Instant Information For Hospitals, Doctors, Patients, and Health Plans
“Imagine an American healthcare system where doctors and hospitals can instantly verify patient insurance information before or at the time of care. From any health plan. With any electronic system…” These words are the vision of the CORE (“The Committee on Operating Rules for Information Exchange”) which is backed by several health plans, providers, agenncies, and vendors. Among its initiatives are a Universal Provider Datasource (UPD), real-time electronic funds transfer for claims, real-time status, real-time eligibility at the point of care.
Banks HIPAA status – Beginning the Convergence of Banking and Healthcare
Prior postings to the Federal Register dating back to first quarter of 2012 have noted that banks will be involved in the data interchange between plans and providers as they begin to support EFT. This makes the bank in effect a clearing house, subject to HIPAA regulations regarding privacy and security.
Standards such as this will start to integrate electronic funds and protected patient data requiring new standards and consideration of new issues.
From the CAQH letter to HHS:
“Some financial institutions will continue to translate nonstandard payment/processing information received from health plans into the CCD format…[and] become de facto health care clearinghouses as defined by HIPAA. To the extent, however, those entities engage in activities of a financial institution, … they will be exempt from having to comply with these HIPAA standards with respect to these activities.”
CAQH Releases CORE IFR for EFT and Remittance
CAQH CORE announced that the Centers for Medicare and Medicaid Services (CMS) issued an Interim Final Rule (IFR) with comment period – Administrative Simplification: Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice Transactions.
Health plans Backing CORE
Aetna, Cigna, several state Blue Cross Blue Shield plans (Blue Cross Blue Shield of Michigan, CareFirst BlueCross BlueShield, Excellus Blue Cross Blue Shield, Independence Blue Cross Healthcare Service Corporation and Wellpoint, which own several Blue plans), United Health.
Providers Backing CORE
Leading providers who back CORE include Adventist, Dignity Health, Cedars-Cinai, Healthcare Partners, Mobility Medical, New York Presbyterian, North Shore Health System, Physician Healthcare Network, Spectrum LaboratyrNetwork, and University Physicians.
Standards Groups and Associations Backing Core
AHIP, ASC X12, Blue Cross and Blue Shield Association (BCBSA), Delta Dental PLans, HL7, Healthcare Association of New York State, Healthcare Billing and Management Association, LINXUS, National Committee for Qualty Assurance (NCQA), National Council for Prescription Drug Programs (NCPDP), JN Shore (WEDI Affiliate) Private Sector Technology Group, Utah Health Information Network (UHIN).
Government Agencies Backing Core
Louisiana Medicaid – Unisys, Michigan Department of Community Health, Minnesota Department of Human Services, Oregon Department of Human Resources.
Vendors Backing CORE
CareMedica Systems, Electronic Data Systems (EDS), Electronic Network Systems (ENS, owned by Optum), First Data, Gateway EDI, Healthare Adminstration Technolgies, IBM, Optum, InstaMed, mPay Gateway, National Account Service Comany (NASCO), NetGen Healthcare Information Systems, Payerpath (Misys), Recondo, Secure EDI Health Group, and TriZetto.
Realizing Benefits of Core Require Updated Healthcare IT Infrastructure
CORE will have the effect of reducing lengthy waiting periods for patients who wish to know if they are eligible, what the status of a claim is, and what their out of pocket reimbursement will be and when it will be received. It will force health plans and providers to replace decades old mainframes that use ‘batch’ oriented mechanisms to answer these and other questions with near real-time capabilities. In the future, CORE will help move healthcare to more of a retail experience for the consumer, “…at the point of care.”
The IFR adopts the Phase III CORE EFT & ERA Operating Rule Set, including:
- EFT Enrollment Data Rule
- ERA Enrollment Data Rule
- EFT & ERA Reassociation (CCD+/835) Rule
- Uniform Use of CARCs and RARCs (835) Rule, with the CORE-required Code Combinations for CORE-defined Business Scenarios
- Health Care Claim Payment/Advice (835) Infrastructure Rule (except for the batch acknowledgement requirements)
The Catch – Will Health Plans and Other Healthcare Organizations be Able to Support CORE any time Soon?
Public comment may be submitted at http://www.regulations.gov until October 9, 2012. The direct link to the published document is here: