Healthcare price transparency is a crucial issue. Patients, who value clarity about their out-of-pocket responsibility, often struggle to determine the cost of procedures or services before receiving them leading to the passive acceptance of charges and exposure to “surprise” bills that can be financially burdensome or even catastrophic. One way the federal government is driving greater price transparency is through the passage of the No Surprises Act (NSA). Among other requirements, the NSA requires healthcare providers to generate a Good Faith Estimate (GFE) detailing the expected cost of a procedure, item, or service. It further compels health plans to produce an Advanced Explanation of Benefits (AEOB) that details the expected out-of-pocket expenditures for which an insured patient is responsible.

 

Though promising in its spirit, federal implementation guidance for GFE and AEOB workflows is still being developed, making conformance with these NSA requirements complicated. As industry seeks coalescence around solutions, the recently updated CAQH CORE Eligibility & Benefit Operating Rules can support these workflows and are critical to promoting greater transparency.

 

These operating rules establish consistent requirements for the exchange of information regarding a patient's insurance coverage and benefits between providers and health plans. Healthcare organizations can leverage these requirements to pre-populate coverage data to automate workflows and ensure the accurate delivery of GFEs and the downstream AEOBs they inform. The specific rule requirements listed below streamline conformance with the NSA, supporting timely cost estimates and advancing the goals of price transparency.

 

• Real-time delivery: Health plans must respond to an eligibility inquiry within 20 seconds of receiving the request. Prompt responses enable providers to quickly identify a patient’s covered benefits and develop timely GFE estimates, promoting transparency in pricing and helping patients make informed decisions about their care.
   
• Network status: Patients who receive care from in-network or preferred providers reduce their out-of-pocket costs. Health plans must indicate to providers at the point-of-care whether they are in or out-of-network, enabling shared decision-making between patients and providers and avoidance of unexpected expenses.
   
• Patient financial responsibility: Eligibility responses from health plans to providers must include patient financial responsibility detail for a medical service or procedure, including a range of deductible, copayment, and coinsurance information. This information enables providers to generate accurate out of pocket costs to be collected from patients prior to care delivery.
   
• Remaining coverage benefits: Health plans are required to inform providers about a patient's maximum and remaining coverage benefits for a set of services. This information allows providers to understand the number of visits or hours that remain over the course of a series of treatments, enabling a more accurate and transparent estimate across the continuum of care.

 

• Prior authorization determination: Manually discovering the need for prior authorization causes administrative burden and can contribute to surprise costs if requirements are not fully understood. The CAQH CORE Operating Rules aid in avoiding these challenges by compelling health plans to indicate whether prior authorization for a service or procedure is required during eligibility verification. By facilitating an upstream understanding of prior authorization status, providers can trigger GFE and AEOB workflows that are inclusive of prior authorization requirements prior to the service being delivered.

 

The CAQH CORE Eligibility & Benefit Operating Rules are a key component of the effort to improve price transparency in healthcare. The operating rules promote the exchange of information necessary to generate accurate GFEs and downstream AEOBs. The rules have the added benefit of helping patients understand the costs associated with their care so they can make informed decisions about their treatment. In addition, the rules reduce administrative burdens and costs through automation, enabling more time for patient care.  

 

To learn more about these operating rules and how your organization may implement them to support price transparency efforts contact core@caqh.org.