The Affordable Care Act mandates creation and adoption of "operating rules" to make the HIPAA administrative and financial transactions more uniform.

But there are real-world realities emerging that must be taken into account as operating rules are developed, says Gwendolyn Lohse, deputy director of industry group CAQH and managing director of the group's CORE initiative to create such rules.

CORE is working with NACHA - The Electronic Payments Association to develop operating rules for electronic funds transfer and electronic remittance advice transactions. One theme emerging is a call for a combined EFT/ERA transaction where funds and data flow together through the nation's Automated Clearing House network for financial transactions. But a combined transaction for all providers is not practical at this time, Lohse said on Dec. 3 in written testimony before the National Committee on Vital and Health Statistics, a federal advisory body.

Many providers today receive separate EFT and ERA transactions that vendors or provider staff members reconcile. "Transitioning from the current model would require significant work flow changes for providers--at a time when they are struggling to adopt a number of mandates, including implementation of ICD-10 and electronic health records," Lohse testified. "Moreover, some providers are not yet interested for reasons that include concerns about the privacy and security of health information and financial data as they flow to different entities through various networks, not to mention the more basic resistance to change.

"Finally, the first and last mile in the payment process includes many small health plans administered by third party administrators, and hundreds of thousands of small providers. No doubt we will see consolidation in the coming years, but addressing the reality and diversity of stakeholders will need to be part of the solution. All this said, long-term goals with milestones could--and should--be established by the industry as it considers various models."

Testimony on additional EFT/EFA issues, as well as an update on other operating rule initiatives also presented to NCVHS, is available at caqh.org.

--Joseph Goedert

 

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