Streamlining operating rules beneficial


By 2014, the core operating rules will likely have a major effect on reimbursement and revenue cycle processes and, as a result, payments, according to speakers who represented the payer, provider and banking perspectives at a Tuesday session on titled “The Business Side of Care” during the 2013 HIMSS Annual Conference & Exhibition. 

As of the first of this year, healthcare organizations had to establish eligibility for health plan and claims-status transaction standards. The core operating rules build upon a range of standards, which are healthcare-specific and industry-neutral and support the national health IT agenda.

According to presenter Ross Lippincott, vice president of provider regulatory programs at UnitedHealthcare, it’s necessary for the industry to enhance the usability of standards to make them address system gaps, support electronic data exchange and recognize interdependencies in transactions. 

“Operating rules encourage an interoperable network that is vendor agnostic,” Lippincott said. 

For physicians, the operating rules and standards enable them to make claims faster and collect reimbursement, said Franco Rizzolo, CEO of Suburban Orthopedic Medical Center.

 “It’s a win-win getting detailed information in a standard format and not go crazy looking for the format,” Rizzolo said. “It’s been a real time saver for us.”

Rizzolo said that there are a number of back-end processes that can reduce the cost of doing business. For example, “if we can do some pre-certification, it could save us some time, and time is money,” he said.

Some hospitals, even small ones, are already receiving electronic fund transfers. “It’s easier to reconcile all the patient-care payments and it’s saving time from an administrative perspective,” said Deborah Essex, director of admissions at Aspen Valley Hospital.

“We’re looking forward to more payers getting on and making it more streamlined for us,” she said, adding that the hospital is putting the processes in place and is conducting some patient pre-certification online instead of via telephone.

Lippincott said the operating rules provide for incremental steps to increased operating functionality. In the next iteration, if the eligibility transactions were to include certain extra components that are most frequent requests from providers, “we could eliminate up to 20 percent of our call volume,” he said.