HHS Posts Health Claims EFT Regs

Health plans may have to comply with new electronic funds transfer (EFT) and remittance advice standards by Jan. 1, 2014.

The U.S. Department of Health and Human Services (HHS) has released the new EFT and remittance advice standards in an interim final rule set to appear in the Federal Register Jan. 10.

Comments will be due 60 days after the official publication date.

“If we receive comments that compel us to change any of the policies we are finalizing in this interim final rule with comment period, we will seek to finalize any such changes to allow sufficient time for industry preparation for compliance,” HHS officials say in a preamble to the interim rule.

HHS officials warn plans against blaming problems with complying with the new standards on the banks or other financial institutions that help them with their EFT operations.

“The health care EFT standards adopted herein apply to health plans, and health plans are ultimately responsible for ensuring compliance with the standards regardless of whether a health plan puts the data into standard format itself or uses a financial institution to do so,” officials say. “We expect that some health plans will need to educate their financial institutions about the health care EFT standards adopted herein in order to ensure compliance.”

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required regulators to develop standards that health care organizations could use to exchange information about transactions such as claim submissions.

Today, providers and health plans are exchanging more information through automated systems, but gaps remain. Private health insurers are still using paper checks to make most payments to doctors, officials say.

Officials cite estimates that U.S. businesses of all kinds are making an average of 43% of their payments to other businesses through the EFT system, and that health insurers are making only 15% of their payments to doctors, hospitals and other providers through EFTs.

Doctors who want to get payments from plans through the EFT system must fill out a long form for each insurer that will be paying them via EFTs, officials say.

Plans that use EFT systems to make payments typically send the payments electronically but still send the remittance advice – the document explaining why the amount the plan is paying is different from the amount the provider has billed – on paper, without use of any standard mechanism that makes it easy for providers to match the payments with the remittance advice notices.

Even when a health plan transmits electronic advice electronically, it usually uses a system separate from the EFT system to deliver the notice.