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Administrative Simplification:  Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice (ERA).

The Affordable Care Act (ACA) contained a number of “Administrative Simplification” provisions to reduce the administrative burden for practices related to the billing and collecting payments from many different health insurance plans ----including Medicare and Medicaid.

These provisions affect almost all healthcare plans. In July 2011 the Department of Health and Human Services (HHS) released its first set of rules related to the ACA administrative simplification requirements--- it enables physician practices and other healthcare providers to quickly and securely electronically obtain reliable patient health plan eligibility and benefits information, and to check the status of a submitted claim.

On August 10, 2012 the HHS released a second final rule to promote administrative simplification, referred to as the Electronic Fund Transfer (ETF) and Electronic Remittance Advice (ERA) Operating Rule Set, that builds on current electronic communication standards and defines operating rules that must be followed by all health plans(payers) that:

  • Facilitates the ability of physician practices and other healthcare entities to receive claim payments electronically, and to automatically match (reassociate) explanations regarding any adjustments to these payments by the health plans with the correct claim.
  • Defines the maximum data set that a health plan can require a practice to submit to qualify for electronic payment under these operating rules.
  • Standardizes the format that a health plan must use for companion guides that explain the policies and requirements for practices and clearing houses to engage in these payment transactions.

The HHS believes that these operating rules will increase the use of electronic claims payments by physician practices and other healthcare providers and thus, reduce the burden, cost and time to receive these insurance claim payments.

Studies reported in the rule have found that the average physician spends three weeks a year on billing- and insurance-related tasks, and, in a physician’s office, two-thirds of a full-time employee per physician is necessary to conduct these tasks. Electronic fund transfers are currently used for less than 40 % of all healthcare claims payments to providers. Most of the cost associated with the implementation of these rules will be borne by the health plans, who must implement them by January 1, 2014.

Practices are not obligated to use EFT for payments under this rule. Practices can continue to receive these transactions on paper (i.e. checks) if they choose. View a copy of the Electronic Fund Transfer (ETF) and Electronic Remittance Advice (ERA) Operating Rule Set

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