Over the past two decades, the healthcare industry has made significant strides in adopting technology and processes that enhance the experience for both providers and patients. Despite this, one area of progress—streamlining the administrative workflow—often is overlooked. Accomplishing this is crucial to improving efficiency throughout the industry.
Advancements in Automation
To date, efforts to automate and improve business processes have saved health plans and providers $187 billion annually, according to the 2022 CAQH Index.(1) For example, today 91% of coordination of benefits transactions are performed electronically. This is a marked improvement from just eight years ago, when more than half of these transactions were still done manually.
However, opportunities remain. Take the use of electronic prior authorizations, for example, which grew from 7% in 2014 to 28% in 2022.(1) In response to the growing concern that manual prior authorizations not only are time-consuming and expensive, but also can delay patient care, the industry must make further progress in this area. According to the 2022 CAQH Index, by fully automating this workflow, medical providers can save 11 minutes per transaction. This would translate to a 66% reduction in the cost of conducting a prior authorization.
Ultimately, further automating manual transactions could save the medical industry an additional $22.3 billion a year. Approximately 93% of these savings—$20.7 billion—could be realized by providers. Greater automation not only benefits providers, but it also reduces administrative burden and creates more time to focus on patient care. This is particularly important as we face an aging population with more complex health concerns.(2) These potential savings underscore the importance of continued work to automate healthcare transactions.
Operating Rules Drive Automation and Efficiency
The CAQH Committee on Operating Rules for Information Exchange (CORE) is an independent industry initiative focused on driving interoperability through the adoption of operating rules—industry requirements designed to make electronic data transactions more predictable and consistent regardless of the technology. Cross-industry standardization is crucial to driving automation, and interoperability, at scale.
CORE was created in 2006 to support HIPAA by driving adoption of electronic standards for administrative transactions to automate the exchange of data between health plans and providers.
Today, CORE has developed eight sets of operating rules to address transactions across the revenue cycle that work together to remove cost and complexity from the healthcare ecosystem. CORE operating rules address eligibility and benefits, claim status, electronic payments and remittance, prior authorization and referrals, attachments, healthcare claims, attributed patient rosters, benefits enrollment, and premium payments. By leveraging consistent, defined data requirements, connectivity, and infrastructure, the path to adopting automated processes is clearer and more efficient for providers and health plans.
By promoting automation and easing the burden of manual processes, patients ultimately reap the benefits of more informed and timely care delivered at a lower cost.
Federally mandated operating rules related to eligibility and benefits were groundbreaking when first published and are the reason providers receive robust, electronic eligibility information on patients in real time, including detailed information on benefit coverage by service type and patient financial responsibility. These operating rule requirements enable providers to understand, before or at the time of service, whether a patient has coverage and then ultimately can collect payment. The impact of these requirements is substantial. By promoting automation and easing the burden of manual processes, patients ultimately reap the benefits of more informed and timely care delivered at a lower cost.
And although many industries have transitioned to digital documentation sharing, providers continue to fax, print, or mail information to substantiate care—even as health plans request more specific data before paying claims. The CORE Attachments Operating Rules further digitize claims submission and prior authorization documentation exchange while reducing the cost and time of exchanging these materials, providing immediate value to busy providers and staff.
The benefits that CORE operating rules bring to provider organizations, and the industry at large, grow as adoption and standardization increase at scale, reducing administrative complexity and, ultimately, reducing costs. For instance, if a provider contracts with several health plans that each follow their own data requirements, managing these workflows becomes complex and time-consuming. But, if each health plan adheres to CORE operating rules, the process becomes uniform, predictable, and streamlined.
What’s Next?
There are still gains to be made in alleviating administrative burdens and reducing costs. As healthcare evolves, CORE operating rules are updated, and new rules are introduced to ensure the industry has access to timely guidelines that drive automated data exchange and support innovation.
In July 2023, the National Committee on Vital and Health Statistics (NCVHS), a federal advisory body to the U.S. Department of Health and Human Services (HHS), recommended additional CORE operating rules to HHS for federal mandate. These rules provide critical infrastructure for some of healthcare’s most pressing challenges. For example, updates to the eligibility and benefits operating rules enable providers to have automated information on a patient’s detailed benefit coverage at the procedure code level, need for prior authorization, telehealth benefits, and attribution status under a value-based contract, among other advantages.
Additionally, CORE is regularly evaluating industry progress, convening work groups and developing best practices to improve other areas of opportunity and drive collaboration across the industry. CORE participants currently are developing new operating rules related to value-based care, healthcare claims, and specialty medication eligibility covered under the medical benefit.
Operating rules continue to reduce barriers to electronic information exchange and interoperability. And, as the industry starts the transition to emerging standards such as application programming interfaces to support administrative data exchange, operating rules can bridge the gap between existing and emerging technologies. This will ensure consistent data and expectations while enabling interoperability across organizations at varying points along the technology adoption spectrum.
Join the Movement to Transform Healthcare
There is still much work to be done in improving healthcare administration, but defining and implementing operating rules (and standardization relative to the transfer of data) that drive effective automation is the right step toward a more streamlined ecosystem.
However, to realize the full benefits of this progress, the industry must commit to widespread adoption and ongoing collaboration. Through joint effort and coalition building, we can find and implement solutions to the medical industry’s most pressing administrative challenges. Ultimately, when stakeholders from across the industry work together, we can provide a better healthcare experience for everyone.
References
The 2022 CAQH Index Report. CAQH. www.caqh.org/sites/default/files/2023-05/2022-caqh-index-report.pdf
James E, Morton S, Dunn W. Addressing the health needs of an aging America: new opportunities for evidence-based policy solutions. University of Pittsburgh Center for Caregiving Research, Education and Policy, 2015. https://www.healthpolicyinstitute.pitt.edu/sites/default/files/SternCtrAddressingNeeds.pdf