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V610 HIPAA Business Issues


... schedule, work plan and implementation strategy for achieving compliance; planned use of contractors or vendors; ... Workers Compensations Plans, ... – PowerPoint PPT presentation

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Title: V610 HIPAA Business Issues

V610 HIPAA Business Issues
  • Catherine Schulten
  • Healthcare Business Development Manager
  • Healthcare Sales
  • Catherine.Schulten_at_sybase.com

  • Sybase HIPAA Expertise
  • Sybase Industry Leader
  • HIPAA Websites
  • An overview of HIPAA
  • Status of the HIPAA Regulations
  • ASCA
  • Transaction Addendums
  • Q A

Sybase in HIPAA
Sybase HIPAA Expertise
  • AFEHCT, co-chair ASPIRE workgroup (CMS 1500 and
    UB92 print image gap analysis/demonstration
  • HL7 membership, ASIG workgroup (claim
  • X12N membership, TG3 WG3 (HIPAA Implementation
    and Modeling)
  • Testified on HIPAA issues to NCVHS
  • WEDI Board of Directors 02-04, Co-chair
    Emerging Technologies
  • WEDI SNIP, Co-chair Translations sub-workgroup
  • NCPDP membership
  • EHNAC accredited

Sybase Industry Leader
Source Gartner Research DF-15-0891 8 January 2002
Integration Brokers for HIPAA in Health Plans
  • Gartner Research Note
  • the most-often mentioned vendors were those
    with a strong historic presence in this market
  • Sybase, the most frequently mentioned vendor,
    was early to market with its HIPAA add-in
  • Sybases EDI Server is a very strong specialty
    mapper, able to handle the complexity and provide
    the throughput required to process healthcare

Sybase Industry Leader Healthcare Channel
Payer Vendors
  • Trizetto embedded solution for EDI and Process
  • HSD/Perot embedded EDI solution for Diamond
  • OAO MC400 embedded EDI solution
  • CSC PowerMHS recommended solution

HIPAA Websites Where to find information
HIPAA websites
  • Workgroup for Electronic Data Interchange (WEDI)
  • www.wedi.org
  • WEDI Strategic National Implementation Plan
  • http//snip.wedi.org/
  • Association for Electronic Healthcare
    Transactions (AFEHCT)
  • www.afehct.org
  • HHS Administrative Simplification
  • http//aspe.os.dhhs.gov/admnsimp/

HIPAA websites
  • Accredited Standards Committee X12 (ASC X12)
  • www.x12.org
  • Health Level 7 (HL7)
  • www.hl7.org
  • National Council for Prescription Drug Programs
  • www.ncpdp.org
  • Centers for Medicare and Medicaid (CMS)
  • http//cms.hhs.gov/
  • Designated Standards Maintenance Organizations
  • www.hipaa-dsmo.org

WEDI Website
Admin Simp Website
CMS Website
DSMO Website
An Overview of HIPAA HIPAA 101
HIPAA Documents
The Act
The Final Rule
Implementation Guides
  • Enacted by Congress
  • Signed by the President
  • Promulgated by the
  • Secretary of HHS
  • Reflects Public
  • Congress Comments
  • Developed by ANSI
  • Standards Development
  • Organizations
  • Cited for use by the Final
  • Rule

An Overview of HIPAA The Act
  • Health Insurance Portability and Accountability
  • Public Law 104-191, 8/21/96
  • Improve Portability and Continuity of Health
    Insurance for Groups and Individuals
  • Combat Waste, Fraud and Abuse
  • Promote the Use of Medical Savings Accounts
  • Improve Access to Long Term Care
  • Simplify the Administration of Health Insurance
  • Administrative Simplification
  • Transaction Code Set Standards
  • National Identifiers
  • Security
  • Privacy

