Will HIPAA transactions ever be standard?

February 9, 2007

When the HIPAA electronic transaction standards went into effect in October 2003, they were expected to simplify administrative transactions in healthcare. But instead, they merely clogged up the works (Medical Economics, "Not getting paid? Blame HIPAA," June 4, 2004). The key problem was that the payers hadn't reprogrammed their information systems to accept standard transactions. Instead, they issued hundreds of "companion guides" that tweaked the standards to fit each of their systems.

When the HIPAA electronic transaction standards went into effect in October 2003, they were expected to simplify administrative transactions in healthcare. But instead, they merely clogged up the works (Medical Economics, "Not getting paid? Blame HIPAA," June 4, 2004). The key problem was that the payers hadn't reprogrammed their information systems to accept standard transactions. Instead, they issued hundreds of "companion guides" that tweaked the standards to fit each of their systems.

But progress toward real standardization is being made. Eighteen months ago, the Coalition for Affordable Quality Healthcare (CAQH), a health plan advocacy group, convened about 100 insurers, providers, and vendors in a Committee on Operating Rules for Information Exchange (CORE). Building on HIPAA and other standards, this committee has developed rules for exchanging eligibility and benefit information that have been approved by the government. Twenty health plans and other organizations have agreed to start using the CORE standards in March. Among them are Aetna, AultCare, Blue Cross Blue Shield of North Carolina, Emdeon, Health Plan of Michigan, Health Net, Humana, Mayo Clinic, McKesson, Montefiore Medical Center, Siemens, and WellPoint and its 14 subsidiary Blues plans. United, CIGNA and Kaiser Permanente are members of CORE but haven't yet committed to using its standards.

The next step for CORE is to agree on standards for looking up claims status, says Chris McNamara, the spokesman for CAQH. Further down the line, the committee will tackle claims submission as well, he says. If and when it does that, will practices be able to submit claims directly to more payers without going through clearinghouses? "Time will tell," replies McNamara.