CLEAN AND CLEAR: COLORADO INITIATIVE PUSHES TRANSPARENT CLAIMS PROCESSES A UNIFORM SET OF PAYMENT RULES AND EDITS CAN LEAD TO HUGE PAYOFFS Published with permission of the American Medical Association (AMA) In the physician practice, the claims management revenue cycle consumes up to 14 percent of practice revenue. The complexity and lack of transparency in the existing system has also become increasingly problematic for patients who are asked to shoulder greater financial responsibility for healthcare services. Today, it is difficult – if not impossible – for patients to anticipate the specific, potentially significant financial obligation they may incur for healthcare services. One significant contributor to healthcare administrative costs and confusion is the lack of standardization in code edits. At a 2011 National Committee on Vital and Health Statistics hearing, HBMA testified that “the lack of standardization for coding conventions, code pair edits, and explanation for denials allows idiosyncratic payor edits to proliferate.” These payor-specific edits, which account for approximately 61 percent of all claims denials, often cause physician and billing company confusion, which can lead to burdensome appeals processes and wasted physician resources that could otherwise be spent on patient care. In order to address such concerns, a Colorado initiative has been created to relieve administrative burdens, improve transparency, and save millions in healthcare costs. In 2010, Colorado’s governor signed the Medical Clean Claims Transparency and Uniformity Act (otherwise known as the Colorado Clean Claims Initiative) into law. The act required the executive director of the Colorado Department of Health Care Policy and Financing to convene a task force of industry and government representatives to develop a standardized set of payment rules and claim edits to be used by payors and healthcare providers in Colorado. Accordingly, the Colorado Clean Claims Task Force was created, consisting of a volunteer membership of approximately 25 experts, including national representatives from many health plans, software vendors, and provider groups, including the Colorado Medical Society and the American Medical Association (AMA). In order to promote transparency and acceptance throughout the industry, all meetings and developments of the task force are open to any member of the industry and the general public. Over the past three years, the Colorado Clean Claims Task Force has crafted a standardized set of logic rules based on existing national industry sources, including the National Correct Coding Initiative (NCCI), the Centers for Medicare & Medicaid Services (CMS), the Medicare physician fee schedule, the CMS national clinical laboratory fee schedule, the Healthcare Common Procedure Coding System (HCPCS) and directives, the AMA’s Current Procedural Terminology (CPT) coding guidelines and conventions, and national medicalspecialty society coding guidelines. These logic rules are designed to guide the adoption of a uniform set of payment rules and edits. Current Status and Future Plans The task force has recently called for payors to submit all claims edits that they wish to be used in the standardized set. In order to be utilized on a Colorado claim by a commercial payor, an edit must be submitted for inclusion in the database. All edits received will then be analyzed to ensure their compliance with the logic rules, including validation that each rule and edit is properly based on a recognized national clinical source. In 2015, the task force will release the complete edit set and payment rule library for a full public review. This public review period will also permit a more formal testing of the library in order to ensure it meets the needs of the claims revenue industry. The full edit set will then be formally implemented in 2017 and subsequently updated on a quarterly basis. 20 HBMA BILLING • JULY.AUGUST.2014
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