Tool Streamlines Electronic Funds Transfer From Health Plans

The Council for Affordable Quality Healthcare (CAQH), a nonprofit alliance of health plans and trade associations, has developed an online tool that lets healthcare providers apply for electronic funds transfer (EFT) from multiple health plans. The goal is to increase efficiency and save money by eliminating the need for doctors and other providers to enroll in EFT separately for each health plan in which they participate.

The tool is free to providers. CAQH charges health plans modest fees to participate.

Aetna and Cigna, each of which has about 800,000 providers in their national networks, already offer EFT enrollment through the CAQH online enrollment tool. CAQH hopes that every health plan will eventually participate in the program, said Robin Thomashauer, executive director of CAQH, in an interview.

This is a realistic expectation based on experience, she said, citing CAQH's universal provider datasource (UPD) service, which allows providers to submit a single credentialing application to their payers. Around a million providers use that tool to submit credentialing and other professional information to 700 health plans, hospitals, Medicaid agencies and other organizations, according to CAQH.

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"When we started that, very few plans were using it," Thomashauer noted. "Our model is that large plans can create a critical mass at the beginning. And as providers interact with them and like the offering, they'll talk to the other plans and get them engaged. That's our approach here as well."

Although many health insurers belong to CAQH, she added, they aren't bound to participate in its initiatives. "Each plan makes their decision about whether they're going to participate."

In CAQH's announcement, Susan Turney, MD, president and CEO of the Medical Group Management Association-American College of Medical Practices Executives, commented, "CAQH’s universal EFT tool offers an efficient and effective way for providers to easily -- and at no cost to them -- adopt electronic payments. This is a win-win for providers, payers and patients themselves as administrative savings can be redirected toward care delivery."

Only about a third of claims payments are currently made electronically, according to the Department of Health and Human Services (HHS). A statement from CAQH attributes that partly to "the current cumbersome and burdensome enrollment processes which require that providers enroll separately with each payer. The switch to EFT for provider reimbursement will eliminate the need for redundant paperwork, reduce the time spent on printing, mailing and receiving checks, lower lockbox fees, as well as enable tighter security on monetary transactions."

In the future, Thomashauer said, CAQH might offer additional tools to simplify administrative transactions between providers and payers. Among those might be electronic remittance advice (ERA), she said.

The Committee on Operating Rules for Information Exchange (CORE), a branch of CAQH, has created operating rules for both EFT and ERA, as well as other transactions, to facilitate the use of HIPAA transaction standards that are already in effect. The Centers for Medicare and Medicaid Services (CMS) has imbedded those operating rules in a regulation that requires all HIPAA-covered entities to use them, starting Jan. 1, 2014. Private payers are required to offer EFT after that date, and CMS has announced that, beginning in January 2014, that's the only way it will pay providers.

The CMS program has run into some snags of late. A month ago, the agency announced it would delay enforcement of the use of the eligibility and claims status operating rules, which were supposed to take effect on Jan. 1.

This week, Emdeon, which operates a leading claims clearinghouse, announced that it had been hired by CMS "to define the processes and tools needed to move electronic healthcare transaction standards to a new version."

Emdeon elaborated, "The purpose of the project is to define the activities when new HIPAA and ACA [Affordable Care Act] transaction standards are adopted to avoid the implementation issues that have been associated with revised transaction standards in the recent past. According to CMS, the intent of the project is to greatly reduce the likelihood of technical issues going undetected until after the standards are adopted and to eliminate the negative impacts such technical issues would have on the healthcare industry."

The mention of ACA standards seems to refer to the operating rules for HIPAA transactions, which are required by the ACA.

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