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Increasing efficiency and reducing burdens in the health care revenue cycle


How physicians benefit from standardized operating rules

Erin Weber is Vice President, Committee on Operating Rules for Information Exchange (CORE) at CAQH.

Erin Weber is Vice President, Committee on Operating Rules for Information Exchange (CORE) at CAQH.

With all of the innovations and transformations in health care over the past decade, one area where the industry made significant progress is largely overlooked: Streamlining business processes to ensure seamless patient care and engagement.

Health plans and providers now save $187 billion annually due to the efforts the industry has made over the past several years to automate and improve administrative transactions. This has been the result of collaboration, prioritization and intense focus – and has led to fewer burdens on providers, a better experience for patients and overall lower costs. But, despite this progress, much work remains.

The 2022 CAQH Index found that – by finishing the job and fully automating ten common administrative transactions related to verifying insurance coverage, submitting claims and supplemental information, and sending and receiving payments – the medical industry could save an additional $22.3 billion annually. Of that, $20.7 billion, or roughly 93%, would be realized by health care providers.

To continue – and accelerate – our progress going forward, it is worth assessing what has worked in the past.

An industry collaboration

Nearly 20 years ago, stakeholders from across the industry came together and established the Committee on Operating Rules for Information Exchange (CORE) at CAQH with a mission to accelerate automation and improve the exchange of health care business data. Today, CORE participating organizations include health plans representing 75% of the insured U.S. population, health care providers, vendors, government entities, associations, standard-setting organizations, and other health care organizations.

Among other initiatives, CORE develops operating rules that improve interoperability and efficiency and remove cost and complexity in health care. In 2012, the secretary of the Department of Health and Human Services designated CORE as the national operating rules authoring entity for HIPAA-mandated electronic transactions. Since that time, three sets of CORE Operating Rules were federally mandated under HIPAA, with others under currently consideration.

The impact of CORE operating rules

The benefits brought by operating rules extend to the entire continuum of care.

Take prior authorizations, a transaction that occurs millions of times every year. When conducted manually, they create friction for health plans and providers and often result in delays in care.

CORE Operating Rules for the X12N 278 transaction streamline and clarify prior authorization correspondence and set a two-business-day requirement for approval or denial. Currently, these operating rules have been adopted by commercial health plans representing at least 20% of covered lives across the country.

And, as health plans ask for increasingly specific patient information before paying claims, providers continue to fax, print, or mail information to substantiate the care provided. The CORE Attachments Operating Rules further digitize claims submission and prior authorization transactions and reduces the cost and time associated with exchanging these materials.

What’s next

CORE Operating Rules are developed through a trusted, consensus-based process to complement and build on technical standards. As health care evolves, CORE Operating Rules are updated to ensure the industry has access to timely, up-to-date guidelines that drive automated data exchange and support innovation.

This summer, the National Committee on Vital and Health Statistics, a federal advisory body to HHS, recommended another set of CORE Operating Rules to HHS for federal mandate.

These rules provide critical infrastructure for some of health care’s most pressing challenges, enabling providers to have automated information on a patient’s detailed benefit coverage, need for prior authorization, telehealth benefits and attribution status under a value-based contract before or at the time of service, among other advantages.

At the same time, CORE is regularly evaluating, convening work groups and developing best practices to improve other areas of opportunity. Currently, CORE is prioritizing initiatives related to claims, value-based care, health care payments, and specialty medication eligibility under the medical benefit.

A call to action

To realize the full benefits of operating rules and administrative automation, the health care industry must come together and commit to widespread adoption and ongoing collaboration.

There are a number of ways providers can make an impact in streamlining the business of health care, including:

Join CORE. By participating in CORE, individuals and organizations can play a critical role in the development of operating rules, modernizing administrative workflows and setting the direction for the future of health care business processes.

Earn CORE Certification. Becoming CORE-certified enables an organization to demonstrate that its systems and products conform with applicable operating rules and are prepared for potential audits. CORE awards Certification Seals to entities that create, transmit or use the health care administrative, clinical, and financial transactions.

Utilize and share CORE resources. CAQH CORE has produced a variety of resources to provide education and help increase industry productivity. The organization also holds regular, complimentary webinars on pressing health care topics.

CORE’s model – industry-led, consensus-based and focused on transactions where improvements could have the greatest impact – has been proven through the reduction in costly, manual transactions. But health care administration is still too burdensome and complex. The opportunity to leverage CORE’s trusted and independent approach more broadly will have a profound impact on care delivery, provider burdens and the member experience.

Erin Weber is Vice President, Committee on Operating Rules for Information Exchange (CORE) at CAQH.

To learn more about CAQH CORE please visit: www.caqh.org/caqh-core.

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