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PPACA: Feds Set Health EFT Regulations

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The U.S. Department of Health and Human Services (HHS) has released an interim final rule that could help standardize U.S. health care electronic funds transfer (ETF) and electronic data interchange (EDI) systems.

HHS is adopting operating rules developed by the Council for Affordable Quality Healthcare (CAQH), Washington, for health care EFT transactions and for “remittance advice” transactions.

The term “EDI” can refer to any formal system two parties use to share information over a computer network.

An “EFT” system is a network that users can use to make and receive payments.

“Electronic remittance advice” (ERA) is the message a payer sends to notify the recipient that the payer has sent a payment.

HHS officials say they have adopted most of the provisions in the Phase III of CAQH’s Committee on Operating Rules for Information Exchange (CORE) EFT & ERA Operating Rule Set, including CAQH’s CORE v5010 Master Companion Guide Template.

HHS has not adopted a CAQH proposal regarding health care claim payment batch acknowledgement requirements. HHS Secretary Kathleen Sebelius needs to adopt an acknowledgement standard before she can adopt the batch acknowledgement requirements, and she has not yet adopted the acknowledgement standard, officials say.

HHS released a batch of health care claim EFT regulations in January and health plan ID rules in April. It posted electronic health claim and eligibiliity notice regulations in July 2011. 

Members of Congress added EFT and EDI standard-setting authority provisions to the Patient Protection and Affordable Care Act of 2010 (PPACA) in an effort to reduce U.S. health care system administrative costs.

Researchers have found that U.S. physicians spend an average of 3 weeks worth of time per year on billing and insurance related tasks, and that collecting payments takes up 40% of the time of physician practices’ nonclinical employees, HHS officials say in a preamble to a preliminary version of the regulations that was posted on the Web.

U.S. health care providers still get 70% of their payments in the form of paper checks, and payers still send 75% of their remittance advice notices through the mail, officials say.

Congress tried to help HHS bring order to electronic health care communications in 1996, when it included standards provisions in the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HIPAA, and HHS efforts to implement HIPAA, left many gaps, and, as a result of those gaps, technology vendors and users have implemented the standards that already exist in so many different ways that users of different systems still trouble connecting, officials say.

Health plans have created more than 1,200 “companion guides” to explain how they are implementing the HIPAA requirements, but the guides themselves vary, according to the American Medical Association, Chicago.

PPACA requires HHS to develop a single set of operating rules for each type of EDI transaction, to make the way vendors and users implement the standards as uniform as possible, officials say.

HHS officials are hoping the new EFT, EDI and ERA temporary regulations will help the U.S. health care achieve $3.3 billion in net savings from 2013 through 2023.

Commercial health plans and benefit plan administrators should end up with $529 million to $757 million in net savings over that same 10-year period, officials estimate.

The regulations are set to appear in the Federal Register Aug. 10, and the compliance date will be Jan. 1, 2014.

Comments on the regulations will be due 60 days after the official Federal Register publication date.


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