The health care reform plan issued by Senate Finance Committee chair Sen. Max Baucus (D-Mont.) calls for mandated adoption of "operating rules" that would significantly tighten the standards of HIPAA administrative/financial transactions. It also would increase the number of transaction sets.
The "operating rules" referenced in the plan are those developed under the voluntary CORE initiative under way for several years. CORE is the Committee on Operating Rules for Information Exchange within CAQH, a Washington-based payer advocacy group. The initiative seeks to build industry consensus on tightening of the HIPAA standards to facilitate health care financial/administrative transactions and offer more information to providers.
CORE started with Phase I of an electronic eligibility/benefit determination transaction. The recently completed Phase II of CORE further tightened the eligibility/benefit determination transaction and included claims status. Participants now are developing prior authorization and remittance transactions in Phase III. A small number of insurers are core-certified. Providers will receive full benefits of CORE transactions when their billing system and claims clearinghouse are CORE-certified. America's Health Insurance Plans, a national trade association for health plans, earlier this year called for mandated use of the CORE transactions.
Baucus' plan is called a "Chairman's Mark," which is a detailed explanation of provisions that will be the basis of negotiations in the Senate. It is not yet formal legislation written in legislative language, but a 223-page plain-English document. The document details the history of the HIPAA transactions and their limitations, then states:
"The Chairman's Mark would establish a timeline for accelerating the development, adoption and implementation of a set of operating rules for each HIPAA transaction for which there is an existing standard. The operating rules would be consensus-based, and reflect the business rules around which health plans and providers would uniformly use the HIPAA standards. The Mark would add the electronic funds transfer (EFT) of health claims payments as a HIPAA transaction and provide for the adoption and enforcement of a standard for EFT."
Under the Baucus plan, health plans would be fined annually for not complying with new "HIPAA operating rules" by April 1, 2014. "For each day that a plan is non-certified or non-compliant, the Secretary of HHS would access a fee of $1 per covered life until certification is complete," according to the Chairman's Mark. "The fee would not exceed a maximum of $20 per covered life. The penalty would be assessed per person covered by the plan for which its data systems for major medical policies are not in compliance."
Full text of the Chairman's Mark is available at the top of the home page at congress.gov.
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