Opportunities for Improving the Healthcare Claims Process with CAQH CORE Operating Rules Presented by Robert Bowman
As presented at HBMA's 2023 Fall Conference September 26th-28th, 2023.
In 2022, CAQH CORE published Attachments Operating Rules to drive adoption of electronic attachments during healthcare claims processes. By adopting electronic standards and the CAQH CORE Attachments Operating Rules, the industry is expected to see significant savings. Per the 2021 CAQH Index, an annual benchmark report which tracks the adoption of electronic administrative transactions, manual submission of attachments costs the medical industry $5.46 per transaction and electronic adoption could save upwards of 75% per transaction. Data from the pending 2022 CAQH Index, combined with several pilot studies measuring the impact of the attachments operating rules will contextualize the impact of these new operating rules. Session participants will learn about how existing rules support the request, flow, and acknowledgment of attachments for claims and identify data-based cost and time savings for the industry. Session participants will also hear updates from the CAQH CORE team on 2023 healthcare claims initiatives. CAQH CORE will be convening an industry work group in the first half of the year to further improve existing healthcare claims workflows. Based on opportunities identified by an advisory group comprised of industry experts held in late 2022, industry stakeholders will focus on addressing key topics that include addressing provider burden reduction originating from rejected claims and establishing how existing claims workflows can be applied to drive the adoption of value-based payments (VBP). This diverse group of plans, providers, vendors, government agencies, and associations will further refine the opportunities identified. Speakers will summarize the potential for claims operating rules under VBP contracts, telehealth, appeals, claim rejection notification, and error reporting.
Course participants will be able to:
- Summarize how recently published CAQH CORE Attachments Operating Rules help streamline the healthcare claims workflow
- Identify recent trends in the industry around the electronic adoption of healthcare claims
Bob Bowman is the Principal, Interoperability and Standards, of CAQH CORE, a non-profit alliance of healthcare industry leaders whose mission is the creation and adoption of healthcare operating rules that support standards, accelerate interoperability, and align administrative and clinical activities among providers, payers and consumers. Bob oversees the CORE Rule development process; directs the CORE Certification program, which was designed to demonstrate adoption of the CORE rules; serves as a CORE liaison to the standard development organizations (SDOs); is a member of the Board of Directors of WEDI – Workgroup for Electronic Data Interchange; and supports CORE’s industry education and outreach. Prior to joining CAQH CORE, Bob served as the EDI manager for Humana, Inc. He also worked as an implementation manager – implementing EDI, Web, and HIPAA projects for state, federal, and commercial clients across the country.