Monthly Archives: July 2014

Health Plan ID: The Difference Between Health Plan and Payer is Clear as Mud.

When Health Plan Identifier (HPID) first came on the health IT landscape a few years ago, it seemed pretty easy to understand.  It was a part of CMS’ continued administrative simplification effort within healthcare.

Boy were we all wrong.

Last week, Peggy H. and I attended a WEDI Summer Forum held in Minneapolis.  The topics ranged from ICD-10, Attachments, and HPID.  A CMS administrator presented a HPID session via conference call.  However, I think there were more questions and confusion rather than answers.

Over the course of the past few years (and during last week’s sessions), some of the concerns of implementing HPID are as follows:

1) How do health insurance companies (I purposely used this language) enumerate based on the definitions of Controlling Health Plan (CHP) and Sub-Health Plans?  It’s not as easy since this requires a deep dive into how a particular organization is structured.  Are they part of a greater organization with separate corporate entities operating in multiple locations, e.g. states?  That would be require a conversation w/attorneys and the finance folks.

2) Large provider organizations voiced concern about impacts to them.  (This was a complete surprise to me).  A provider may have their general ledger setup w/different health insurance companies they file claims to differently based upon who/how remittances are sent.  Will the right enumerators on claims/remittances be correct or could they potentially mess up a provider’s books?

3) HPID is required on the HIPAA-covered transactions based on how the Final Rule is currently written; however, it has surfaced that CMS may not have intended it to be used on transactions after all.  They apparently want to create a database that lists all payers (or is it health plans????) in a single location.  Uses for this single source of information is pure conjecture at this point.

4) There is a difference in the definition between a ‘health plan’ and a ‘payer’.  I have been in healthcare for over 15 years and in my experience, these two terms are used synonymously.

Gotten your head around any of this?

For the last point regarding the difference in the definition of health plan and payer, WEDI has published an issue brief that explains this further.

CMS Investing in State Led Medicaid Innovations

Much like the creation of the CMS Innovation Center that was a part of the ACA, CMS is launching a $100 million initiative, the Medicaid Innovation Accelerator Program.  The intention of this program is to help fill in some of the gaps in different reform initiatives that will help in reducing costs while improving quality and care for Medicaid members.  Read more here.