Availity Blog

Leading by Following the Rules


9.19.2017 By Erin Weber, Associate Director, CAQH CORE


When it comes to adopting the latest technological advancements, the U.S. healthcare system is something of a paradox. Information technology is widespread in clinical care—most hospitals and physician practices now use electronic medical records, and healthcare systems and health plans aggregate and analyze patient data to determine the effectiveness of care and patterns in population health.

However, healthcare is behind other industries in streamlining administrative processes, in part due the industry’s complex nature. Many transactions between health plans, vendors, and providers are still conducted manually, and at great expense. According to the 2016 CAQH Index, health plans and providers could save $9.4 billion annually by automating common business transactions, such as prior authorizations and remittance advice.

Recognizing the need for greater automation, the CAQH Committee on Operating Rules for Information Exchange® (CAQH CORE®) brought entities from across government and the industry together to develop healthcare operating rules for electronic business transactions.

Rolled out in phases over the past decade, these operating rules define how different platforms can share funds and data seamlessly. Widespread adoption of operating rules would enable and accelerate the development and use of interoperable business systems. This has been proven in banking, travel, and in other industries.

Over the past five years, healthcare implementation of these rules has accelerated but is not yet universal. To support adoption, CAQH CORE offers a certification program enabling organizations to demonstrate to their business partners that they adhere to the operating rules.

Today, CAQH has awarded nearly 325 voluntary CORE Certifications to health plans, providers, vendors, and clearinghouses. Certified health plans alone touch the lives of 76 percent of the commercially insured U.S. population and 44 percent of those publicly insured. For the providers and patients in these health plan networks, this means faster and easier processing of claims and insurance verification, significantly reducing costs and frustration.

While Availity and other CORE-certified entities are forward-thinking, other healthcare technology companies haven’t made industry-wide interoperability a priority. Now is the time to close that automation gap. Healthcare leaders using the operating rules must continue to drive momentum by encouraging their vendors and business partners to do the same. Because when everyone follows the rules, the healthcare industry can realize the true value of interoperability.

Saving $9.4 billion through business process automation will free up resources for better care delivery and better outcomes. Widespread adoption of operating rules would be a big step toward making these savings—and a more efficient healthcare system—a reality.


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