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A feature story in the November issue of Health Data Management examines the rollout of HIPAA “operating rules” to better standardize electronic claims and related transactions, while giving providers more information from insurers. Only insurers are mandated to support the rules, although it’s obviously good business for software vendors to also comply. Operating rules for eligibility verification and claim status now are in force, with a January 2014 compliance date for electronic funds transfer and electronic remittance advice rules. A group of rules come in 2016: claims/encounters, coordination of benefits, plan enrollment/disenrollment, plan premium payment, referral certification/authorization, and claims attachments if that transaction is ready.

Rolling Adoption
The Committee on Operating Rules, an initiative of stakeholder collaborative CAQH, has been developing operating rules in an effort that began as voluntary and was mandated in the health reform law. Not all insurers are complying with the initial eligibility and claims status operating rules; adoption has been a rolling process in 2013. In general, national insurers and major regional ones are compliant, but many Medicaid programs are not; even Medicare won’t support real-time operating rules for status until sometime in 2014. Rolling adoption of the EFT and ERA rules can be expected during 2014, although payers increasingly in the second half of 2013 began supporting the rules.

Early Benefits
Already, the initial eligibility and status operating rules are starting to level the playing between providers and payers, says Franco Rizzolo, D.C., a chiropractor and administrator at Suburban Orthopaedic Medical Center in Newark, N.J. Without eligibility operating rules, payers responded to an inquiry with a yes-no answer even though they had more information they could give. Now, Rizzolo can fire off a query and learn not only that a patient has coverage, but what the deductible is and how much is left, and what services fall under the benefit plan. The practice saves 40 hours a week in staff time, has reduced days on accounts receivable by 65 percent and is getting paid much quicker with fewer denials.

Matching Remittance & Payment
Most patient accounting systems in hospitals and practices already support automated receiving and posting of ERA, but reconciling remittance with actual payment remains a manual process, says Chris Seib, chief technology officer at claims clearinghouse InstaMed. But providers will see real value in 2014 as payment codes in remittance will be more standardized, and tracing numbers will support automated matching of remittance with payment, says Jay Eisenstock, head of provider e-solutions at Aetna.

Growing EFT Use
Many insurers before 2013 offered electronic remittance advice but not electronic funds transfer, and they increasingly are offering it now before the 2014 deadline, says Noam Nahary, director of e-commerce and revenue cycle systems at Montefiore Medical Center in Bronx, New York. Providers wanting to use EFT/ERA operating rules should assess gaps in their information systems soon, get in the queue for vendor updates, and try to get some level of priority in their own organization despite the urgency of other issues, he advises. “You have to make some noise to get attention.”

Start Work Now
There still is time during 2013 for insurers and providers to get in position to take advantage of the EFT/ERA operating rules in January, says Steven Lazarus, president of Boundary Information Group, a consultancy. Health plans should let their banks know that they want to create a health care EFT. Every bank has to receive an EFT, but not all banks offer a health care-specific version of an EFT, so they’ll have to create one, and banks offering a health-specific EFT will need to tweak it to add a tracing number. “For some banks, this is going to be a brand new wrinkle in the process,” he adds.

Press Your Vendors
For providers, CAQH offers the EFT Enrollment Utility on its Web site as a one-stop shop to enroll in EFT with multiple insurers. In September, only Aetna and Cigna were participating, but Lazarus says the hope is that 10-15 payers will soon be on board. Providers also can enroll on individual payer Web sites. Provider systems need updates to send, receive and properly populate data fields. Insist your vendor support the rules or change vendors, he adds. Some third-party vendors offer bolt-on products to support operating rules. “The integration is messy, but worthwhile if your vendor isn’t going to provide the service.”

Get Involved
Few expect a claims attachment operating rule to be ready for prime time in 2016, but the time is fast approaching to prepare for the others. Some organizations, including Aetna, will start work in 2014 to prepare for 2016, says Jay Eisenstock, the head of e-provider solutions. He advises organizations with fewer resources to start work in early 2015 and not count on an extension of the deadline. With so many operating rules coming in 2016, more help is needed from more stakeholders to develop the rules, says Noam Nahary of Montefiore Medical Center. “It really is a collaborative undertaking to create operating rules. Get involved, make it an agenda item and start the conversation.”

Click here to read the article originally published by Health Data Management.

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