The Affordable Care Act mandates the creation and use of operating rules for electronic funds transfers (EFTs) and electronic healthcare payment and remittance advice (ERA) transactions, with the requirement that those rules be adopted no later than July 1, 2012, and become effective no later than Jan. 1, 2014.
The EFT and ERA Operating Rules Subgroup, which that includes providers, payers, clearinghouses, the financial industry and others, has worked to create and recommend operating rules for EFTs and ERAs.
The subgroup acts under the auspices of the Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange (CAQH CORE) – a national private sector initiative recommended by the National Committee on Vital and Health Statistics. The subgroup's recommendations were due to CORE by August 1.
CORE sent out a survey to industry stakeholders to determine top priorities in rulemaking. Seven areas from which operating rules could be drawn were developed from the responses to the survey, said Stuart Hanson, vice president and product line manager for Healthcare Solutions at Fifth Third Bank, one of the co-chairs of the sub-workgroup.
Those areas identified were:
• Identify a set of data elements required for standardized healthcare EFT enrollment.
• Identify a set of data elements required for standardized healthcare ERA enrollment.
• Make Claim Adjustment Reason Codes and Remittance Advice Remark Codes more uniform.
• Require accurate identification of the health plan so that when a provider receives an EFT there's no question as to which payer it is coming from.
• Limit the elapsed time between a payee's receipt of an EFT payment and a matching ERA transaction.
• Enable providers to specify preference for EFTs and ERAs based on Tax Identification Number or National Provider Identifier.
• Provide a crosswalk between the ACH CCD+ standard and the ASCX12 835 v5010 to ensure proper creation of messages to improve the ability of payees to re-associate or match these transactions.
Having operating rules changes everything, said Robert Tennant, senior policy advisor at the Medical Group Management Association.
"It's a huge opportunity, frankly, for the industry to streamline, to cost-save, to make more efficient some of these very burdensome and onerous transactions, which many of them occur on paper," he said. "You get sent a paper check. Three weeks later you get the remittance advice. You've got to match them up, figure out if you got paid the right amount, do the reconciliation and go to the bank. A lot of those things you'll be able to automate. Every time you automate, you improve the efficiency."
Dan Rode, vice president of policy and government relations for the American Health Information Management Association, agreed that operating rules would have a positive impact.
"It's another way to both save the accounting aspect as well as to improve cash flow," he said. "So they've got two wins that they could get out of this."
Despite the positives and the extensive vetting through a broad cross-section of stakeholders, industry insiders do expect some disagreements. That's why the recommendations are being offered nearly a year before the rules need to be finalized, said Hanson.