The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

New CMS EDGE Server Requirements Challenge Health Plans

By Bryan Briegel/Friday, October 10, 2014
On Wednesday, October 1, Centers for Medicare & Medicaid Services (CMS) hosted a special webinar on EDGE server requirements for issuers of ACA-compliant small group and individual plans on and off the Exchange, subject to the Risk Adjustment and Reinsurance programs. The webinar has left many health plans confused – CMS’s updated enrollment file requirements are a fundamental shift away from specifications issuers have been coding to since May 2013, when CMS announced the enrollment technical and business rules.

What was announced? In short, effective immediately, all enrollment extracts that have been coded to comply with CMS specifications have been rendered incorrect, and will not support the Risk Adjustment Transfer payment calculations – one of the key reasons for submitting data to the EDGE servers. As an EDGE server host and partner with a number of health plans, we at Truven Health Analytics have been working with our clients to handle these changes. 

Here is some background for those new to the game: CMS announced late this summer that it expects issuers to load 2014 enrollment and claims data to their EDGE servers by December 5, 2014, so issuers may receive estimates of their reinsurance payments and risk scores. Since the inception of the program, the enrollment file – and its required structure – has been the most complex and challenging file to produce. Compounding this has been the lack of clarity on how to set a particular field called “Enrollment Period Activity Indicator” (EPAI) and the companion requirement mandating how dependent records must fall within bounds of enrollment start and end dates of their subscriber’s record.

From the October 1 announcement, through the eventual late October 7 release, the CMS shift in requirements left issuers in limbo – suspending any coding activity on enrollment extracts or for those who may have completed coding, and left them considering resourcing a rapid response team to review and revise the extracts. 

Since the October 7 release, the Truven Health EDGE team has reviewed the updated requirements and is working with our issuer partners to re-code their extracts. In helping our issuer partners prepare for the CMS December 5 EDGE data load and initial CMS report run, many have discovered gaps in their billing and rendering provider IDs. CMS has specified that provider IDs are required for claims submitted to the EDGE server and will reject claims with missing IDs. Truven Health has worked with CMS to validate that billing and rendering provider IDs may be used interchangeably on a claim. Additionally, if there is no provider ID information available, issuers may use a proxy or “dummy” ID in its place; for example, a constant string of “333333333333333” while setting the provider ID qualifier as 99. CMS will publish updates to provider ID requirements within the next few weeks via REGTAP, where CMS promulgates business rules and technical requirements for EDGE.

For Truven Health’s part, we’ll continue to monitor these events and share information that impacts your EDGE server work and partner with you to keep in step with CMS.

Bryan Briegel
Director, Operations

Although Not Typical, Walmart’s Employee Benefit Costs Worth Noting

By Anita Nair Hartman/Tuesday, September 16, 2014
Anita Nair-Hartman imageA recent CNBC article discussed Walmart’s announcement that it will spend far more than anticipated on employee health coverage and have to trim its earnings forecast for the year. The retailer expected more workers to seek coverage under the Affordable Care Act’s (ACA) mandated coverage requirement, but the actual number topped their projections. Although this news has gotten a lot of attention, National Business Group on Health research indicates that most employers aren’t expecting as large of a jump in healthcare costs as Walmart, and Truven Health research supports this. As the CNBC article points out, Walmart’s employee base has some unique characteristics -- including low-wage workers in states where Medicaid expansion didn’t occur, forcing them to chose Walmart (rather than Medicaid) coverage. These aren’t typical employer circumstances.

Nonetheless, after years of low healthcare inflation, employee benefit costs have grown this year, and Wall Street is going to be keeping an eye on the impact to every company’s bottom line. For employers, monitoring benefits spend and strategy is more critical than ever. Equally important will be engaging employees in healthcare decision making, improving health and productivity through wellness programs, and remaining vigilant on fraud and waste.

Anita Nair-Hartman
Vice President Market Planning and Strategy

Ensuring Success in the Health Plan Marketplace

By Anita Nair Hartman/Thursday, September 4, 2014
Anita Nair-Hartman imageA recent New York Times article discussed the impact of competitive health insurance markets on the cost of purchasing health insurance, particularly via Marketplaces. Health plans are just beginning to understand and create market-based products tailored for consumer needs and market competition. Competition motivates health plans to improve value and align consumer needs with products and services, resulting in the consumer benefits of lower premiums and additional services and coverage.

