Spotlight Analytics Update

Spotlight Business Analytics helps healthcare organizations run custom analytics on health data including market share, patient origin, disease prevalence, cost of care, and comparative costs and outcomes for acute care hospitals.

We are pleased to announce our partnership with the Lown Institute to add civic and care leadership measures to Spotlight. Augmenting Spotlight’s market share, disease prevalence, and demographic analyses with the Institute’s equity, value, and outcomes measures will provide Spotlight subscribers with a more comprehensive and relevant view of health system performance. We are working on and plan to have these new datasets incorporated into Spotlight for use at the beginning of the year.

The current data status is:

Loaded & available for use:

• Massachusetts Hospital Inpatient Discharge Data FY19
• Massachusetts Emergency Department Discharges FY19
• Rhode Island Hospital Inpatient Discharge Data FY20

Received & ready for use soon:

• Massachusetts Observation Data FY19

• Lown Institute measures

• Massachusetts Emergency Department Visit Data FY20

• Massachusetts Hospital Inpatient Discharge Data FY20

• Massachusetts Observation Data FY19

Future planned data:

• Massachusetts Observation FY20
• New Hampshire Facility Discharge Data Sets (Application pending)
• Maine Hospital Inpatient and Outpatient Data (Application pending)

Please feel free to drop us a line with any questions or comments at spotlight@mahealthdata.org. In the meantime, thank you for being a Spotlight Analytics user and a member of this community! Feel free to visit our Spotlight Business Analytics page or email us at the address above for more information.

DGC Update

January 2022 Regulations: No Surprises Act

The No Surprises Act was part of the consolidated budget bill passed at the end of 2020. The law indicated most of its provisions take effect on the first day of new plan years on or after January 1, 2022. Two major regulations related to the law have been released as interim final rules (IFRs), but the vast majority of clauses do not yet have corresponding regulation. In an interesting move, several major clauses are supposed to be implemented anyway in a good faith effort to meet the requirements of the law. Regulation for most of these components are expected in the future at which time adjustments might be needed for existing implementations.

Let's take a look at the various clauses of the act and what we know about enforcement of each.

Price Transparency for Care

The price transparency components of No Surprises falls into three major categories: emergency services, non-emergency services, and continuity of care.

The first IFR covered emergency services, redefining the federal definition of what constitutes an emergency service and a rule that all emergency services must be covered at in-network cost sharing for patients and these payments must be included in in-network deductible and out of pocket maximum rules for the patient.

There are several different areas addressed for non-emergency services. First, any out-of-network providers practicing at an in-network facility must be covered as if they're in-network providers. This is true for hospitals, hospital outpatient centers, critical access hospitals, and ambulatory surgery centers; urgent care centers are not currently on the list but are being considered. Visits to these facilities do not have to be onsite; telehealth counts, as does imaging or laboratory work actually performed offsite or sent offsite for evaluation but offered through the facility. It is unclear if office visits at a separate location offered through the auspices of the facility also count; there are indications they do but it has not been explicitly stated either way. Patients may sign away this right in some but not all circumstances, but doing so must be voluntary with no coercion; a partial list of bad behaviors that invalidate consent is included in the IFR.

The major component of the rules for non-emergency services revolve around cost estimates for patients. The process and requirements for these differ depending on whether the patient is insured or uninsured/self-pay (defined as choosing not to use their insurance within the regulations).

In both cases, either when a service is scheduled or at the request of a patient, a provider organization initiates the process by creating a good faith estimate (GFE) of what the services will cost. The GFE is organized around a scheduled service even if it's performed by multiple providers or at multiple facilities or both. A primary provider is responsible for gathering estimate information from all of the other providers and including it in a single GFE.

For uninsured or self-pay patients, the GFE is sent directly to the patient in a format of the patient's choosing; this is outlined in IFR 2. For insured patients, the GFE is sent to the patient's payer. In both cases this must happen within three days if a service is more than ten days in the future (or not scheduled) and one day if it's within three days of the expected date of service.

After a payer is sent a GFE from a provider they have the same time frame of one or three days to produce an Advanced Explanation of Benefits and send it to the patient/member in the format of their choice.

While not binding, estimates are expected to be in the ballpark; patients are allowed to dispute bills from any provider when they differ from the estimate received for those services by more than $400.

Both patients and out-of-network providers have the ability to dispute bills (patients) or payer payment amounts (provider) using a process outlined in the second IFR.

Continuity of care requirements cover care that's already underway when a provider and payer sever their contract and a provider moves from in-network to out-of-network. The No Surprises Act requires that the payer continue to treat this care as if it were in-network for a minimum of 90 days after the relationship is severed and the provider continue to accept both payer and patient payment at in-network rates.

