The CMS shelved the work of the Accredited Standards Committee of the American National Standards Institute, a respected national standards development organization.
In its place, the CMS substituted its own work in the form of a March 2013 companion guide (PDF) that ended up being tweaked multiple times through August. The CMS' action added one more increment of delay and variability to a massive software development effort that has been described by one participant as one of the most complex in the nation's history.
CMS officials have not responded to requests to explain their choice. During an update Monday on the status of HealthCare.gov fixes, administration officials said the CMS is “actively” working on the issue and expects to provide more information soon.
“We started in January 2012,” said John Bock, an independent health IT consultant from Albany, N.Y., who served as co-chairman of ASC's committee to address enrollment and the healthcare exchanges. “We met every week for an hour and a half,” he said. “I can't tell you the number of hours several of us spent on the calls trying to get things done.”
Their task was to adapt the ASC X12 834 health insurance benefits enrollment standard to meet the needs of the federal and state health insurance exchanges created under the Patient Protection and Affordable Care Act. All told, between 50 and 60 people worked on the assignment, Bock said, with a core group of 20 to 25 staying through to the finish. The workgroup included several federal government representatives, he said.
It produced a balloted, final specification in October 2012. In an unusual move for ASC, made because time was of the essence and the key revision was needed by programmers at the nation's health plans and the exchanges, the specification was made public even before it was given a final review and official publication, which came in December 2012.
It was in October last year, Bock said, just as they finished, that word passed from the feds they wouldn't be using the ASC committee's work. “From a regulatory adoption cycle, it appears there wasn't time to make the change,” Bock said.
There have been troubles with the 834 ever since. The implementation of the 834 standard has not been the main glitch with HealthCare.gov, but it is one of the multiple difficulties with the site.
Last week at a House Energy and Commerce Committee hearing, Rep. Adam Kinzinger, (R-Ill.) asked Cheryl Campbell, senior vice president of the federal exchange's prime contractor, CGI Federal, about problems with the 834. One health plan, Kinzinger said, reported a claim showing up with three spouses in the electronic message. Others had dependent children listed as spouses, he said.
“By far this is the most complex (system) in our country for a very long time,” Campbell said.
Problems with the implementation specification for 834 have caused a lack of readiness and agility to handle variability in 834 enrollment transactions by some plans, said John Kelly, principal business adviser at Edifecs, Bellevue, Wash., a claims-management services provider,
The 834 standard is commonly used by the healthcare industry for enrollment messages between health plans and employers and other purchasers of health insurance coverage. In the federal and state-run insurance exchanges, 834 performs the enrollment function, too. But it has been given a new task that it was not initially designed to do and one that is unique to the exchanges.
In the exchanges, the 834 transmits how much of the premium an enrollee will pay out of pocket and how much, if any, will be covered by the ACA provision of federal premium tax credits. The 834 carries that information to the health plans and HHS.
Bock said there is “quite a bit of difference” between what the ASC panel devised in its October 2012 implementation specification for the 834 and what the feds used in its March 2013 guidance to tackle the payment splits.
“With our group,” he said, “we understood the data and what was needed, so we created homes for those data elements.” For example, he said, with the payment amounts, “we've got a dollar amount field we created for that.”
In the fed version, in contrast, the cost-sharing amounts were placed in a text field, “which was intended to be an entity (insurance company) name,” he said.
The die is cast now, though, at least in the near term, he said. Plans and exchanges can't adopt the ASC specification, even if they thought it was better.
“There was no choice,” Bock said, “Once the feds made the decision this was the version to use, it was thou shalt use this version. What's out on the street right now is obviously functional, because we're doing it, but it requires a fair amount of cobbling together.”
Follow Joseph Conn on Twitter: @MHJConn