Mandates in the health reform law to adopt "operating rules" for a series of existing and new HIPAA transactions between 2013 and 2016 should easily be achievable, two consultants familiar with the health care electronic data interchange business say.

Industry stakeholders have worked for five years to reach consensus on the rules, which seek to make electronic claims and related transactions far more uniform than they are today, says Rachel Foerster, principal at Rachel Foerster & Associates Ltd., Beach Park, Ill.

Working under the CORE (Committee for Operating Rules) initiative of payer advocacy group CAQH, providers, insurers, clearinghouses and software vendors have created operating rules for the eligibility/benefit determination and claim status transactions, and this year will complete initial rules on prior authorization and remittance transactions, and more tightening of the claim status transaction. "CORE has the infrastructure in place to do this," Foerster says. "It's a well-established, well-vetted, working function."

CORE's first three years were spent on working through political issues, getting organizations on board, finding compromise, and developing initial rules, says Pat Kennedy, president of PJ Consulting in Rockville, Md. The initiative has moved quickly on creating and adopting rules during the past two years and has substantial momentum to finish the task, he contends.

Most major commercial insurers, clearinghouses and vendors support existing CORE rules, Kennedy notes. "The marketplace is ready today. I don't think we're going to have a problem moving this forward for 85 to 90 percent of the industry."

Noting that 2016, the final compliance date for the last of the operating rules, is six years out, Foerster adds: "I don't see anything that will be an impediment to achieving the timeframes in the new law."

But how uniform the operating rules eventually will make the HIPAA transactions still is an open question. "The CORE rules incrementally move the industry to uniform use," Foerster explains. "We start by bringing consistencies to key aspects of transactions that bring value." So finding consensus remains tricky even if CORE stakeholders are committed to the program. "How much can you put in a CORE rule that will not impede adoption?" she asks.

--Joseph Goedert


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