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Obamacare Rollout Hampered By Operating Rules Lag
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Ken Terry
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Ken Terry,
User Rank: Apprentice
11/10/2013 | 9:48:31 PM
re: Obamacare Rollout Hampered By Operating Rules Lag
Pwanderschied: If insurers can already receive files in the 834 standard, why is CMS requiring health plans to use operating rules for the 834 in 2016? Why is CAQH CORE devising those rules. And why would CMS use a version of 834 different from the standard?
pwanderscheid
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pwanderscheid,
User Rank: Apprentice
11/4/2013 | 7:50:51 PM
re: Obamacare Rollout Hampered By Operating Rules Lag
This article is inaccurate in that CMS chose to not even use the 834 in its standard HIPAA approved format. They took the base 834 and then took liberties on some data elements and how some fields are used. No amount of Operating Rules would have helped. Most payers have been able to accept the standard 834 since the HIPAA transactions were mandated since being able to accept them was required, while enrollment submitters were not mandated to use it to submit enrollment electronically. Since the so called 834 that CMS is using does not follow the standard accepting itGs almost the same as taking in a proprietary CMS format and had to be specifically programmed for.
Ken Terry
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Ken Terry,
User Rank: Apprentice
11/1/2013 | 8:26:39 PM
re: Obamacare Rollout Hampered By Operating Rules Lag
I don't think CMS ever wanted to sabotage the insurance exchanges, Andx. That would be self-defeating, since CMS is responsible for making them work--or at least the federally run marketplace and the state exchanges it's partnered in. I think this was just a typical example of bureaucratic shortsightedness.

David--the right things haven't happened yet because CMS planned them in the wrong order.
andyx
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andyx,
User Rank: Apprentice
10/31/2013 | 4:07:14 PM
re: Obamacare Rollout Hampered By Operating Rules Lag
this appears to be another symptom caused by the politics of ACA. while the cause appears to be government agency incompetence, it seems to me that the root cause of this problem is the hope by certain decision makers that the ACA would somehow be delayed or repealed. This notion has feed numerous actions on the part of providers and insurance industry ecxecutives delaying their actions in the misplaced desire that implementation of ACA would be delayed. Included in this type of problem is compliance with HIPPA, the failure of industry to implement backend transmission rules, the lackluster acceptance of ICD-10 and the foot-dragging of CMS itself. those actions by CMS to accomodate industry tardiness makes CMS look poorly prepared for ACA. CMS has also a poor understanding of Republican strategy so they also did not execute their efforts to address their tasks to implement ACA. While this article is brilliant in idetifying this abuse of the ACA it is but one more symptom of an industry and agency lingering on a past that cannot be sustained and they are all in various stages of denial over ACA.
The law of the land is and has been clear. Unfortunately both the industry and CMS must accept and act on the law of the land or the law is violated. Both bureaucracies have to accept ACA as real. Today, and likely for some time to come, bureaucracies have wonderful hindsight and very little foresight.
Public Healthcare Policy is flawed because the data supporting objective decisions is so corrupted that it is useless for policy analysis and formulation. Helath Care policy in the U.S. today and for a reasonable future will remain the opinion of a few leaders in the legislative and executive branches of the federal government. In order for this to be corrected CMS must focus on waste, fraud, and abuse of public healthcre programs AND pay the bills on claims on a sound accounting basis.
Congress must take notice:
--CMS does not know how much fraud there is.
--CMS does not have a definition of the concept of abuse.
--CMS has only an understanding of Waste as an exception to policy but no way to discern it in the payment record.
--Congress must listen to the testimoney to them, and read the reports commissioned by them. The IG, OMB, FBI and CMS all have testimoney ON-THE-RECORD that Waste, Fraud and Abuse, by criminals, not only providers, amounts to 40%-60% of the $1.8 Trillion spent by CMS for public healthcare.
David F. Carr
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David F. Carr,
User Rank: Author
10/29/2013 | 9:44:54 PM
re: Obamacare Rollout Hampered By Operating Rules Lag
So the right things happened in the wrong order?


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