Streamlined claims rule would save your practice time, money

July 13, 2011

Fed up with the hours on the telephone to untangle claims issues with insurers? A new proposed rule could help. It requires insurers to use uniform transmission formats and standardized forms when they seek information or provide claims and coverage information to doctors.

A proposed rule may offer some relief if you, like most physicians, would rather be seeing patients than trapped on the telephone for interminable hours, providing additional information to insurers and arguing about claim denials.

The interim final rule was released in early July by the Department of Health and Human Services (HHS) and is available for comment until Sept. 6. It requires insurers to use uniform transmission formats and standardized forms when they seek information or provide claims and coverage information to doctors.

Citing a study that appeared in the journal Health Affairs last year, HHS says the new rules would save an estimated $12 billion in the healthcare system by reducing telephone calls between physicians and health plans, lowering postage and paperwork costs, creating fewer claim denials for physicians, and automating healthcare administrative processes.

HHS offered an example of how the new rules, which would take effect at the beginning of 2013, could simplify your practice processes: For some health plans, an electronic inquiry about a patient’s eligibility elicits a yes or no answer, whereas others provide full information such as patient co-pays and deductibles. The proposed rule would require the more detailed response in every instance.

The proposed rule, which closely tracks the recommendation of the Council for Affordable and Quality Healthcare’s Committee on Operating Rules for Information Exchange, is the first of several to be created in response to the simplification provisions of the Patient Protection and Affordable Care Act. In the future, expect to see new requirements related to:

Standards and operating rules for electronic funds transfer and remittance advice;
A standard unique identifier for health plans;
A standard for claims attachments; and 
Requirements that health plans certify compliance with all Health Information and Portability and Accountability Act standards and operating rules.

A benefit of more streamlined, standardized information could be a reduction in error rates. A recent American Medical Association report found that health plans make errors in nearly 1 out of 5 claims and that 3.6 million more commercial claims had processing errors than last year, representing an increase of 2%.

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