Alliance formed to develop information-exchange rules

One of the group's goals is to standardize health plans' electronic patient eligibility and benefit data, so that physicians have quicker access to better information.

By Tyler Chin — Posted June 27, 2005

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More than 50 medical societies, insurers, hospitals and technology companies have launched an initiative designed to make it easier for physicians to obtain patient insurance information electronically.

Under the initiative, members of the alliance, including the American Medical Association, will develop information-exchange rules to enable doctors to submit an electronic eligibility inquiry regardless of the billing system they have in their office to learn which participating health plan covers that patient and that patient's co-payment and deductible, said Robin Thomashauer, executive director of the Council for Affordable Quality Healthcare.

The Washington, D.C.-based nonprofit coalition of the nation's largest health plans and networks is spearheading the initiative. It is modeled on the process the financial industry used to develop information-exchange or operating rules that enable customers of one bank to withdraw cash from any automated teller machine whether or not that ATM is owned or operated by their banking institution, Thomashauer said.

"CAQH should be commended for reaching out to physicians in this important initiative to solve a vexing problem that has demanded a solution for some time," said AMA Chair J. James Rohack, MD. "This will go a long way in alleviating physicians' frustration with health plan administrative operations. We are optimistic that the next step in this endeavor will yield accurate, real-time information detailing patient-specific cost-sharing responsibilities and health plan payments to physicians."

If the industry adopts the information-exchange rules so that they become industry standards, physicians will gain quicker access to up-to-date patient eligibility information, which will help improve their cash flow and save them time, said Trevor Stone, manager of private sector advocacy at the American Academy of Family Physicians, which also is participating in the initiative.

The AAFP also believes the effort could serve as the foundation for the industry to develop information-exchange rules for other transactions, including precertification and claim status inquiry, that will improve administrative efficiencies for both physician and insurers, Stone said.

Other participants include the American College of Physicians, the Centers for Medicare & Medicaid Services, Aetna Inc., WellPoint Inc., Humana Inc. and Kaiser Permanente.

A key goal of the initiative is to standardize and provide a minimum set of eligibility and benefit information to doctors, CAQH's Thomashauer said. "If a plan wants to offer more, that's wonderful, but what we want to do is get to a robust enough minimum data set so that [physicians] will have what they need to make decisions rather than getting some and still having to make the phone call [to get the rest of the information they need]," she said.

Today, physician offices spend a lot of time trying to obtain patient insurance information via the phone or different Web sites.

"If you're a physician and contract with 10 different plans, you have to get it differently from every one of those plans because some of them have it online and some don't," Thomashauer said. "There's variability in the way you access information, and there's also variability in the amount of information you get from each plan," she said.

Some small plans provide physicians only a yes or no answer as to whether patients are insured; others give all the information that CAQH hopes plans participating in its initiative will make available to physicians; and others fall somewhere in between, she said.

CAQH anticipates that the alliance will develop and test the rules by the end of the year. The next step would be for insurers to invest in making sure their legacy systems can provide and make their data available, and for vendors that sell practice management systems -- and clearinghouse services -- to incorporate the rules into their system.

Rule adoption would be voluntary, Thomashauer said. But she is optimistic that, because they are helping draft the information-exchange rules, participating insurers will then adopt them. It also would be in their financial interest to adopt them, she said.

Physicians would not have to scrap their existing billing systems.

"What the vendors are telling us is that they would include this in the new release" of their software and doctors would get the upgrade as part of their annual support and maintenance agreement, Thomashauer said.

Whether doctors will have to pay a fee to do online eligibility inquiries will depend on the vendor they bought their practice management system from or clearinghouse that they use, she added.

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External links

Council for Affordable Quality Healthcare on its online eligibility and benefits initiative (link)

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