Zelis VP of Legislative Affairs Speculates that Section 1104 Regulatory Enforcement is Coming

In November, Zelis Healthcare announced the addition of Matthew Albright, formerly of the Centers for Medicaid and Medicare Services (CMS) and the Center of Affordable Quality Healthcare (CAQH), as its new Vice President of Legislative Affairs – a role that will serve as a critical advocate for rational regulatory approaches and helping Zelis and its clients predict and react with confidence to today’s ever-changing legislative landscape.

Since that time, Albright has been busy monitoring the regulatory landscape and identified an area which has the potential to impact all healthcare payers and one with which he is intimately familiar:  Section 1104 of the Affordable Care Act. Albright strongly believes that regulatory enforcement for this mandate is on its way.

“Remember the flurry of regulations implementing Section 1104 of ACA that mandated requirements around the administrative transactions?” Albright asks. “Between 2011 and 2014, multiple regulations were published that required payers to implement the operating rules on eligibility, claims status, Electronic Funds Transfer healthcare payments, and electronic remittance advice transactions. Then… nothing.”

While this silence may seem assuring to healthcare payers, Albright has taken notice of activity from the National Standards Group of the CMS, which tell another story entirely.  “It can be tempting to assume there is no threat on the horizon when you couple the facts that Section 1104 regulatory activity seemingly went dormant and the newly republican controlled administration is aiming to repeal the ACA,” Albright states. “However, conservative pundits are speculating that repeal and replace of the ACA will be neither sudden or necessarily complete and while the nation considers ACA’s future destiny, there are strong indicators that CMS is busy developing an enforcement strategy for Section 1104.”

Albright has assessed that not only is regulatory enforcement coming, but health plans, TPAs and other business associates all have cause to be concerned. To help our clients understand the impending regulatory threat, Albright has authored a position paper outlining the warning signs of the impeding compliance program and analyzes the current regulatory trends that will likely shape it.

Albright brings an informed and highly reliable perspective to the very real risks of non-compliance and what organizations can do to protect themselves. Prior to joining Zelis Healthcare, he oversaw the certification program CAQH Committee on Operating Rules for Information Exchange (CORE) that tests organizations for conformance with the operating rule requirements of the PPACA. Additionally, Mr. Albright served as Director of the Administrative Simplification Group at CMS where he was responsible for drafting the regulations that specifies the Section 1104 PPACA requirements of the Health Insurance Portability and Accountability Act (HIPAA) administrative transactions.

“I think the best thing that all plans, TPAs and business associates can do is use this time l to do all they can to make sure their systems are ‘com­plaint-proof,’ ‘compliance review-proof,’ and ready for the expected audits. This is especially true if a health plan or an associate hasn’t looked closely at some of the HIPAA transaction requirements.” Says Albright. “I’ve added some steps that a plan or business associate might use to develop a playbook for future audits, which I hope will be helpful for our clients.”

Copies of Albright’s paper are available for download.

If you are not currently in compliance with Section 1104 or are unsure if your current solution covers you adequately, Zelis can help.  Contact your account manager for more information.