Doctors welcome speedy access to patients' health plan status

Joseph Stubbs, MD, an internist in Albany, Ga., has watched more patients than he can count walk out of his office after receiving medical treatment only to discover, sometimes weeks later, that the bill he sent to the patient's insurer has been denied.

It's a frustrating yet common occurrence for Dr. Stubbs and physicians nationwide, who aren't always able to check a patient's health plan status while they are still in the physician's office.

But a new set of rules promises to ease the stress physicians face as the Council for Affordable Quality Healthcare, a nonprofit alliance of the nation's largest health plans and networks, has developed a plan it says will make it easier for physicians and other health care professionals to verify patient insurance information.

CAQH's Committee on Operating Rules for Information Exchange says it has developed a series of rules built on existing HIPAA standards to make electronic transactions more efficient regardless of the technology in the physician's office.

More than 15 health plans, including Aetna, WellPoint and Humana and 30 vendors including Availity and Athenahealth, have agreed to implement the CORE rules in their own business practices by March 31, 2007.

CORE's participants extend beyond health plans to include various vendors, associations, government agencies, hospital systems and medical societies, including the American Medical Association.

CORE operating rules will allow physicians who contract with participating members to get up-to-date benefits information from any of the participating health plans in 20 seconds or less. CAQH officials say the physicians aren't required to purchase new equipment beyond what is currently used in their offices because the health plans and vendors are already working to implement the technology. Nearly 70 million people are covered by health plans committed to using the CORE rules.

"This will help us take care of the problem at the point of service instead of realizing it after they've left," said Dr. Stubbs. "People are very mobile. They change jobs and insurances quickly even if they work in the same business. This will help avoid costly and time-consuming mistakes in terms of billing."

The CORE operating rules are designed to help physicians in three areas. First, the rules will help doctors determine whether the health plan covers the patient. Second, the rules help determine patient benefit coverage. Finally, the rules help confirm coverage of certain treatments, as well as the patient's co-pay amount, coinsurance level and base deductible levels.

Bob Greczyn, CAQH board chair and also CEO and president of Blue Cross Blue Shield of North Carolina, said this is the first phase of initiatives aimed at relieving the administrative burden related to verifying insurance coverage.

Additional eligibility components and business transactions will be launched in later phases in 2007. For now, health plans and vendors are working behind the scenes on technical issues in anticipation of the March 31, 2007, deadline.

Trevor Stone, a private sector advocacy specialist for the American Academy of Family Physicians, said the CORE rules give physicians peace of mind because they know exactly what they're going to get when they send a query to participating health plans.

AAFP is also a CORE participant.

"Chasing money down is much more challenging once the patient leaves the office," Stone said.

This set of CORE rules is also considered by some to be the foundation for real-time claims adjudication in future phases of the CORE rules, Stone said. Real-time claims adjudication would allow physicians to be able to find out before the patient leaves the office not only the patient's insurance information, but also how much of the visit is being paid for by the insurer, and how much is the patient's responsibility.