HHS Issues Interim Final Regulation On Electronic Claims Payment Operations

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The Department of Health and Human Services Aug. 7 released an interim final rule guiding the operation of electronic health care claim payments from insurers to providers, which along with two related rules could save up to $9 billion over a decade, the department said.

Comments on the rule, which is scheduled to appear in the Aug. 10 Federal Register, are due Oct. 9. HHS did not issue a proposed rule.

The rule with comment period implements parts of Section 1104 of the Patient Protection and Affordable Care Act, which requires the adoption of operating rules for health care electronic funds transfers (EFT) and remittance advice transactions.

The compliance date for operating rules for EFTs and remittance advice transactions is Jan. 1, 2014.

Third Regulation.

The interim final rule is the third in a series of regulations published on the issue. In 2011, HHS published the first regulation that adopted operating rules for two electronic health care transactions to make it easier for physician practices and hospitals to determine whether a patient is eligible for coverage and the status of a health care claim submitted to a health insurer.

On Jan. 10, HHS published an interim final rule, which included standards for health care claim payments made via EFT and for electronic remittance advice (ERA) (03 HCDR, 1/6/12). In July, CMS announced that rule was final and in effect (135 HCDR, 7/16/12).

Taken together, the rules could save between $2.7 billion and $9 billion over the next decade “by reducing inefficient manual administrative processes for physician practices, hospitals, and health plans,” HHS said.

“These new rules will cut red tape, save money and ensure doctors spend more time seeing patients and less time filling out forms,” HHS Secretary Kathleen Sebelius said in the release.

Providers to Benefit.

The Centers for Medicare & Medicaid Services in a fact sheet said physician practices, hospitals, and health plans will benefit most under the rule because they are the receivers of the transactions and not the senders.


The rule and two related measures will save between $2.7 billion and $9 billion in administrative costs over 10 years by reducing inefficient manual administrative processes for physician practices, hospitals, and health plans, HHS says.  

HHS in a press release said the operating rule includes “best business practices on how electronic transactions are transmitted and often target obstacles that physician practices and health insurers have with using electronic transactions.”

“For instance, the rule announced today requires insurers to offer a standardized, online enrollment for EFT and ERA so that physicians and hospitals can more easily enroll with multiple health plans to receive those transactions electronically,” HHS said. “The rule also requires health plans to send the EFT within a certain amount of days of the ERA, which helps providers reconcile their accounts more quickly,” it added.

The rule requires health plans to implement best business practices that will make it less difficult for providers to enroll in EFT and ERA, connect with health plans, and reassociate and reconcile the EFT and the ERA data, the rule stated. Participation is not mandatory for providers, however.

HHS assumed that 60 percent to 80 percent of health plans currently do not have electronic enrollment for both EFT and ERA and will be required to offer it to providers.

Savings, Costs.

The rule is expected to provide a net savings for providers of between $300 million and $3.3 billion over 10 years, CMS said. The agency estimated that the cost to implement the operating rules is $1.2 billion to $2.7 billion for government and commercial health plans and third party administrators.

The cost to providers associated with initial enrollment in the EFT claims payment system will be about $7.3 million from 2014 through 2018, the rule said.

In an Aug. 7 statement, the Medical Group Management Association said it supported the rule, noting that “receiving and processing paper checks is cumbersome and inefficient. These standardized operating rules will increase efficiency and allow practices to allocate resources to patient care instead of wasteful administrative tasks.”

By Steve Teske  

The rule is at http://op.bna.com/hl.nsf/r?Open=bbrk-8wxl4p.

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