medicaidA recent report by the Council for Affordable Quality Healthcare, Inc. (CAQH) reveals that state Medicaid programs are falling behind when it comes to fully embracing electronic claim submissions, reimbursements, prior authorizations, and other related processes. CAQH’s Committee on Operating Rules for Information Exchange (CORE) found that agencies and health plans covering just over forty percent of patients enrolled in Medicaid have earned a CORE certification level.

In contrast, close to eighty percent of commercial health plan beneficiaries and more than seventy percent of Medicare Advantage plan beneficiaries are enrolled in a CORE certified plan. This certification serves as an indicator that healthcare organizations transmit or utilize the CORE committee’s established administrative and financial transaction Operating Rules, which consist of four phases. These rules establish the standards for things like electronic eligibility and claim status.

There are already CORE plans in the works to implement a fifth phase to further elaborate on electronic claims management. This phase will require a greater amount of information in prior authorization transactions and streamline provider data submission to cut down manual follow-ups involving providers and health plans. Per the CAQH report, Medicaid agencies and health plans could see more than $4 billion dollars a year in savings if they were to adopt all four of the CORE phases.

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This update is by Medical Accounts Systems, a full-service healthcare revenue cycle management company providing a number of services including insurance follow up and managed care disputes, physician reimbursement, extended business office services, and more. For additional information on our services or for any questions you may have on topics such as medical revenue cycle consulting, please call 877-759-6315.