HIPAA Health Insurance Portability and
Accountability Act of 1996
Title I
Title II
Title III
Title IV
Title V
Fraud Abuse Medical Liability Reform
Administrative Simplification
Insurance Portability
Tax Related Health Provision
Group Health Plan Requirements
Revenue Off-sets
Code Sets
Administrative Simplification Components of HIPAA
Security Polices, Procedures and Technical
Mechanisms Utilized to secure personally
identifiable electronic health care data either
at rest or in motion
Privacy Standards to protect the privacy of
individually identifiable health information
Electronic Transactions, Unique IDs, Code
Sets Implementation Standards used for the
electronic transmission of specific health care
Administrative Simplification Components of HIPAA
Electronic Transactions
Unique Identifiers
Code Sets
Security Standards
Why HIPAA? Simplify the Administration of
Health Insurance
  • Reduce Direct and Overhead Costs
  • Reduce the Accounts Receivable Cycle
  • Improve Accuracy
  • Reduced Data Entry Time
  • Smaller/Faster Transmissions at Lower Cost
  • Reduce/Eliminate Rework
  • Avoid/Reduce Data Entry FTE
  • Reduce Operational Costs (office supplies, postal
    costs and telephone charges)

Why HIPAA? Simplify the Administration of
Health Insurance
  • Improve Process that directly impacts healthcare
    stakeholders -
  • Improved patient, provider and payer support
  • Efficient information delivery
  • Improved quality
  • Fosters good will with patients
  • Fosters closer working relationships between

Why HIPAA? Simplify the Administration of
Health Insurance
  • Create a Competitive Advantage -
  • Increase responsiveness between healthcare
  • Penetration of new markets
  • Easier to do business
  • Improved relations with other organizations

Providers, Payers, Clearinghouses
  • All must comply with the mandates of HIPAA
    Administrative Simplification with the following
  • Providers who wish to conduct transactions via
    paper may continue to do so and avoid HIPAA
    compliance mandates
  • Employers, Workers Compensations Plans, Life
    Insurance Plans not under HIPAA jurisdiction
  • Under ASCA, Medicare will require electronic
    claim submission by 10/16/03 for providers of a
    certain size. Other payers may also choose to
    refuse paper transactions in the future.

What happens if I do not comply?
  • Penalties for transaction non-compliance
    specified in the Act
  • not more than 100 for each such violation,
    except that the total amount imposed on the
    person for all violations of an identical
    requirement or prohibition during a calendar year
    may not exceed 25,000

What happens if I do not comply?
  • Penalties for wrongful disclosure of individually
    identifiable health information specified in the
  • Fine of not more than 50,000, not more than 1
    year imprisonment
  • False pretenses, fine of not more than 100,000,
    not more than 5 years imprisonment
  • Commercial advantage, personal gain, malicious
    harm, fine of not more than 250,000, not more
    than 10 years imprisonment

HIPAA - Promulgation of Proposed and Final Rules
  • Federal Rule Making Process
  • Publication of Notice of Proposed Rule Making
    (NPRM) in the Federal Register
  • Public Comment Period
  • Review and Response by appropriate agency (HHS)
  • Office of Management and Budget (OMB)
  • Publication of Final Rule in the Federal Register
  • Congressional Comment Period
  • Effective date of Final Rule
  • Compliance date

NPRMs and Final Rules
  • NPRM
  • A draft set of instructions
  • Proposes HOW to comply
  • Open to review and comments
  • Final Rule
  • Response to NPRM comments
  • Contains both front matter and the regulation
  • Publication establishes the compliance date

Status of the HIPAA Regulations
  • Final Rule was made effective 10/16/00
  • Original Compliance date 10/16/02
  • ASCA 1-yr Extension date 10/16/03
  • Claim Attachment in development
  • Report of First Injury in development

Status of the HIPAA Regulations
  • Final Employer ID published 5/31/02
  • NPRM Provider ID published 5/7/98
  • Plan ID in development

Status of the HIPAA Regulations
  • NPRM published 8/12/98
  • Final Rule published ??/??/??
  • (expected August 02)
  • Compliance date ??/??/??
  • (August 04)

