Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Policy and Regulation News

How the Affordable Care Act Influenced CORE Certification

An important reason why CORE certification and CORE operating rules are vital to adhere to under the Affordable Care Act’s requirements is that it enables clearer and more efficient data sharing.

By Vera Gruessner

Health plans, vendors, and providers will need to meet CORE certification requirements in order to comply with mandates under the Patient Protection and Affordable Care Act. CORE stands for Committee on Operating Rules for Information Exchange and involves an aligned method of sharing data between electronic systems among health payers and providers.

CORE Operating Rules

CORE operating rules were required under the Affordable Care Act to improve data sharing and strengthen the flow of administrative information throughout the healthcare continuum.

For more information about CORE operating rules and CORE certification, spoke with Gwendolyn Lohse, Deputy Director, and Managing Director of the Committee on Operating Rules for Information Exchange (CORE) at CAQH, the organization responsible for meeting this ACA mandate.

When asked How CAQH CORE Operating Rules benefit health plans and consumers, Lohse replied, “Information needed at the time it is needed is a major benefit. Some key examples for the health plan side, there are efficiencies and also cost savings that align with uniform operating rules.”

“This allows the health plans to move off of manual response for the billions of transactions that they manage for financing the health system. You can imagine doing billions of transactions manually is just not effective or efficient. It’s quite costly,” Lohse continued. “You can move off of that into an electronic environment and you’re allowed to communicate using national expectations.”

READ MORE: How the Affordable Care Act has Impacted Health Payers

With the Affordable Care Act requiring Americans to have healthcare coverage through the individual mandate or else risk a tax penalty, the number of policyholders has skyrocketed in recent years, which means the sheer volume of administrative and financial data is higher than ever before. As such, it is vital for payers to have a uniform way to share data.

“As we move from much more insured consumers in the US population, with the uninsured rate below 10 percent now, it’s even more important as we move to more insured individuals that there is a way for us to communicate on financial transactions. As a benefit to consumers, it allows these individuals to learn their roles and responsibilities on a financial and on a documentation basis - what needs to be provided to help that payment system move forward,” Lohse pointed out.

“It really is the collective piece of it. Without doing that together, it won’t benefit the nation. You need a whole system that people are supporting.”

Another important reason why CORE certification and CORE operating rules are vital to adhere to under the Affordable Care Act’s requirements is that it enables clearer and more efficient data sharing as well as greater connectivity or interoperability between multiple healthcare IT systems, says Lohse.

When asked whether CORE certification assist in improving data sharing and interoperability among health payers, Lohse answered, “Absolutely, it definitely does. Because of the content, operating rules support existing standards, requiring more use of them. For instance, when claims get denied, there are many different reasons.”

READ MORE: Revisions to Affordable Care Act May Improve Payer Performance

“Those were not communicated content-wise in a common way. What the operating rules have done is to ensure that content for the reason and the action needed to follow-up is communicated using recognizable data content. Another example is co-pays, coinsurance, and deductibles. All of those are required by the operating rules.”

Having industry standards employed by all health payers across the nation will assist in interoperability between healthcare IT systems, she acknowledged.

“It really does help with interoperability in the sense that every system in the US exchanging data is dependent upon another system,” she added. “It also is promoting industry neutral standards.”

Lohse also discussed the important role the Affordable Care Act played in affecting CORE certification and the greater usage of CORE operating rules. Ever since the recommendations were released, the compliance around the CORE operating rules increased with more vendors and payers becoming certified.

When asked how the Affordable Care Act influenced CORE certification, Lohse replied, “I think one of the things the Affordable Care Act did with regard to compliance expectations is that it did put and raise the expectations that compliance of the operating rules and underlying standards would be certified in some way for the health plans.”

READ MORE: Is the Health Insurance Industry Heading on a ‘Death March?’

“Therefore, the health plans rely on vendors to fulfill some of their obligations,” she continued. “The health plans would have to engage their business associates. It raised the bar on the expectation of needing to report your compliance and certify for your compliance. It provided significant penalties if the industry wasn’t to do that. So it has spurred on additional interest in CORE certification.”

The way CORE certification works is by ensuring that payers, vendors, and providers accomplish the program through phases or steps. This will enable greater success and organizations will have less of a burden to handle by allowing them more time and opportunity to accomplish each step of the process.

“We always anticipated voluntary core certification to occur in phases,” she said. “These entities are either providing services among large and small health systems, so they bite off changed management in pieces that they can aggressively but reasonably accomplish. That’s why the rules are in phases and the certification is in phases, so you set a high bar but you don’t set it so high that no one can get over it.”

“We are seeing that that  phased approach works,” she continued. “There are a number of large health plans and providers working with vendors to get CORE certified, but the certification occurs in phases. As we work to adopt various e-health initiatives, we need to do them in aggressive but reasonable steps and CORE certification demonstrates that.”

Lohse also discussed how CORE certification is truly becoming a more popular topic and initiative among health payers across the country. Many are helping not only write the rules but also adopt these standards.

“The large majority of payers are at the CORE table. In fact, 70 percent of the commercial insurers are at the CORE table and they’re not only there writing the rules, but they’re actually implementing the rules, which is more essential through the voluntary CORE certification,” she concluded.


Dig Deeper:

Affordable Care Act Brought the Uninsured Rate to 9.1%

How the Affordable Care Act Changed the Face of Health Insurance


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