Quick Verification of Patient Benefit Info on the Horizon

Family physicians concerned about the daily hassle of verifying patients' insurance information will welcome a recent announcement from the Council for Affordable Quality Healthcare, or CAQH. Help is on the way.

According to a Sept. 14 press release, more than 20 leading health care organizations -- including Aetna, BlueCross BlueShield Association, Humana, WellPoint and Health Net -- will soon be electronically exchanging patient eligibility and benefits information with health care providers.

With the benefit of a new set of operating rules developed by CAQH's Committee on Operating Rules for Information Exchange, or CORE, by March 31, 2007, physician offices communicating with participating plans will be able to

The information transfer will take 20 seconds or fewer.

CAQH estimates that 70 million Americans are covered by the health plans that have committed to the CORE rules.

"Today's announcement is the first wave of an industry campaign to reduce unnecessary administrative burden related to verifying patient information insurance coverage," said CAQH Board Chair Bob Greczyn in the press release. Greczyn, also CEO and president of Blue Cross and Blue Shield of North Carolina, continued: "These stakeholders are taking a revolutionary step that will help define the future of electronic communication between health plans and providers."

In an interview, CAQH Executive Director Robin Thomashauer pointed out that in the current system, physicians -- or their office staff -- spend an inordinate amount of time gathering patient insurance information that varies widely among health plans. She said that CORE's work would ensure that physicians get consistent information from all participating payers.

"It's all about simplifying a process that is a critical first step in health care delivery," that is, improving access to information at the moment in time when the physician most needs the information, she said.

Thomashauer said that for the next few months, the organizations that have committed to using the CORE operating rules will work with a CAQH-authorized testing vendor to certify that their health information technology systems are in compliance with the rules.

The certification component is critical, said Thomashauer, because it's a "guarantee" that the certified organizations will be able to deliver the promised information.

She said CAQH is hopeful that participation in the initiative will grow. "We continue to work on bringing more organizations on board both to help develop rules and to implement the rules," she said.

CAQH wants practice management software companies, technology companies and claims clearinghouses to commit to the initiative, said Thomashauer. "We want to create a powerful network of organizations communicating the benefits of CORE."

The AAFP is one of 20 organizations, including the American College of Physicians, the American Health Information Management Association, Medical Group Management Association and the e-Health Initiative, that have endorsed the CORE rules and signed a CORE pledge (PDF file: 2 pages / 20 KB. More about PDFs.) to signal support for the initiative.

"We're not operating in a vacuum," said Thomashauer. There are government agencies -- including CMS and TRICARE -- included in the 90 organizations participating in the CAQH initiative. Having input at the federal level "is really important as we look at the long-term acceptance of these rules," she said.