The Status and Savings of HIPAA Transactions

The 2013 U.S. Healthcare Efficiency Index, an annual report on progress being made to electronically transmit claims and related transactions, finds plenty of work still to be done.

About the Report About the Report

Advocacy organization CAQH produced the report with Milliman Inc., which offered provider survey services and benchmarking analysis. Commercial health insurers covering 104 million covered lives contributed data, which included 1.3 billion claims and 3.3 billion related transactions. Data reported in the 2013 Index reflects activity for 2012 and accounts for about 40 percent of the insured U.S. population. The data does not include pharmacy transactions. (Photo: Fotolia)

On the Horizon On the Horizon

With HIPAA operating rules to make transactions more uniform effective in 2012 for eligibility and claim status transactions, and in 2013 for electronic funds transfer and remittance advice, further Index reports will start to give a picture on the effectiveness of the operating rules. Other operating rules expected in 2016 will cover claims/encounters, coordination of benefits, health plan enrollment/disenrollment, plan premium payment, referral certification and authorization, and claims attachments. Attachment standards may not be ready for prime time and could be delayed. (Photo: Fotolia)

Findings of the Report Findings of the Report

Claims continue to substantially lead the parade with 91 percent submitted electronically. Fifty-six percent of surveyed payers are using electronic payment. Electronic remittance is being used at an adoption level of 53 percent, but the effective adoption rate is likely lower “because more than 10 percent of electronically delivered claim remittance advice documents are also requested and delivered by another method,” according to the report. “Eliminating this duplication would yield additional savings.” Adoption rates for eligibility and claim status are unclear because of a low response rate and the preliminary nature of how health plans are tracking this information. (Photo: Fotolia)

Payer Savings Payer Savings

CAQH and Milliman estimate that automation of six transactions could save providers and payers billions of dollars each year. Health plans could annually save $460 million from increased use of eligibility verification transactions, $410 million from electronic prior authorization, $280 million from claim status inquires, and a combined $280 million from electronic claims submission, claim payment and remittance advice/payment posting transactions. Total annual savings: $1.43 billion. Payer costs of 74 cents per manual claim could fall to 26 cents. Other savings include eligibility ($3.28 to $0.06), prior authorization ($3.95 to $0.18), claim status ($3.84 to $0.06), claim payment ($0.66 to $0.21) and remittance ($0.45 to $0.21). (Photo: Fotolia)

Provider Savings Provider Savings

Hospitals, physician practices and other provider organizations also would see substantial savings if electronic transactions become commonplace, according to the report. The savings include claim submission ($1.84 to $0.28), eligibility ($3.55 to $0.16), prior authorization ($18.53 to $5.20), claim status ($2.25 to $0.23), claim payment ($1.83 to $0.30) and remittance ($1.83 to $0.30). In total, providers could save $6.7 billion annually. (Photo: Fotolia)

The 2013 U.S. Healthcare Efficiency Index is available here .

The 2013 U.S. Healthcare Efficiency Index, an annual report on progress being made to electronically transmit claims and related transactions, finds plenty of work still to be done.

 

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