An Update on ACA-Mandated Operating Rules: What You Need to Know

Operating Rules (n): the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.
- Patient Protection and Affordable Care Act (ACA)

The ACA’s definition of “operating rules” may seem a bit complex, but the intention is all about simplification. In short, operating rules make electronic transactions in healthcare more consistent and predictable, no matter what technology is used. The rules help all entities interoperate more smoothly by advancing or building on the standards we already have in place. According to the group that developed the rules, the Center for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE), the endeavor to improve interoperability will not only reduce costs and administrative hassles, but it will also “foster trust among all participants.”1

We probably had your attention with “reduce costs and administrative hassles.” The U.S. Department of Health and Human Services (HHS) estimates these operating rules to save providers, health plans and government $12 billion over the coming ten years.2 Though the onus of implementation of operating rules falls to payers, providers are directly impacted, and if all goes as intended, those impacts will be positive ones.

CAQH CORE states that all rules build on applicable HIPAA requirements and other standards and address a range of factors that must be clearly defined to make interoperability successful. These factors include but aren’t limited to security, rights and responsibilities of all parties, transmission standards and formats, response time standards, liabilities, error resolution, and exception processing. In other words, the rules are thorough and will benefit payers, providers and, ultimately, patients as well.

The path to implementation of the operating rules is being carried out in three phases. Here’s a quick look at each, with clarification regarding why providers should take notice.

Phases I & II: Eligibility and Claim Status
Deadline for payer compliance was January 1, 2013, and payers covering more than 30 million lives are reported in compliance to date. What does this mean for you? Thanks to standards for electronic eligibility and claims status, providers should be able to more easily connect to payers electronically to verify patient eligibility, even prior to and during patient visits. This connectivity accommodates the creation of cleaner claims, eliminates manual eligibility checks and improves ability to monitor claims status, resulting in cleaner claims, more responsive denial corrections, faster payments, and reduced staff time on administration functions.

Phase III: Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)
Deadline for payer compliance with these rules is January 1, 2014. These mandates require payers to include trace numbers with EFT payments. This bodes well for providers, as the trace numbers will simplify payment and remittance reconciliation by helping to match payments with the associated Electronic Remittance Advice (ERA), greatly cutting administrative time and effort. A more streamlined EFT process ensures providers get paid faster.

Emdeon: Ready to Operate!
Emdeon is at the core of operating rule creation. We’re keenly in tune with the very technical aspects required to create rules and codes that will interoperate. You’ll find us at the center of the work groups that determine best solutions—testing, coding, disproving and proving what works.

With our hands-on knowledge, we are planning to be at full remediation by third quarter of this year and will be ready to test with all commerce in fourth quarter, well in time for payers meeting the next Operating Rules deadline.

Perhaps we feel at home on the leading edge of this mandated initiative because it’s so in tune with our core business. With our nimble solutions, we’ve been facilitating interoperable transactions, claims tracking and faster payments for our customers for years. Our customers won’t miss a beat as the ACA continues to progress throughout the healthcare system.

For questions or details on operating rules or other aspects of the ACA, continue to follow Emdeon through this newsletter. We’ll keep you apprised of what you need to know to be compliant and triumph in this new era of healthcare.

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