Initiative Addresses Hassles of Patient Insurance Verification

"Tracking down eligibility and benefits information costs provider practices in the United States millions of dollars each year," Robin Thomashauer, executive director of the Council for Affordable Quality Healthcare, said recently. "It's a significant problem, but it doesn't have to be."

Thomashauer spoke to AAFP News Now about one of CAQH's current projects, the Committee for Operating Rules for Information Exchange, or CORE. Stakeholders involved in the project include representatives from health plans such as BlueCross BlueShield Association, Humana Inc. and WellPoint; government entities such as CMS and TRICARE; specialty societies including the AAFP, American College of Physicians and AMA; claims clearinghouses; and practice management software organizations.

"What's needed is a set of operating rules that will promote interoperability and facilitate real-time, comprehensive, secure transfer of reliable patient data between providers and health plans," said Thomashauer. "And that's what CORE is working to achieve."

Thomashauer compared CORE's efforts to the exchange of confidential information that takes place every minute of every day in the banking world.

"We've modeled CORE on the processes that led to the strict information-exchange rules that make direct deposits and ATMs possible," said Thomashauer. "And because we have so many industry partners around the table, CORE has a very real opportunity to similarly transform the health care industry."

Software to implement phase one of the project should be available to physicians by December, she said.

Trevor Stone, AAFP's manager of private sector advocacy, represented the AAFP at the first face-to-face meeting of CORE participants June 29 in Washington, D.C. Group members have been brainstorming via teleconference since January.

"It appears the wheels are turning on this effort to develop standard, interoperable operating rules for insurance eligibility information exchange," said Stone.

According to Stone, phase one will enable a physician's front office staff to get immediate confirmation on:

Phase two, expected to launch sometime in 2006, could include an update Stone called "accumulator" software that would verify the patient's remaining deductible amount. Stone said this feature could help reduce physicians' bad debt expense by alerting front office staff when collections should be made at the time of service.