Association Executive Directors Community

Transaction Operating Rules Compliance?

  • 1.  Transaction Operating Rules Compliance?

    Posted 20 days ago
    We are experiencing challenges with a claims processing system deployed by Optum that does not appear to comply with the standardized transactions and operating rules required by federal rules. Seeking any success any of you have had around messaging those issues at state or federal level.

    Optum's system omits functionality required by the operating rules, or has the functionality but it isn't working properly. Missing functions include 277 reports (entirely), 835s (for some encounters and services), non-standardized and inaccurate denial codes that don't describe the info needed to correct and pay the claim. HIPAA established and the ACA enhanced standard transactions and operating rules for payers (see Enforcement and Compliance Overview).

    We're struggling to describe and quantify the scale of Optum's noncompliance. Numbers don't seem to do justice to it -- our very rough estimate that it has decreased revenue by at least 16% and has increased costs through the hiring and redirection of FTEs to manage a process that should be automated. Our members describe the claims processing system as "simply surreal," or say, "We've lost every tool we have to manage the business." It is hard to quantify the Optum harms separately from the COVID harms.

    As we have tried to message the importance of revenue cycle management and the need for a standardized transactions, I fear we may lose our legislative audience in the complexity.

    In any of your struggles with state payments or MBHOs, have any of you successfully leveraged the federally-mandated operating rules or standardized transactions? Federal compliance efforts in this area look non-existent. Anyone tried it? Anyone leveraged the federal standards into state enforcement? These standards are incorporated by reference into Optum's contract with the state.

    Send ideas! Or care packages!


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    Shannon Hall
    Executive Director
    Community Behavioral Health Association of Maryland
    Catonsville MD
    410-788-1865 ext 2
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