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Operating Rule Enforcement Delay: Good News or Bad?

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As you may be aware, the Centers for Medicare and Medicaid Services (CMS) has decided to delay enforcement of two Operating Rules mandated under the Affordable Care Act (ACA). As I discussed in an earlier blog post, the Operating Rules for eligibility and claim status took effect on January 1, 2013. However, any organizations that aren’t yet in compliance with these Operating Rules won’t be penalized until March 31, 2013.

While an enforcement delay may sound like a good thing, for most practices it just means it’ll be a little longer before the benefits of the ACA start flowing their way. With the delay, payers have additional time to further standardize and provide additional useful information in their responses to eligibility and claim status information requests.

Here’s how CMS explains the postponement in a press release:

“…the Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) announced that to reduce the potential of significant disruption to the health care industry, it will not initiate enforcement action until March 31, 2013, with respect to HIPAA covered entities (including health plans, health care providers, and clearinghouses, as applicable) that are not in compliance with the operating rules adopted for the following transactions as required by the Affordable Care Act: eligibility for a health plan and health care claim status. Notwithstanding OESS’ discretionary application of its enforcement authority, the compliance date for using the operating rules remains January 1, 2013.”

The delay may be good news for any payers and/or practices not yet able to produce and process 5010 data in its entirety. It’s bad news, though, for anyone looking forward to more standardized payer responses.

As we wait for the enforcement period to begin, practices should take the time to review their software to be sure it’s capable of both producing 5010 requests and processing 5010 responses. They should also educate themselves on the capabilities associated with the new ACA requirements, including patient eligibility responses.

After the enforcement delay is over, practices that choose to utilize these new required updates should start to see improved revenue collection due to more effective patient payment collection and reduced claim denials and payment delays. This will be a result of having more complete and timely benefit information. With 5010 and the new ACA eligibility and claim status requirements, payers are required to provide additional and consistent data, which means practices will be able to quickly and easily leverage the data at their fingertips.

In the coming months, practices not currently using eligibility data will miss out on the chance to better manage their understanding of patient benefit information—and lower overall costs. There’s no questioning that benefit: It’s very good news.

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