At the inaugural hearing of the Affordable Care Act (ACA)-mandated Review Committee in June, CAQH CORE presented compelling testimony that operating rules have resulted in significant contributions to the business needs of the healthcare industry. CAQH CORE also emphasized that many opportunities still exist to use operating rules to achieve interoperable data exchange.

The Review Committee was created via the Affordable Care Act to periodically review existing administrative transactions for which standards, code sets, identifiers, or operating rules have already been adopted by mandate and are currently in use.  The National Committee on Vital and Health Statistics (NCVHS), a statutory advisory committee that makes recommendations on health information policy and standards to the HHS Secretary, was selected as the Review Committee body. In turn, NCVHS leadership delegated the responsibility of the Review Committee to the NCVHS Subcommittee on Standards.

As the authoring entity for operating rules designated by the HHS Secretary, CAQH CORE was in a unique position to offer an assessment on the impact of operating rules use to date.  CAQH CORE based its testimony on a variety of data sources including polling results from thousands of webinar participants over the past two years (since the initial mandate), summaries of requests for technical assistance and information from nearly 200 voluntary CORE Certifications achieved by healthcare companies representing significant national market share. CAQH CORE also conducted a survey in May 2015 of more than 120 health care stakeholder organizations to provide added insight. The 2014 CAQH Index, which annually monitors progress and estimated cost savings associated with the adoption of electronic administrative transactions across the healthcare industry, supplied additional quantitative information.

In her remarks, CAQH CORE Managing Director Gwendolyn Lohse provided evidence that increasing adherence to all three currently adopted operating rule sets for eligibility, claims status inquiry and response, and electronic remittance advice and electronic funds transfer (EFT/ERA) is resulting in substantive industry improvements. She listed greater productivity and cost savings, better access to real-time data and increased provider confidence in data accuracy as examples of these improvements. 

Lohse cited a number of examples to support this position. For example, over 60% of the CAQH CORE May 2015 survey respondents reported increased productivity from the electronic eligibility and benefits checks from reduced telephone inquiries and collections. Additionally, the CAQH Index found that an average of 72% of health plans (representing an 80% increase from 2009-2013) and 54% of providers already have adopted electronic claims status for a similar benefit in reduced inquiry labor costs alone.

At the same time, Lohse identified several opportunities to improve operating rules content, such as including additional patient-specific data (e.g., benefit limits, out-of-pocket maximums) and coordination of benefits (COB) information to identify patients with overlapping coverage.  Respondents to the CAQH CORE May 2015 survey indicated that the content supplied by health plans in electronic transactions is often less content-rich than that available by phone or web portal.

CAQH CORE also noted that evidence suggests that many practice management systems (PMS) are not making administrative simplification changes to their products quickly enough. The resulting information transmission gap may prevent the industry from achieving the benefits offered by widespread use of the operating rules.

In her final comments to the Review Committee on behalf of CAQH CORE, Lohse stated that relying primarily on large, comprehensive changes to the operating rules every decade may need to be reevaluated. These large-scale transformations require considerable resources for the industry to execute.  More timely incremental changes described as “ongoing” or “incremental maintenance” – perhaps every two years – could more easily modify the operating rules to respond to changing industry business needs, an effort which CAQH CORE is already undertaking to improve the ERA transaction.

The Review Committee will consider the CAQH CORE testimony as well as that of other presenters, and report back on their observations and recommendations sometime in 2016.

The full testimony of CAQH CORE to the HHS Review Committee is available on the CAQH website. Additional information and tools to assist entities to better understand and comply with the CAQH CORE Operating Rules is also available.