Process to set electronic transaction standards is 'broken,' says MGMA

Doctor computer medical records
Practices are subject to 'unfair business practices' according to the MGMA. (Getty/BrianAJackson)

The nation's largest group representing physician medical practices says the process to set electronic transaction standards between providers and health plans is "broken" and the government is failing to protect practices from unfair business practices.

In a letter to the National Committee on Vital and Health Statistics (NCVHS), the Medical Group Management Association (MGMA) outlined a series of recommendations to revise the process for the development and adoption of new and revised HIPAA administrative simplification standards.

The trade association said improvements are needed to streamline communications between providers and health plans. Its critique came in response to a request for public comments on draft recommendations for a “predictability roadmap” published in August by a NCVHS subcommittee on standards.

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The subcommittee of the government group plans to hold a hearing Wednesday and Thursday in Washington, D.C., on the draft recommendations.

The MGMA renewed its call for the Centers for Medicare & Medicaid Services (CMS) to more aggressively enforce health plan compliance with mandatory electronic transaction standards and operating rules. The MGMA earlier this year said CMS had not issued any enforcement fines related to a health plan’s failure to comply with HIPAA and Affordable Care Act (ACA) administrative simplification requirements for mandated transactions, operating rules, national identifiers and code sets.

In its letter to NCVHS, the MGMA called for an overhaul in how standards and operating rules are developed. “The current process for developing and adopting electronic transaction standards and operating rules is broken and must be repaired. The process is overly protracted and significant streamlining is necessary if physician practices are to achieve the benefits of administrative simplification in a timely manner,” the MGMA said.

“Adding to these challenges, [CMS] has abdicated its leadership role by failing to issue or in fact rescinded guidance protecting physician practices from unfair business practices and by taking a hands-off approach to enforcement of health plan noncompliance,” the group said.

CMS, for instance, unexpectedly removed guidance from its website earlier this year which prevented health plans from forcing physician practices to pay fees to receive their payments electronically. The guidance gave providers the right to refuse virtual credit card payments that can cost them money and stopped payers from charging all but minimum transaction fees to receive electronic payments.

After a 2017 survey revealed that about 1 in 6 physician practices are forced to pay fees for receiving electronic payments from health plans, the MGMA called on the government to prohibit the practice.

The MGMA said recent results from the CAQH Index, measuring use and costs of the HIPAA electronic transactions and operating rules, suggest administrative transactions are underutilized and billions of dollars in saving are unrealized. 

The MGMA also called for greater input from physician practices in developing new standards.

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