Operating Rules: what you should know to be prepared


As the Supreme Court debates the constitutionality of The Patient Protection and Affordable Care Act (ACA), there is a lot of uncertainty and anxiety about the future of the legislation. While most media attention is focused on the status of the individual mandate, there are other aspects of the legislation that are equally if not more important.

One of these aspects is the concept of Operating Rules. If the ACA legislation is upheld, these rules could significantly affect how providers and payers perform business activities related to electronic information exchange. 

What are the Operating Rules?
Basically, the Operating Rules are designed to make electronic healthcare transactions more predictable and consistent in terms of data content and business process, promoting standardization between and across providers, payers and other healthcare partners.

The Operating Rules build on existing standards and implementation specifications and address a variety of topics, including information security, transmission formats, response times, exceptions processing, error resolution and so on. The rules are designed to provide clarity for areas not previously or adequately addressed by standards and implementation expectations.

If the Supreme Court upholds the ACA legislation  -- or at least the part that relates to Operating Rules -- payers, providers and other healthcare entities will be required to comply with the rules over the next several years. For example, those rules relating to eligibility and claim status will need to be implemented by all HIPAA-covered entities no later than Jan. 1, 2013. Compliance with additional Operating Rules will be staggered, with key implementation dates stretching to 2016.

There is a silver lining
On the surface, the need to comply with yet one more requirement of the ACA may seem onerous and challenging; however, there is a key benefit to the Operating Rules for healthcare practices that should not be underestimated. The rules aim to standardize processes and by requiring compliance from all healthcare entities, especially payers, the rules may ultimately simplify the way healthcare business transactions occur.

Implementation could result in a future where providers do not have to keep track of various requirements for different payers but instead follow a uniform approach to eligibility verification, claims editing, claims submission and denials management. This could not only enhance efficiency but also reduce the likelihood of errors thus limiting rejections and denials.

To verify that payers are taking compliance seriously, the ACA requires all payers to attest to their compliance by the outlined compliance dates. If a payer is not compliant by the required deadline, they will be penalized financially. This represents one of the first times that payers are being held accountable for changing their processes. As such, the legislation is strongly motivating payers to examine their processes and put plans in place to support compliance.

How the rules will affect your practice
Due to the variety and scope of the Operating Rules, each practice will be impacted differently. In some cases, you may begin to see changes in the way payers do business. While Medicare and the larger commercial payers may not change their processes dramatically, smaller payers may need to revamp their current approach depending on the amount of data involved in a particular rule and the payer's existing processes.

What you can do to prepare
Since the future of Operating Rules is in flux, there are not too many actionable items on which a practice can focus. With that said, there are a few activities in which you should engage.

First and foremost, you should educate yourself on the different Operating Rules and what specifically they will entail regarding data and workflow processes. There are many resources available to help with this effort, including information from the Committee on Operating Rules for Information Exchange (CORE) of the Council for Affordable Quality Healthcare (CAQH).

Practices should also consider reaching out to their practice management (PM) software vendors to ensure the software can process any new data required as part of an Operating Rule. For example, the Operating Rule related to the data and content of eligibility requests (Eligibility and Benefits 270/271 Data Content Rule) requires payers to send providers information about a patient's financial responsibility for deductibles and copays as well as patient demographic information when a patient is found in the payer's system. Your practice should verify that its PM system can accommodate this influx of data, and if it cannot, it should put plans in place to ensure accommodation going forward.

A final action is to keep current with the status of the ACA legislation. When the Supreme Court makes its decision, the future of Operating Rules and the processes and data governed by them will become clearer thus pointing you in a direction for further effort.

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