Enforcement expectations for these vary; see the summary chart below for specifics.

Patient/Member Services

There are a variety of patient and member services that can affect cost of services also included in the No Surprises law. There are strict new provider directory requirements for both payers and providers meant to ensure that provider directories are up to date and that, if they aren't, patients aren't responsible for bad information they contain. Providers are required to send payers updated information whenever they start a new contract, end a contract, have material changes, or if the payer requests them. Payers are required to verify the information in their provider directories at least every 90 days; if they can't verify a provider's information they must be removed from the directory. In addition, payers are required to respond within 1 business day to requests about provider or facility status. Patients relying on incorrect information gained from the directory or an inquiry cannot be penalized and services from the relevant providers or facilities must be treated as in-network in terms of cost sharing, deductibles, and out of pocket maximums.

No Surprises also has new requirements for insurance cards. Insurance cards must include a patient's major medical deductible, major medical out of pocket maximum, a telephone and website for consumer assistance, and either information about or a website containing information on additional deductibles and out of pocket maximums if they exist.

Provider Directory and insurance card clauses don't have regulations yet but are enforced to a "good faith effort to implement" level starting in January 2022.

No Surprises also includes requirements around education, notification, and promotion of its other requirements. These include requirements that payers and providers post public notices about no surprise billing and patient rights in each physical facility, provide a one page written document about their new rights to patients, and post information about patient rights on their public websites. The requirement to supply these with some basic information about the required content is covered in IFR 1 but additional information about these and possibly additional disclosures is expected in future rules.

Other Clauses

The No Surprises Act also includes other requirements. It prohibits gag clauses or similar clauses in agreements between payers and providers that directly or indirectly prevent disclosure or access to provider-specific price, cost, or quality data. It also includes compensation disclosure requirements for insurance brokers, plan managers, benefits consultants and similar personnel.

Quick Summary of Enforcement

In summary, here's a list of what is and is not being enforced right away:

Enforced January 1, 2022 (or first plan rollover thereafter):

1. Gag clause prohibition (no regulation expected)
2. Emergency services clauses (IFR 1)
3. Rules and payment models for out-of-network providers at in-network facilities (IFR 1)
4. Patient consent requirements for signing away out-of-network protections for non-emergency services (IFR 1)
5. Good Faith Estimates for uninsured/self-pay patients covering a single provider/facility (IFR 2)
6. Dispute resolution for uninsured/self-pay patients (IFR 2)
7. External review eligibility (IFR 2)
8. Coordination of care clauses (good faith effort, regs to come)
9. Insurance ID cards (good faith effort, regs to come)
10. Provider Directory (good faith effort, regs to come)
11. Disclosures, education, notifications, and promotion (general content in IFR 1, specifics as good faith effort, additional regs to come)

Not Enforced until later:

1. Good Faith Estimates and Advanced Explanation of Benefits for insured patients using their insurance
2. Consolidated Good Faith Estimates for uninsured/self-pay individuals containing all providers/facilities for a single service (delayed one year, IFR 2)
3. Dispute resolution for patients using insurance (outlined in IFR 2 but not applicable until related estimates are required)

Unclear:

1. Compensation transparency rules

And there you have it - everything we currently know about No Surprises so it doesn't surprise you as much as it surprised us.

NEHEN reduces administrative burden through the adoption of standardized transactions. It is a cornerstone service for payer and provider trading partners wishing to exchange industry standard X12, HIPAA compliant transactions in a real-time, integrated manner using APIs. Because of our unique governance, non-profit status, and membership-based model, NEHEN is able to offer very competitively priced services relative to the market.

For information about NEHEN please contact us at members@nehen.org.

2021 started with a rushed Prior Authorization final rule from CMS - one that followed a draft with only 17 days of public comment over the holidays. It had inconsistencies and included a lot more than prior authorization features - most notably, it mandated that payer => payer exchange use FHIR and added a Provider Access API mandating payer => provider data exchange - but it was a logical follow up to the May 2020 interoperability rules and as well as an attempt to address and automate a process (prior authorization) most folks agree is burdensome on payers, providers, and patients.

The Biden Administration put a 60 day hold on all regulations put forward in the later days of the Trump Administration and, somewhat surprisingly, this rule is still on hold nearly a year later. We agree that the rule needed some revising - getting rid of those inconsistencies and putting it through a normal comment period come immediately to mind - but it addressed some important areas and made some useful modifications to existing regulations. One of the big questions for 2022 is whether it will come back and, if so, in what form? Check out our 2022 predictions for some thoughts on this.

Also at the start of the year, new hospital price transparency requirements started. They were just the tip of the iceberg, as we soon discovered. As the year moved forward, we discovered that a law passed without a lot of fanfare in late 2020 (as part of the consolidated budget) would become more and more of a focus. The No Surprises Act included a wide ranging set of policies and requirements around price transparency and continuity of care. While most people focus on the requirements around good faith estimates from providers and advanced explanation of benefits from payers, there's a lot more to the law that affects everything from insurance cards, out-of-network payments, end of payer-provider contract requirements, provider directory validation with related patient responsibility requirements, and more. It's big, and most of it goes into effect at the start of the first new insurance plan year on or after January 1, 2022. Only a small portion of the bill has corresponding regulations. A few of the provisions have been put on enforcement holds pending related regulation, but in many cases folks are supposed to make their best effort to comply without regulation until that regulation can happen. We'll discuss this further in our predictions for 2022 and in our standalone article on the No Surprises Act.

With the change of administration came personnel changes and our longtime friend Micky Tripathi became the National Coordinator for Health IT (head of ONC). One of the big pushes that followed is the idea of "equity by design" or trying to ensure health equity by consciously thinking about it as part of planning everything they do. Health equity and SDOH were big in other ways this year, with numerous events focusing on it (our own DGC Deep Dive on SDOH was by far our most attended with over 300 people registered and, at its height, more than 200 concurrent attendees). Congress is also on the bandwagon with several bills in process on SDOH, SDOH data, SDOH analysis, and more. If passed and signed into law most of these will have data and interoperability implications. Again, more on this in our 2022 predictions.

Also from ONC came enforcement of the first information blocking requirements in the spring, requiring providers to share requested health information (within consent frameworks). Initially only clinical data within USCDI is required, but more comprehensive data requirements (EHI) are coming in 2022. This information - including notes - must be shared in the format requested (if feasible) unless one of eight allowed exceptions can reasonably be applied to a request.

Halfway through the year on July 1 came the official enforcement date from CMS for Patient Access APIs and Provider Directory APIs. Some payers did the bare minimum to meet the requirements and some went all in. According to some industry surveys and analysis as many as 75% of payers still weren't in full compliance with Patient Access APIs in the late fall. Edifecs reported some of their payers had difficulty implementing FHIR facades; others were overwhelmed by the amount of data going through the pipes. Many payers who did comply waited to see patients arrive in droves, requesting their data, but it didn't always happen for a variety of reasons: lack of patient knowledge that they can get this data, lack of patient connection between API support and app support, and the difficulty third party apps had in finding and connecting to payers. When they did connect with payers, third party app developers had trouble dealing with the variance in the data sent by the payers, the lack of test data and environments, and with understanding which plans each payer did and did not support. Hopefully this will start sorting itself out better in 2022, but we're not making any specific predictions about it.

Underlying all of it was the continued effects of the pandemic which still remains with us, sucking up much of the oxygen in the industry. Providers are still in overdrive - Massachusetts has a new order delaying some non-emergency surgeries and other care because hospitals are overwhelmed again despite the relatively high vaccination rates here. The vaccination process highlighted many additional deficiencies in public health data and interoperability (on top of those discovered in testing, contact tracing, and outcomes reporting in 2020).

2021 - it's been a busy, invigorating, frustrating, and complex year that's brought us closer to data standardization, interoperability, and understanding how to successfully collaborate across organizations. Most importantly, it's brought us closer to a patient-centric healthcare system, one that enables each patient to access and control their own data. It's also shown us how far there is to go and the role data and interoperability needs to play in areas like health equity and addressing SDOH, improving public health capabilities, and moving even further into patient-centric healthcare. What's next on this journey? Who knows? We're making some predictions about 2022 - only time will tell if they come true.

We'll take a serious look at 2022 momentarily, but in the meantime here's a crossword puzzle for a lighter look at what's ahead. Send us your answers at newsletter@mahealthdata.org if you'd like but we'll post an answer key next time! 

ACROSS
2. They're at the center of everything
3. Healthcare API framework
5. ONC is doing it by design
7. Uses data to predict outcomes
10. Know the cost
13. Chairman of the Board

DOWN
1. They oversee privacy and security of third party apps
2. Get permission for a service from a payer
4. Translating the vocabulary of healthcare from one standard to another
6. Our new analytics partner
8. She's retiring and we'll miss her
9. All outcomes are known
10. CMS regulated exchange starting in 2022
11. Our exchange services arm
12. Food insecurity, homelessness, etc.