Unprecedented progress toward uniform set of claim edits

Clean Claims icon

Marilyn Rissmiller, Senior Director, Health Care Financing

A Colorado task force has made unprecedented progress toward developing a standardized set of health care claims edits and payment rules, and is recommending that the federal Health and Human Services (HHS) designate this initiative as a national pilot.

The Colorado Clean Claims Initiative is an effort by the state of Colorado, strongly supported by CMS, to standardize CPT claims edits across all private payers. The initiative was enacted by the Medical Clean Claims Transparency and Uniformity Act in 2010 – also strongly supported by CMS – that was designed to save the state millions of dollars a year with the understanding that payers and providers will undergo less administrative redundancy and waste. Current estimates place the savings of standardization of the millions of claims edits at $80 million to $100 million a year in Colorado alone.

“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 and Development.

The legislation laid a framework for the group’s work:

“The base set of rules and edits shall be identified through existing national industry sources that are represented by the following: (I) The NCCI; (II) CMS directives, manuals and transmittals; (III) the Medicare Physician Fee Schedule; (IV) the CMS National Clinical Laboratory Fee Schedule; (V) the HCPCS Coding System and directives; (VI) the CPT coding guidelines and conventions; and (VII) national medical specialty society coding guidelines.

“The task force shall consider standardizing the following types of edits, without limitation: (A) unbundle; (B) mutually exclusive; (C) multiple procedure reduction; (D) age; (E) gender; (F) maximum frequency per day; (G) global surgery; (H) place of service; (I) type of service; (J) assistant at surgery; (K) co-surgeon; (L) team surgeons; (M) total, professional or technical splits; (N) bilateral procedures; (O) anesthesia services; and (P) the effect of CPT and HCPCS modifiers on these edits as applicable.”

The group’s work is also intended to provide greater transparency across payers and to make it easier for patients to determine the cost of treatment and their financial obligations.

CMS actively participates in the 28-member task force, which also comprises representatives from major private payers, claims software vendors, the Colorado Medical Group Management Association, the American Medical Association, local physician billing personnel and the state of Colorado. The work of the task force is guided by principles that focus on administrative simplification: Consistency, standardization, transparency and improved system efficiency.

The task force submitted a report to the General Assembly in January 2013, which resulted in a bill sponsored by Sen. Irene Aguilar, MD, and Rep. Sue Schafer concerning the development of standardized rules in processing medical claims and extending the deadlines for the task force, and authorizing appropriation of state funds for the development of a set of rules. In the report, the group noted it has had more success getting and keeping key stakeholders involved and achieving consensus on difficult issues than any other state or national initiative of its kind.

“Despite coming to the table with different concerns and perspectives, task force members have demonstrated their commitment to finding consensus on a standardized set,” the report’s authors wrote.

All stakeholders – especially specialty societies in Colorado and nationally – were invited to be engaged in the entire process. Aggregated comments were posted online and considered by the task force for inclusion in the resulting set of rules. The process required initial consensus from all members of the task force on the initial draft, distribution for public review and comment, second review by the task force, and official response to comments and final consensus.

Now, after nearly four years of work, the group has made tremendous progress toward achieving its goals. Key accomplishments include:

  • Compiling definitions and associated payment rules from several different sources for 32 payment rule modifiers;
  • Achieving consensus on a list of 24 payment rules;
  • Completing the rule development process for all payment rules;
  • Drafting the governance for a transitional entity to maintain the edits;
  • Procuring a vendor to perform data analytics functions during the 2014 period; and
  • Making substantial progress in creating a model for sustaining the output of the task force into the future.

Colorado leads the nation in efforts to standardize claim edits and payment rules across private payers, and the task force hopes to be a model for the rest of the nation – where the savings could be multiplied across many states.

Colorado physician leaders met with the Colorado congressional delegation in March 2014 as part of the American Medical Association’s National Advocacy Conference (NAC) in Washington, D.C. All delegation members expressed support for federalization. In fact, Colorado’s two U.S. Senators, Sen. Mark Udall (D) and Sen. Michael Bennett (D), previously worked together on an administrative simplification provision of the Affordable Care Act that would allow the HHS secretary to designate Colorado’s Clean Claims Initiative as the national model.

For more information on the initiative and the task force, go to www.hb101332taskforce.org.


Categories: Communications, Colorado Medicine, Practice Evolution, Payment Reform, Interacting With Payers