CAQH –the Council for Affordable Healthcare – announced today that more than 20 leading healthcare organizations have committed to making it significantly easier for physicians and other health professionals to verify patient insurance information . IBy March 31, 2007, these organizations will electronically exchange eligibility and benefits information with providers, including physicians.
"Today´s announcement is the first wave of an industry campaign to reduce unnecessary administrative burden related to verifying patient insurance coverage," said Bob Greczyn, CAQH Board chairman and CEO and President of Blue Cross and Blue Shield of North Carolina. "These stakeholders are taking a revolutionary step that will help define the future of electronic communication between health plans and providers."The participating plans include: Aetna, Inc.; AultCare; Blue Cross Blue Shield of North Carolina; Emdeon; Health Net, Inc.; Health Plan of Michigan; Humana Inc.; Mayo Clinic; McKesson Provider Technologies; Montefiore Medical Center; Siemens; and WellPoint, Inc. and its 14 Blue-licensed subsidiaries. Several practice management systems vendors have also been involved in the development of the technical standards, dubbed “CORE”.
According to CAQH, a nonprofit alliance of the nation’s leading health plans, networks and trade associations working to simplify healthcare administration, provider practice staff often spend hours researching and making follow-up calls to obtain insurance information. The CORE operating rules will allow providers to get the information from any participating health plan in 20 seconds or less. Nearly 70 million Americans are covered by the health plans committed to using the CORE Phase I rules by March 2007.
The other leading healthcare organizations that also have committed to follow the CORE rules by the March 2007 date include the following vendors and clearinghouses: ACS State Healthcare; Availity, LLC; athenahealth, Inc.; GHN-Online; HTP, Inc.; MedAvant Healthcare Solutions; MedCom USA; MedData; NaviMedix Inc.; Passport Health Communications and Quovadx, Inc.
CAQH also announced that 19 organizations are endorsing the CORE Phase I rules. Those organizations are Accenture; the American Academy of Family Physicians; the American College of Physicians; the California Regional Health Information Organization; Claredi, an Ingenix Division; Edifecs, Inc.; the eHealth Initiative; Foresight Corporation; the Greater New York Hospital Association; the Healthcare Financial Management Association; the Healthcare Information and Management Systems Society; the Medical Group Management Association; the Michigan Public Health Institute; Microsoft Corporation; MultiPlan, Inc.; Pillsbury Winthrop Shaw Pittman, LLP; the Smart Card Alliance; URAC and the Workgroup for Electronic Data Interchange.
CAQH launched CORE to promote health plan-provider interoperability and improve provider access to administrative information. The voluntary industry-wide initiative has brought together more than 85 healthcare industry stakeholders — health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and banking industry experts — to develop CORE´s first set of operating rules, finalized earlier this year, which are modeled on those used to make ATM banking an everyday occurrence. A complete list of CORE participants is available at http://www.caqh.org/ben_participating.html.
The CORE operating rules will help providers 1) determine whether a health plan covers the patient, 2) determine patient benefit coverage and 3) confirm coverage of certain treatments, as well as the patient´s co-pay amount, coinsurance level and base deductible levels (as defined in the member contract). In addition, the rules establish policies governing the exchange of that data, including:
Standard inquiry acknowledgements
Maximum response times
Minimum hours a system must be available
Standard 270/271 companion guide flow and format
The CORE initiative will create operating rules to address additional eligibility components and business transactions in Phase II (2006-2007) and later phases (2007-and beyond). CAQH plans to launch the CORE Phase II operating rules in late 2007.
Chris McNamara, a spokesman for CAQH, suggested that practices might ask their software vendors if there will be any upgrades or other changes – and if there will be a costs – in order to participate in this initiative. In addition, they should be hearing more from any participating plans as we get closer to the implementation date.
This is certainly good news, as it will dramatically cut the time needed to verify information. There may still be some lags in being notified that a patient has dropped a plan, but that should still only account for a small number of patients.