With all the regulation changes that have happened and have yet to happen, navigating the healthcare revenue cycle can be overwhelming. So much of what physicians do is overseen by one regulatory committee or another. In fact, often it is multiple committees that oversee one aspect of healthcare. Understanding what the healthcare professional needs to comply with can be costly. That is why having a medical claims clearinghouse on your side is a powerful partnership that no healthcare practice should be without.
In 2010 congress passed the Affordable Care Act (ACA). This law put into place numerous regulation changes. Some of those changes were obvious, like increased patients with insurance, others were not so obvious, such as insurance companies providing administrative and financial transactions that are compliant with the standards set forth. A medical claims clearinghouse is there to help manage these changes on behalf of the physician. They can help physicians by cutting through overwhelming documentation and let them know what they need to act on. They also maintain the relationship with the insurance company when it comes to the electronic interchange of data. This allows the medical claims clearinghouse to advocate for the provider when it comes to establishing connections for the administrative and financial transactions the insurance companies are now required to provide physicians. These transactions include, but are not limited to, electronic eligibility and benefit verification and electronic explanation of benefits (EOB’s).
With the ACA a number of regulatory bodies became prominent in the healthcare industry. One of those bodies is the CAQH body. They are responsible for the CORE operating rules. CORE operating rules are mandated operating rules in section 1104 of the ACA. The purpose of these operating rules is to: