Growing need for interoperability
Healthcare reform is driving a greater need for efficiency, resulting in the formation of Accountable Care Organizations (ACOs) and provider consolidation. As provider organizations using different systems work together, there is a much greater need to integrate heterogeneous environments to achieve system interoperability. However, healthcare information is often not easily exchanged among providers because of paper-based processes or systems that are not compatible. In fact, 71% of providers surveyed said the lack of system interoperability is a
The U.S. healthcare payments market is growing and changing rapidly – in fact, it is estimated to have reached $2.7 trillion as a total of payer and patient payments (IDC Health Insights). The fast evolving healthcare payments industry is impacting the way both payers and providers do business.
This week, the 2012 Trends in Healthcare Payments Annual Report was released to highlight the trends impacting the growing industry and the steps that many payers and providers have taken to accommodate for
On January 1, 2014, all payers will be required to support electronic funds transfer (EFT) and electronic remittance advice (ERA). When evaluating how to achieve ERA/EFT, one of the first decisions a payer will need to make is to “build or buy” – whether to use internal resources to build ERA/EFT capability or to work with a third-party vendor.
Regardless of which model a payer follows to achieve ERA/EFT, there are several key considerations that need to be included in the
Recently, we posted a list of five things that payers can do now to prepare for upcoming reform mandates (click here to read the post). This post emphasizes the importance of collaborating with other organizations like clearinghouses, trading partners and vendors, in order to achieve compliance with the mandated CAQH CORE Operating Rules. These relationships are crucial regardless of the approach payers take to achieve compliance.
Below is an outline of the three main models payers can use to meet the
What Are Operating Rules?
Under the Patient Protection and Affordable Care Act (PPACA), the Operating Rules (developed by CAQH CORE) define the guidelines and standards for making electronic healthcare transactions more predictable and consistent, so the industry can be more efficient.
Upcoming mandated Operating Rules include:
Eligibility and Claim Status: Phases I and II
Deadline for payer compliance: January 1, 2013
Why providers should care:
With mandated standards for electronic eligibility transactions, it will be easier for providers to connect to payers to verify patient eligibility
What’s ahead for payers?
On January 1, 2013, payers will be required to meet the first set of mandated operating rules for Eligibility and Claim Status, under the Patient Protection and Affordable Care Act (PPACA). Click here to view the complete set of CAQH CORE Eligibility and Claim Status Operating Rules.
What can payers do to prepare?
1. Focus on Education
Frequently, half the battle of preparing for mandates is gathering all of the information you need. CAQH CORE released an analysis and planning
This webinar has already occurred.
Download a copy of the presentation
Check back for upcoming webinars in the CAQH and InstaMed Webinar Series!
Don’t miss the latest webinar in the CAQH and InstaMed Webinar Series: Are You Prepared for Federally Mandated Operating Rules? Lessons Learned and Best Practices for Implementation
The deadlines for implementing federally mandated operating rules are fast approaching for payers, providers and vendors. Is your organization prepared?
In this webinar, hosted by CAQH and InstaMed, you will learn:
How payers, providers and vendors can
Last year, the majority of surveyed healthcare payers said that less than half of their provider networks did not accept ERA or EFT (read more: 2011 Trends in Healthcare Payments Annual Report). Of the providers who did not accept ERA or EFT during the time of this survey, nearly half said the reason was that they simply preferred paper.
However, according to the HHS interim final rule on EFT standards, payers will need to adopt ERA/EFT by January 1, 2014; and,
For a healthcare payer’s provider network, the process to get paid has always been a challenge. The steps providers take each day, from verifying eligibility and submitting claims, to receiving and reconciling payments, are filled with manual work, paper, errors and delays. As a result, the fragmented, time-consuming and often stressful process to collect payments is adding a lot of cost pressure on providers.
New healthcare reform mandates also put pressure on providers to find ways to get paid more efficiently.
With new regulatory mandates like the medical loss ratio (MLR) pressuring the healthcare industry to improve efficiency, payers and emerging ACOs are looking at ways to reduce administrative costs. For many organizations, one of the more obvious areas in need for greater efficiency is the call center.
In the last decade, the increase in provider call volume has become a growing concern (see: “Health Insurance Call Volume Increasing”). In fact, according to the 2011 Trends in Healthcare Payments Annual Report, call