CMS rule to streamline data for insurance eligibility, claim status inquiries

By Mary Mosquera
04:14 PM

The Centers for Medicare and Medicaid Services has released an interim final rule that describes the standard set of information for two electronic health transactions, one for inquiring about a patient’s insurance eligibility and the other on the status of a healthcare claim submitted to an insurer.

CMS portrayed the rule as common-sense measures that will save money for doctors, patients and insurers. The health reform law called for the measures to cut paperwork. 

The new operating rules will provide greater uniformity of information and transmission formats so that physicians and other healthcare providers can use one type of information request for all insurers rather than being required to use multiple systems. It will also make it easier to automate the transactions, CMS said in an announcement June 30.

[Editor's Desk: This Week in Government Health IT.]

For example, if a physician submits an electronic inquiry to a health plan about a patient’s eligibility, some plans may simply respond yes or no, while others provide information that the physician needs to know at the point of service, such as patient co-pays and deductibles. 

Under the proposed rules, physicians will also get a more detailed response when they ask about the status of a claim they have submitted to a health plan.

Health plans, healthcare clearinghouses, and certain health care providers have until Jan. 1, 2013, to meet the requirements. The rule will be published July 8 in the Federal Register and the public may comment on it until Sept. 6.

These rules will help healthcare professionals operate more efficiently, lowering their costs and reducing hassle for consumers, said Dr. Donald Berwick, CMS administrator. “As a pediatrician, I know how frustrating it can be to spend time dealing with paperwork instead of patient care,” he said.

The new rules could save an estimated $12 billion for physicians, other health providers, and health insurance companies by reducing transaction costs in the form of fewer phone calls between physicians and health plans, lower postage and paperwork costs, fewer denied claims for physicians, and a greater ability to automate health care administrative processes.

Patients should benefit from more accurate information about their out-of-pocket costs at the time of service, and expanded access to care as clinicians will have more time to spend treating patients by spending less time calling health plans. 

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CMS cited a May 2010 study in Health Affairs that found that physicians spend nearly 12-percent of every dollar they receive from patients to cover the costs of excessive administrative complexity. The study found that simplifying these systems could save four hours of professional time per physician and five hours of support staff time every week – time that could be better spent on patient care.

The rule is the first in a series of steps that will streamline and simplify the healthcare operations. Future administrative simplification rules will describe adoption of standards and operating rules for electronic funds transfer and remittance advice; a standard unique identifier for health plans; and a standard for claims attachments. Health plans will also have to certify compliance with all HIPAA standards and operating rules.

The rule largely adopts operating rules developed by the Council for Affordable and Quality Healthcare’s Committee on Operating Rules for Information Exchange (CAQH CORE), a health industry coalition that focuses on ways to simplify health care administration for plans and providers. A set of CAQH CORE potential operating rules that are currently in use in the industry on a voluntary basis have demonstrated a significant return on investment.