Strategic Solutions Annual Healthcare Payments Innovations Summit


Phoenix, AZ

Robert Bowman, CAQH CORE Associate Director of Transactions, will present on Monday, January 22. The description of his session is below.

From Policy to Bottom Line: Improving Revenue Cycle Performance with Use of Operating Rules for Healthcare Transactions

There is widespread consensus that administrative costs in healthcare are excessive. An industry-wide transition to replace manual processes with electronic, real-time transactions is ongoing to reduce the cost of doing business in healthcare and meaningfully impact efficiency, productivity, and data quality. The nonprofit CAQH CORE is a key driver of this transition as the HHS-designated operating rule authoring entity.

Health plans are currently required to use transaction standards and operating rules when exchanging administrative data with providers. To date, operating rules addressing eligibility, claim status, electronic remittance advice (ERA), and electronic funds transfers (EFTs) are federally mandated and rules for claims and prior authorization are industry driven. These transaction standards and operating rules can significantly improve revenue cycle performance through real time transaction, delivery of more robust patient financial information, easier reassociation of EFTs and ERAs, and a common infrastructure between trading partners. Furthermore, specific CORE-defined Business Scenarios for the uniform use of Claims Adjustment Reason Codes (CARCs) and the Remittance Advice Remark Codes (RARCs) increase the ability to auto-post and better understand adjustments and denials reported in the remittance advice which reduces manual follow up.

The purpose of this session is to:

  • Build awareness of the HIPAA administrative simplification provisions, new voluntary operating rules for claims and prior authorization, and how operating rules and standards can improve revenue cycle performance.
  • Understand why coordination between health plans, providers and vendors is critical to reap full administrative simplification benefits.
  • Share real world examples of how industry is benefiting from the use of operating rules for administrative healthcare transactions and key action steps to ensure maximum gains.

See the full agenda here

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