Status of the HIPAA Regulations
  • Final Rule was made effective 4/14/01
  • Compliance date 4/14/03
  • Guidance document published 7/01

HIPAA Implementation Guides
  • Developed and Maintained by the Standards
    Development Organizations (SDOs)
  • X12N www.wpc-edi.com , free to download
  • NCPDP www.ncpdp.org, 500 for copy of standard
    and data dictionary
  • HL7 www.hl7.org (click on Special Interest
    Groups, Attachments, Publications), free to
  • SDOs are ANSI accredited organizations
  • Open to all interested participants
  • X12 membership ranges from 750 to 5,250
  • NCPDP membership is 550
  • HL7 membership fees ranges from 150 to 12,000

HIPAA Implementation Guides
  • Developed and approved in the style and manner
    adopted by the development organization
  • Intention is to provide a non-ambiguous set of
    instructions for each transaction
  • Questions of interpretation may be submitted to
    the DSMO web site or to the developers of the

Implementation Guides v. Standards
  • Implementation Guides support a uniform and
    unambiguous interpretation of each electronic
  • They specify limits and guidance for
  • Currently, there are 12 X12 and 2 NCPDP published
    HIPAA Implementation Guides
  • Standards are purposefully non-specific and open
    to interpretation
  • Trading Partners decide what data content to send
  • X12 Standards exist today for over 500 different
    transaction types and for over 25 versions

HIPAA X12N Transactions
Eligibility Inquiry 270
Eligibility Response 271
Enrollment 834
Request for Review 278
Premium Payment 820
Review Response 278
Claim/Encounter 837
Remittance Advice 835
Request Additional Information 277
Attachments 275/HL7
Additional Information 275/HL7
Status Inquiry 276
Status Response 277
HIPAA X12 Cross Reference
HIPAA Transaction ASC
X12 Standard Health Care Claim/COB
Professional X12N 837 X098
Institutional X12N 837 X096
Dental X12N 837 X097 Claim
Attachment X12N 277 275
HL7 Enrollment/Disenrollment X12N 834
X095 Eligibility X12N 270 271 X092 Premium
Payment X12N 820 X061 Payment Remittance
Advice X12N 835 X091 First Report of
Injury X12N 148 X086 Health Claim
Status X12N 276 277 X093 Referral X12N
278 X094
HIPAA NCPDP Cross Reference
HIPAA Transaction NCPDP Standard Health
Care Claim/COB Real time Version 5,
Release 1 Batch Version 1,
Release 0 Payment Remittance Advice Real
time Version 5, Release 1 Batch
Version 1, Release 0
HIPAA Future Claim Attachment Transactions
  • The claim attachment is a combination of the
    X12 277 or 275 transaction with HL7 data resident
    in the BIN segment
  • Ambulance
  • Emergency Department
  • Rehabilitative Services
  • Lab Results
  • Medications
  • Clinical Notes

Transaction Addendums
HIPAA X12N Transaction Addendums
  • Proposed Rule to adopt a set of transaction
    implementation guide addendums published in the
    Federal Register on 5/31/02
  • Purpose was to modify existing published final
    X12N HIPAA Implementation Guides to provide
    greater clarity and resolve issues that made the
    guides un-implementable
  • This rule proposes to make some limited
    technical modifications to some of the
    transactions standardsas necessary to permit
    initial implementation of the standards within
    the industry.
  • Details of changes are available at

HIPAA X12N Transaction Addendums
  • The proposed modifications to the HIPAA X12
    Implementation Guides do NOT impact the
    transaction compliance deadlines (10/16/02 or
  • Final Rule for Addendums must be published at
    least 180 days prior to the 10/16/03 compliance
    deadline in order for covered entities to legally