As part of the retail and complex channel strategies for health plans, aligning consumer needs (provider network, out-of-pocket-costs, and service coverage) with their products becomes increasingly important, as does ensuring appropriate consumer education on plan design choices, cost transparency, and engagement in healthcare. Health plans that can manage these aspects when offering products in the new Marketplaces will have greater success – gaining more consumers and keeping them for the long-term.

Anita Nair-Hartman
Vice President of Market Planning and Strategy

Smart Use of Urgent Care Helps Consumers, Providers, and Payers Win

By Linda MacCracken/Tuesday, July 15, 2014
Linda MacCracken imageConsumers – people like us, our parents, and our children – wait an average of 19 days for an appointment with a family practice doctor, making healthcare difficult to obtain. When you can take three vacations in the time that you’ll wait to see a doctor, something is really wrong. The magic of the Internet – online Skype appointments and iPhone diagnostics – lacks assurance that something dire hasn’t been missed. This is why doctors train, get credentialed, and ‘practice.’

Providers with smart, extended footprints are doing more. Our data shows that over the next five years, demand for after-hours care in some markets can grow 35%, versus a 22% demand growth for overall Emergency Department (ED) care. The newly insured’s younger enrollees – those under 35 – will use the ED twice as often as when they were uninsured. Nationally, 62% of ED visits are urgent, suggesting that at least one in three can be seen elsewhere.  

Payers are concerned that 70% of ED visits are avoidable, and they can save the $1100/visit by redirecting ED patients to lower-cost sites, such as urgent care centers. Urgent care is right for patient demand, good for the provider access, and effective for payers seeking to contain costs.

Winning the race to profit from the demand for urgent care and improve patient experience calls for delivering the right service, in the right market, with the right access.

Linda MacCracken
VP, Advisory Services

Five Things Employers Want from Health Plan Reporting

By Jennifer Huyck/Thursday, June 19, 2014
Jennifer Huyck imageThese days, health plans are under pressure to deliver more comprehensive and reliable information to their employer clients.

After all, population health is on everyone’s radar, and employers are trying to keep a tight rein on rising costs. Plus, with all the talk of healthcare Big Data, employers have higher expectations of the kinds of information health plans can provide. Information transparency and combining financial and clinical data from multiple sources are becoming critical.

In other words, traditional reporting isn’t going to cut it anymore.

But what, specifically, do employers want from health plan reports?

Based on our partnerships with over 150 of the nation’s largest employers — including 25 percent of Fortune 500® companies — Truven Health experts have compiled the following list of the five most important things employers want when it comes to the health plan reporting.
  1. Acknowledge their different needs. Step away from one-size-fits-all reporting. Each employer client will want to see different slices of data and varying levels of analysis to fit their specific business questions. Reports need to be flexible enough to meet those diverse requests and stakeholders.
  2. Help them educate and inform their senior management team. Benefits managers need to be able to prove to the Powers That Be that the company’s investments in employee health are worth it, and health plan reporting is an important part of that.
  3. Provide consistent, accurate, and timely reporting. Employers want data that they can trust, and they want it quickly.
  4. Show them how to compare themselves to the outside world. Reporting solutions should allow employer clients to compare costs and other points of interest to national and regional benchmarks, so they can identify areas for improvement and recognize successes.
  5. Be consultative and creative. This is perhaps the most notable change in what employers need today versus what they needed in the past. Today, it’s not just about the numbers on a spreadsheet. Employers need those numbers to be meaningful and useful as they try to solve new challenges. And it’s now the health plan’s job to offer guidance along with the numbers.
In short, plans that can provide data and analytics that are flexible and trustworthy, and that answer the “So what?” and the “Now what?” will be the best-positioned to become problem-solving partners that employers can’t live without.

For more details about these five employer reporting needs, download our latest insights brief.

Jennifer Huyck
Vice President, Analytics and Consulting