Operating Rules moving full speed ahead


Now that the Supreme Court has upheld most of the provisions in the Patient Protection and Affordable Care Act (ACA), the first round of Operating Rules will take effect in just a few months. There is actually broad support for this provision because it standardizes and simplifies electronic healthcare transactions, so it’s likely to survive -- even if all or parts of the ACA are repealed.

It’s hard to imagine these rules not being implemented. The Operating Rules are designed to provide clarity and increase productivity by standardizing things like data security, response times and error resolution. As the rules take effect in successive stages, all the stakeholders -- payers, providers and healthcare partners -- will conduct electronic business better than ever before. That will cause more practices to fully embrace the many benefits of healthcare transaction automation.

The Operating Rules also have powerful momentum at the state level. Many states are beginning to implement the rules that are already part of the Committee on Operating Rules for Information Exchange (CORE) certification. For example, states such as Oregon and Colorado already have enacted legislation requiring all health insurance companies to be CORE-certified. It’s not a matter of "if," but "when" these new rules will have an impact on your practice.

Changes on the horizon
Here’s the good news: Because of requirements included in the 5010 transition, many practices have already done most of the work needed to take advantage of the new eligibility and claim status operating rules. Hopefully there are just a few minor tweaks your practice might need to make by Jan. 1, 2013 -- and they can help significantly reduce claims denials arising from faulty eligibility data.

One of the changes is called the patient normalization rule, which is just a fancy way of saying that there will soon be a new data standard for surnames like “Jr.” and “III.” As you can imagine, this will result in far fewer claims denials because Frank Sinatra, Jr., won’t be confused with his deceased father, and so on.

If your practice has had a bad past experience trying to automate eligibility verification, don’t be discouraged. Things have changed dramatically in the last year alone, making implementation much easier. As the Operating Rules take effect in stages over the next few years, your practice will enjoy a number of benefits.

Here’s a preview of how the remittance and electronic funds transfer (EFT) rules scheduled to take effect on Jan. 1, 2014, should make your life easier:

  • Standardization of Reason/Remark codes. This has long been a source of frustration because payers’ “reason and remark” codes have varied wildly. Soon they will be standardized.
  • Guaranteed EFT support. By 2014, all payers must provide EFT support to any provider who requests it.
  • Bank transactions linked to remittance data. This rule will greatly boost your productivity because it requires that bank ACH transactions contain trace numbers that link to remittance data. This will free you from the time-consuming task of manually reconciling the two.

Payers have financial reasons to comply
Payers should also be taking these compliance deadlines very seriously because this is one of the first times the federal government is holding their feet to the fire by requiring them to be compliant or face financial penalties. There is no carrot this time; payers must comply or deal with the stick.

Medicare and some large commercial payers are way ahead of the others in terms of rules-readiness. Smaller payers, on the whole, are the ones who are feeling the most pressure to revamp their current processes.

Because the Operating Rules cover a lot of ground, every practice will be affected differently. Your best allies in preparing for the new rules are teamwork and education. Now is the time to sit down with your practice management (PM) vendor to make sure the software can process any new data required as part of the Operating Rules. It is possible that your PM software is good-to-go, but don’t wait until mid-December to find out.

If you have questions about how the Operating Rules will impact your practice’s workflow and productivity, there are plenty of good educational resources. Start with the CORE information found on the Council for Affordable Quality Healthcare website at www.caqh.org.

This summer’s Supreme Court ruling on healthcare reform provided much-needed clarity and direction. It means the ACA, which slowly chugged out of the station in 2010, is now gaining momentum. The new Operating Rules will help you enjoy the ride.

Ken Bradley is the vice president of strategic planning for Navicure, a medical claims clearinghouse.