Administrative Simplification Compliance Act
Administrative Simplification Compliance Act
  • What is ASCA?
  • In December 2001, the Administrative
    Simplification Compliance Act (ASCA) extended the
    deadline for compliance with the HIPAA Electronic
    Health Care Transactions and Code Sets standards
    one year to October 16, 2003 for all covered
    entities other than small health plans (whose
    compliance date was already October 16, 2003)
  • How does one apply for the 1-year extension?
  • In order to receive an extension, covered
    entities must submit their ASCA compliance plans
    on or before October 15, 2002.
  • The ASCA Model Compliance Form is available
    on-line at http//www.cms.hhs.gov/hipaa/hipaa2/AS

ASCA The Model Compliance Form
  • How extensive is the ASCA Model Compliance Form?
  • The form is simple and easy to complete. The ASCA
    requires the plans to contain summary information
    regarding compliance activities, including
  • budget, schedule, work plan and implementation
    strategy for achieving compliance
  • planned use of contractors or vendors
  • assessment of compliance problems
  • a timeframe for testing to begin no later than
    April 16, 2003

ASCA Medicare claims submission
  • Does ASCA mandate Medicare claims be submitted
    electronically by 10/16/03?
  • ASCA prohibits HHS from paying Medicare claims
    that are not submitted electronically after
    October 16, 2003, unless the Secretary grants a
    waiver from this requirement.
  • It further provides that the Secretary must grant
    such a waiver if
  • there is no method available for the submission
    of claims in electronic form
  • or if the entity submitting the claim is a small
    provider of services or supplies
  • Beneficiaries will also be able to continue to
    file paper claims if they need to file a claim on
    their own behalf

What else is going on?
Sen. Kennedys eHealth Initiative
  • Efficiency in Health Care Act Background and
    Need for Legislation
  • Healthcare is one of the least efficient
    industries in America. Processing a single
    transaction in health care can cost as much as
    12 to 25, whereas banks and brokerages have cut
    their costs to less than a penny per transaction
    by using modern information technology
  • Widespread adoption of modern information
    technology will decrease the time that health
    care professionals spend doing routine
    administrative costs and increase the time
    devoted to patient care.
  • Its estimated that 1 in 4 insurance claims are
    initially rejected or processed in error due to
    incomplete or inadequate information

Sen. Kennedys eHealth Initiative
  • Some Specifics
  • Consumer information The eHealth Act requires
    health plans and providers to give consumers of
    health care comprehensive information about
    billing in an accurate and timely manner. The
    Act provides 250 million in grants to providers
    to help them meet these requirements. 
  • Claims adjudication The eHealth Act requires
    every insurance company to be able to process
    claims immediately, rather than the weeks to
    months such processing currently requires.
  • In addition, the Act requires that plans must
  • process claims with an accuracy of greater than
  • be able to accept claims via the internet and
  • be able to issue denials instantaneously over the

Sen. Kennedys eHealth Initiative
  • 3. Financial Information The eHealth Act
    requires all health plans to provide consumers
    with a statement of account showing claims
    history, status of coverage and information on
  • I Internet Access The eHealth Act requires
    all plans to be able to issue automated referrals
    and provide pre-authorization with an automated
    system. These automated systems must provide
    physicians and consumers with access via the
    internet or a toll-free number. The Act further
    requires that each plan establish a system
    whereby information on prescriptions is available
    to physicians and beneficiaries through a secure
    internet connection without the use of paper.
    The Act also requires that plans establish a
    system to allow physicians with the permission
    of the patient to have access to a patients
    claims history via the internet.

Sen. Kennedys eHealth Initiative
  • 3.    Modernizing Financial Transactions The
    eHealth Act requires health plans to
  •       I.      accept payments from physicians or
    beneficiaries via electronic transfers of funds
  •                           II.     
    implement automated audit controls to monitor
    duplicate payments
  • 4.  Enhancing patient safety The eHealth Act
    sets standards for computerized systems through
    which physicians can enter orders for
    prescriptions, thereby reducing errors from
    mistaken prescriptions or illegible handwriting.
    The Act requires adoption of these systems by
    health care providers. The Act will thus reduce
    over 7,000 deaths that occur annually from
    medication errors. The Act provides 100 million
    in matching grants for hospitals to adopt these

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