Engaging in operating rule development and adoption amidst the era of healthcare automation

Over the past two decades, the healthcare industry has collaborated to accelerate automation, alleviate administrative burdens and lower the cost of conducting common business transactions.

Although much work remains to be done to streamline healthcare administration, the industry’s approach to developing and implementing operating rules to improve revenue cycle automation, independent of standards development, is a success story. As the marketplace, technology and regulatory frameworks continue to evolve, operating rules developed by the CAQH* Committee on Operating Rules for Information Exchange (CORE Operating Rules) serve as a proven approach to simplification and interoperability.

The history of the CORE operating rules

Over two decades ago, HIPAA aimed to streamline healthcare administration by mandating electronic standards for common revenue cycle transactions, including eligibility, claims, payment and remittance advice. Despite implementation, industrywide variation persisted, hindering automation goals. CORE emerged to develop operating rules, or business rules, to address these challenges.

In 2009, the Affordable Care Act recognized the concept of operating rules, defining them as “the necessary business rules and guidelines for electronic exchange of information that are not defined by a standard or its implementation specifications.” Shortly thereafter, the secretary of HHS designated CORE as the national operating rule authoring entity under HIPAA.

Rules in 2024

Today, CORE has eight sets of operating rules that enhance electronic transactions and simplify administrative tasks developed by participating healthcare organizations. HHS has mandated three rule sets through regulation, and in 2023, the National Committee on Vital and Health Statistics (NCVHS) recommended additional rules for mandate, focusing on:

• Benefit coverage
• Telehealth
• Prior authorization
• Value-based payment

The value of operating rules to revenue cycle automation

Operating rules play a pivotal role in automating administrative transactions, contributing to annual industry savings of $193 billion. The CAQH Index notes potential additional savings of $18.3 billion are possible through further automation.

Notably, the CORE Eligibility & Benefits Data Content Operating Rule has significantly increased real-time eligibility verifications. In 2022, an updated Eligibility & Benefits Rule was approved to close remaining automation gaps and advance price transparency. As more health plans and vendors adopt operating rules, provider organizations benefit from improved patient communication, enhanced visibility into prior authorization requirements, more robust coverage information and streamlined office workflows.

How operating rules are developed

CORE participating organizations represent the entire healthcare industry, including provider organizations and health plans representing 75% of insured Americans, as well as government entities, vendors, clearinghouses, associations and standards development organizations. These stakeholders come together in CORE work groups to identify, debate and ultimately reach consensus on operating rule requirements through a formal process. Individuals participating in CORE represent a cross-section of expertise including business, operations, clinical, policy and technical backgrounds to develop operating rules that address information gaps, drive automation and can be integrated into existing workflows.

A focus on 2024 and beyond

In 2012, the CORE Eligibility and Benefits Data Content Rule mandated that health plans provide more comprehensive data in an electronic eligibility verification, including the patient’s deductible, copayment, coinsurance and coverage specifics. From 2013 to 2022, electronic, real-time eligibility verifications increased from 65% to 94%. Automating the final 6% could yield more than $9.3 billion in savings given the industry’s 25 billion annual verifications.

In 2022, CORE participants endorsed an enhanced eligibility rule, now part of a NCVHS-recommended rule package for adoption under HIPAA. If mandated by HHS in 2024, health plans will be required to return additional data points, such as prior authorization details, tiered benefits, telehealth coverage and maximum benefit information, in addition to procedure-code level detail.

As health plans and vendors increasingly embrace operating rules, benefits for provider organizations multiply, enabling improved patient communication, enhanced visibility into prior authorization requirements, more accurate cost estimates and streamlined revenue cycle workflows.
In the future, operating rules present numerous opportunities to automate and streamline revenue cycle processes.

As the industry shifts toward emerging standards such as application programming interfaces (APIs) for administrative data exchange, operating rules serve as a bridge, ensuring uniform data and expectations. This development fosters interoperability across organizations, accommodating diverse points along the technology adoption spectrum.

Get your organization’s voice heard

CORE provides uniformity to common revenue cycle transactions so the industry can automate essential business processes. Ask your vendors and health plans if they are CORE-certified. HFMA encourages its members to partner with CORE. Together, we can drive the creation and adoption of new and updated healthcare operating rules that support standards, accelerate interoperability and align administrative and clinical activities among healthcare providers, health plans and consumers.

For more information

To learn more about the CAHQ’s CORE, please find information at www.caqh.org/caqh-core or attend the 2024 HFMA Annual Conference session “How CORE Operating Rules streamline the revenue cycle: from eligibility to payment” in Las Vegas at 4:10 p.m. PT on June 26.

*CAQH stands for the Council for Affordable Quality Healthcare, which describes itself as “a non-profit alliance of health plans and related associations working together to achieve the shared goal of streamlining the business of healthcare” (caqh.org).