the actual cost of care,” said Barry Keene, co-chair of the task force and the president of KEENE Research & Development.

The task force hopes to be a model for the rest of the nation – where the savings could be multiplied across many states. Its work also is intended to provide greater transparency across payers and to make it easier for patients to determine the cost of treatment and their financial obligations.

The group comprises representatives of major private payers and vendors working with claims across the country, as well as Colorado Medical Society, the American Medical Association, local physician billing personnel and the state of Colorado. Between December 2010 and November 2012, the task force held 25 meetings. Four committees also have met via conference call – one meeting as often as every other week.

Among the task force’s accomplishments:

• Developed guiding principles that focus on administrative simplicity, consistency, transparency, standardization and improved system efficiency;
• Conducted an analysis of, and made a determination that, the Medicare edit set, which is an important source of edits for the standardized set, does include edits to support commercial claims;
• Confirmed that, for the most part, the national medical specialty societies are comfortable with how Medicare develops its edits;
• Reached consensus on definitions for most of the types of edits the task force is required to consider. These definitions will drive selection of the edits in the standardized set;
• Compiled definitions and associated payment rules from several sources for 32 payment rule modifiers and began working through the process of finding consensus on which rules to use;
• Put together a detailed list of data sustaining repository responsibilities and essential functionalities;
• Issued and received responses to a request for information about potential strategies for, and the cost to design and develop, an online data repository;
• Drafted a request for proposals and approved criteria to select a contractor to compile the universe of existing edits and conduct analyses to inform development of the standardized set; and
• Identified alternative procedures for updating and making other changes to the standardized set after it has been implemented.

The legislation that created the Clean Claims Task Force required it to file a report by Nov. 30, 2012 detailing recommendations for a uniform, standardized set of payment rules and claim edits that would be used by all payers to process Colorado claims. It also required a final report be submitted in December 2013.

In its report to the General Assembly, the task force recommended it be allowed to continue its work to develop a standardized set. It also asked that the deadline for the task force’s final report be extended by one year, and that most payers have until Jan. 1, 2015 to implement the standardized set within their claims processing systems (the deadline for domestic nonprofit plans would be Jan. 1, 2016).

“Despite coming to the table with different concerns and perspectives, task force members have demonstrated their commitment to finding consensus on a standardized set and are well on the road to fulfilling their legislative charge but need more time to finish the job,” the report’s authors wrote.

The task force also recommended that the General Assembly’s health and human services committees and HCPF Executive Director Sue Birch write to the Secretary of the Department of Health and Human Services to ask for public access to the rationales for Medicare’s edits. The report noted that Medicare’s edits are a major source of edits for the standardized set but that the task force’s work was made more difficult because it hasn’t been able to determine the rationales for the edits. Nor is the group aware of any compelling reason for Medicare not making them public.

State Sen. Irene Aguilar, MD, is expected to file legislation this session that would extend the task force’s deadline by one year, as recommended. Aguilar and Birch also indicated they will draft letters to HHS Secretary Kathleen Sebelius seeking access to the rationales for Medicare’s edits.

The task force is always interested in physician input or questions. Please contact Marilyn Rissmiller, Colorado Medical Society senior director of health care financing, at marilyn_rissmiller@cms.org. Agendas and minutes for all meetings are available on the task force website: www.hb101332taskforce.org.