experience guide to or implementation and compliance 2015
TRANSCRIPT
edifecs confidential 1Pathways to Partnerships | Experience Guide to Operating Rule Implementation and Compliance
An Experience-based Guide to Operating Rules Implementation and Compliance
John Kelly, Principal Business Advisor, EdifecsAmrita Kalkura, Senior Analyst, Operating Rules, Edifecs
Presenters:
edifecs confidential 2Pathways to Partnerships | Experience Guide to Operating Rule Implementation and Compliance
1. Current State of Industry Readiness
2. Compliance Meaning of compliance First certification Ongoing compliance Penalties
3. Implementation Approach Challenges Implementation approach Edifecs solutions
4. Short Demo
5. Conclusion
Agenda
Industry Readiness
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
Industry Trends
Healthcare Plans Healthcare providers Plans and Providers Combined Average
Adoption Rate for fully electronic HIPAA transaction (Health
Plans)
Eligibility & Benefit Verification
95% 69% 82% 65.3% (‘13)
Claim Status Inquiry 90% 54% 72% 49.6% (‘13)
Source: 2014 CAQH Index. All responding health plans, % of transaction
Adoption rates of electronic transactions broken out by health plans versus healthcare providers
Fully Electronic(HIPAA Standards)
Fully Manual(Phone, Fax)
Partially Electronic(Web Portal, IVR)
Eligibility & Benefit Verification
+14% -1% +13%
Claim Status Inquiry +23% 0% +17%
Year over Year variation by Health Plans Reporting both 2012 and 2013
Eligibility and Claim Status Transaction
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
Industry Trends
Source: 2014 CAQH Index. All responding health plans, % of transaction & NACHA
Healthcare Plans Healthcare providers
Plans and Providers Combined Average
Adoption Rate for fully electronic
HIPAA transaction (Health Plans)
Remittance Advice 55% 47% 82% 46.4% (‘13)
Adoption rates of electronic transactions broken out by health plans versus healthcare providers
Fully Electronic(HIPAA Standards)
Fully Manual Partially Electronic(Web Portal, IVR)
Remittance Advice +8% -16% +52%
Year on Year variation by Health Plans Reporting both 2012 and 2013
Transaction Increase over 2014
Volume of CCD+/EFT
Value of CCD+/EFT
EFT +105% 149 million 876 billion
2014 Healthcare EFT Volume
ERA Transactions
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
CAQH CORE Certified Organizations
Source: http://www.caqh.org/core/core-certified-organizations-pending-and-current
36%
5%32%
27%
Health Plans Providers Clearing Houses Vendors
Compliance
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
What are Operating Rules?
Built on HIPAA standards• Make EDI more predictable
and consistent
• Clear definition of rights and responsibilities
• Clear definition of security and exception processing
Implementation in Phases• Phase I & II - Eligibility
verification & claim status inquiry
• Phase III – Electronic Remittance Advice & Electronic Funds Transfer
• Phase IV - Claim, authorization, enrollment, attachments and premium transactions
System Impact• Impacts both front-end and
backend systems
• Connectivity
• Acknowledgements, responses & exception processing
• Companion guides
• Transaction content (service types, AAA codes, CARC codes, etc.)
• System availability
Industry Impact• Health plans
• Clearinghouses
• Providers
• Vendors (EMR, RCM, etc.)
• ACOs
ACA defines Operating Rule as “The necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications”
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
What are CAQH CORE Operating Rules?
Batch and real time
acknowledgement
Data and connectivity
Companion guide
Response time and availability
Focused on promulgating OR to increase usefulness of and reduce the administrative challenges associated with eligibility and benefit inquiries
Operating Rules – Phase I
Operating Rules – Phase II
Operating Rules – Phase IIIThe Phase II rules build on the Phase I
rules, with additional rules for patient identifiers, patient accumulators, claims status and connectivity.
This CORE Rule builds upon and extends the Phase I and Phase II CORE infrastructure rules to the
conduct ofthe v5010 X12 835
Claim Status
Patient Last Name
AAA Reporting
Eligibility Data Content
Infrastructure CARC and RARC
Re-associationERA and EFT
enrollment data rule
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
What does Operating Rules compliance mean?
Expected to have already implemented phase I,II and III by 1/1/2014
First Certification
Ensure production compliance
• First Certification is a “point in time” snapshot of compliance
• First Certification Testing is not exhaustive
• Health plans must continue to stay compliant in production under changing conditions to avoid penalties
Key Takeaways
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
First Certification
Option 1: CORE Certification
Complete certification testing using CORE authorized testing vendor (e.g. Edifecs)
Submit required documentation to receive CORE seal
Takes 2-3 EDI resources 3-5 months to complete testing
Troubleshoot issues as they are uncovered
Option 2: HIPAA Credential Option
Testing with 3-25 trading partners representing at least 30% transaction volume
Provide contact details of trading partners to CORE Attestation by authorized rep that testing was
performed Effort and time required will vary based on # of trading
partners
First Certification (due by 12/31/2015)
CORE Certification HIPAA
Credential
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
Ongoing Compliance and Drivers
New Line of
Business
Increased Volumes
Resource Changes
Defects and
Changes
New Product
and Benefits
System Version Upgrade
Future State Roadmap & Events
New Trading Partners
New Data Types and Processing
ORCompliant Processing Maintain Compliant Processing
2016Penalties assessed based on
audits
Must prove compliance
during an audit
Must remediate any non-
compliance identified during an
audit
Systems must be available
86% of the time (except
planned downtimes)
90% of transactions
must be compliant on
a monthly basis
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
Illustration of Potential Savings and Penalties
Efficiencies/Cost SavingsReduced phone calls
Health plan avg. savings per call - $ 1.90
Providers avg. savings per call - $3.40
$8 billion savings potential for industry
Compliance/PenaltiesPart of ACA
Health Plans must comply
Compliance based on first certification
Ongoing compliance – random and complaint driven audits
Penalties of $1/member/day up to $20/member/year
Potential penalties can range from 9M (Small State) to 51M (Large State Medicaid Plan)
Doubled penalties for misinformation
State level penalties may exist
Executives must attest compliance
Example - Potential Annual
Savings = $800K[1]
Example - Annual Penalty Exposure
= $10M [1]
[1] Assumptions:
Health plan with 500K members, ~182K eligibility and 73K claim status phone calls per annum
50% reduction in manual phone calls due to Operating Rules
Used CAQH savings calculator: http://www.caqh.org/index_savingscalculator.php
Pathways to Partnerships | Experience-based Guide to Operating Rules Implementation and Compliance
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Impact of operating Rules on Health Plans Implementation Approach Implementation ChallengesCase Study DemoCORE and Product TestingKey Takeaways Resources
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