What comes next? Since its formation, the Committee on Operating Rules for Information Exchange (CORE) has developed eight sets of operating rules to streamline transactions and remove cost and complexity from the healthcare ecosystem. Four of these rule sets — which address eligibility and benefits; claim status; payment and remittance; and connectivity requirements — have been federally mandated. 

As representatives of healthcare business services companies, provider organizations, health plans, and associations, we spend time optimizing data transmission workflows to improve healthcare administration in our day-to-day jobs. Within the health care claims processing landscape, efficiency remains a key challenge. Per the 2022 CAQH Index, over 9 billion claims transactions are sent electronically between providers and health plans each year— even a small change in automating the standards for claims transmission could result in $2.5 billion of savings annually.

Background and Prioritization of Value-based PaymentsThe CAQH CORE Value-based Payment (VBP) Subgroup launched on April 27, and recently had its third meeting on June 8, 2023. As co-chairs of this important initiative, we’re pleased to share more about the rule development opportunities under consideration, as well as some early insights from our first three meetings.

Healthcare payers are using data in new ways to improve the member experience, reduce provider abrasion and streamline operations. In a recent interview with SmartBrief, industry strategist, Tyler Ford, vice president of strategy and partnerships at CAQH discusses key opportunities to better serve members and improve relationships with network providers.What are some trends you’re seeing in health plans’ data strategies?  

Electronic Health Records (EHRs) have become the central resource for provider workflows, facilitating administrative and clinical activities. In fact, according to The Office of the National Coordinator for Health Information Technology (ONC), as of 2021, 78% of office-based physicians and 96% of non-federal acute care hospitals adopted a certified EHR.

Healthcare price transparency is a crucial issue. Patients, who value clarity about their out-of-pocket responsibility, often struggle to determine the cost of procedures or services before receiving them leading to the passive acceptance of charges and exposure to “surprise” bills that can be financially burdensome or even catastrophic. One way the federal government is driving greater price transparency is through the passage of the No Surprises Act (NSA).

When you think about coordinating benefits, you likely think of a costly and time-consuming process with minimal ROI. That’s because many plans take a reactive approach to coordination of benefits (COB) and pay claims before identifying overlapping coverage. This results in the need to recover improper payments which is often performed manually, frustrating to both members and providers, and negatively impacts the entire payment integrity (PI) process. 

On December 19, 2022, the Department of Health and Human Services (HHS) issued a notice of proposed rulemaking (NPRM): Administrative Simplification: Adoption of Standards for Health Care Attachments Transactions and Electronic Signatures, and Modification to Referral Certification and Authorization Transaction Standard.

Customization is often seen as a luxury--a product or solution that is tailor-made to fit one's exact needs. When it comes to customization in the business of healthcare, customization can be counterproductive.

As the current and immediate past Chairs of the CAQH CORE Board, we are excited to discuss the operating rule package currently under consideration for federal mandate. Below we will review the path to federal mandate, the proposed rules, and what to expect next.