Clean Claims Task Force

Saturday, March 01, 2014 11:36 AM

Progress toward a uniform set of claim edits

Marilyn Rissmiller, Senior Director, Health Care Financing

The Clean Claims Task Force – a group of 28 experts including national representatives from many health plans, software vendors and providers – is approximately 38 months into a fully transparent four-year project to develop a uniform set of claim edits that will be adopted by all payers having contracts with providers in Colorado.

A uniform set of medical claim edits and payment rules are conservatively estimated to save approximately $80 million to $100 million per year just in Colorado, and continues to garner interest from other states.

Throughout the process the task force has solicited input from stakeholders and the public: During 2013 four separate bundles of logic rules dealing with different edit and payment rule categories were submitted for public review. Each review period required the rules to be posted for downloading from the task force website; a period for the public to consider the new rules; a period for public input; a period for the task force to revisit and revise the rules as necessary; and the posting of formal statements addressing each request for change and what was done about it.

The task force works by consensus, requiring members to achieve a substantive unanimity around any changes made before such adjustments were posted.

Concurrent with the development of rule logic for the adoption of edits and payment rules, the task force has developed a set of investigative query categories for each rule to allow for adequate vetting of the edit and payment rule library being brought forth. During 2014 the task force will import a universe of existing edits and payment rules from the industry into a database and analyze them for compliance with the uniform rules for acceptance developed. This is an exhaustive and rigorous process but must be conducted for the Colorado uniform and transparently developed edit and payment rule set to have credibility with all those who use it.

To achieve a downloadable library of uniformly agreed upon and transparently adopted claim edits and payment rules, the task force must enlist the help of a data analytics firm that can facilitate the necessary software and user interface to allow for query work. An exhaustive request-for-proposal (RFP) process for a data analytics vendor was conducted in late 2013 and the contract was awarded to Bishop Enterprises of Wilmington, Del.

In early 2014 the task force resolved to add a step in the process as the group prepares for the final release of a starting set of uniform edits and payment rules at the end of this year. The public review of rules was so productive that members now believe it is essential to have a public review of the complete edit and payment rule library. The group has set 2015 as the target period during which to conduct a final and full review by the public of the finished (draft) product. Legislation is currently being drafted in Colorado for this purpose.

Reducing administrative burdens in the health care system and eliminating barriers to quality care is a high priority of the Colorado Medical Society. Additionally, administrative simplification is gaining traction at the federal level. Although the initial development of a uniform and transparent set of claim edits and payment rules has been a Colorado-based initiative, the task force has believed that its long-term sustainability would be enhanced by acceptance at the national level. 

With Colorado physicians receiving early indications of support from their trip to Washington, D.C. in early March for the National Advocacy Conference, the task force is optimistic the Colorado congressional delegation will help to garner interest from the Centers for Medicare and Medicaid Services in a national clean claims initiative.

There is a section in the Affordable Care Act that focuses on administrative simplification initiatives and one of those requires the Secretary of Health and Human Services to seek input into the feasibility of making the development of claim edits more transparent. The Colorado task force has shown that it is feasible and actually has a “product” that could be adopted as the national model.

Colorado Medical Society continues to support the work of the task force members and applauds their efforts as they near completion.