Group develops exchange rules for patient insurance information

NATIONAL REPORTS- The Council for Affordable Quality Healthcare (CAQH) has brought together nearly 70 industry stakeholders-health plans, providers, vendors, government agencies, associations, regional entities and standard-setting organizations-to create and, ultimately, disseminate and maintain operating rules to facilitate real-time, comprehensive, secure transfer of patient eligibility and benefits information. The organization laun-ched the Committee on Operating Rules for Information Exchange (CORE) in response to private sector recognition of the need for an interoperable solution for communicating member data to physician practices.

STREAMLINE THE PROCESS

Currently, according to industry insiders, practices do not have easy access to consistent information on plan coverage, copays, deductibles and other eligibility and benefits information. As a result, practice staff spend countless hours on the phone or Internet sites tracking down the information. The growing consumer-driven healthcare movement and increasing pressure from employers for solutions to spiraling costs is forcing all sides to search for expense savings while maintaining quality care.

"In some cases, plans are simply answering 'yes' or 'no' to eligibility inquiries, forcing the provider to fax or call to receive the copay, deductible, and other information they require. This adds significant and unnecessary time and expense the process for both the provider and the plan," Tennant says.

VOLUNTARY STANDARDS

According to CAQH, CORE will change that by creating a variety of voluntary standards, including clear definitions and interpretations of data elements, technical transmission standards and formats, and standards for data transactions. Those standardized rules will facilitate rapid access to confirmation of :

In addition to defining the content listed above, the operating rules will define other requirements such as response time, exception processing and error management. Additional information requirements will be considered in subsequent phases of the project, according to the organization.

"Interoperability is essential for streamlining the fundamental components of healthcare transactions," says Carl Volpe, CORE steering committee chair and vice president, strategic initiatives with WellPoint Inc.

"We've modeled CORE on the process that led to the strict information-exchange rules that make direct deposits and ATMs possible in banking. And because we have so many industry partners around the table, CORE has a very real opportunity to similarly transform the healthcare industry," Volpe says.

"This industry collaboration in the sphere of administrative simplification has not been commonplace in recent times and we are hopeful that this effort can serve as a springboard to address other areas of healthcare administration," adds Tennant.

The first phase of CORE operating rules is on schedule for finalization and release by January 2006, according to CAQH. The organization is collaborating with the software community to ensure practice management system solutions can take advantage of the operating rules.

"We are hopeful that once the CAQH CORE operating rules are developed, providers will see the ROI in adopting the electronic approach to checking eligibility and to look at purchase software that supports this functionality and the other HIPAA transactions," Tennant says.