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HIPAA Compliance

HIPAA is the acronym for the Health Insurance Portability and Accountability Act of 1996. HIPAA is arguably the single most significant Federal legislation affecting the health care industry since the creation of the Medicare and Medicaid programs in 1965. Under title II of HIPAA, Congress passed the Administrative Simplification provisions of HIPAA, among other things, to protect the privacy and security of protected health information (PHI), and promote efficiency in the health care industry through the use of standardized electronic transactions. President Clinton signed the Kassebaum-Kennedy Health Insurance Portability and Accountability Act on August 21, 1996.

To improve portability and continuity of health insurance coverage in the group and individual markets To combat waste, fraud, and abuse in health insurance and health care delivery To reduce costs and the administrative burdens of health care by improving efficiency and effectiveness of the health care system by standardizing the interchange of electronic data for specified administrative and financial transactions. To ensure protecting the privacy of Americans’ personal health records by protecting the security and confidentiality of health care information
The Privacy Rule sets the standards for, among other things, which may have access to PHI, while the Security Rule sets the standards for ensuring that only those who should have access to EPHI (or Electronic PHI) will actually have access. The main impetus behind these rules is to protect the confidentiality, integrity, and availability of PHI in any form: written, verbal, or electronic. History of HIPAA And How the Security Rule Affects You The Health Insurance Portability and Accountability Act (HIPAA) is the catalyst for change in healthcare. Enacted by Congress on August 21, 1996, its purpose is to enable better access to health insurance, reduce fraud and abuse and lower the overall cost of healthcare in the United States. HIPAA addresses two primary concerns in healthcare Portability and accountability. Title I protects health insurance coverage for workers and their families when they change or lose their jobs. Title II, the Administrative Simplification provisions, requires the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. HIPAA’s Three Rules As the agency charged with drafting the act, HHS distilled the Administrative Simplification provisions into three rules: the Privacy Rule, Transactions and Code Set Standard, and the Security Rule. HHS oversees and enforces the Privacy Rule, while the Centers for Medicare & Medicaid Services (CMS) oversees and enforces all other Administrative Simplification requirements, including the Security Rule.

Privacy Rule Compliance deadline April 15, 2003 The Privacy Rule provides the first comprehensive Federal protections for the privacy of health information. It specifically defines the authorized and unauthorized disclosures and uses of individually identifiable health information. Transactions and Code Set Standard Compliance deadline October 16, 2003 This rule mandates use of predefined transaction standards and code sets for communications and transactions in the healthcare industry. Security Rule Compliance deadline April 21, 2005 The Security Rule addresses security of electronic protected health information (ePHI). Unlike the Privacy Rule, which provided broader protection for all forms of health information—paper, oral, and electronic—the Security Rule is concerned with the technical aspects of protecting ePHI. The Security Rule - What You Need To Know Prior to HIPAA, no generally accepted set of standards existed for protecting health information. As technology evolved, and the healthcare industry moved from paper processes to computers for administrative and clinical functions—such as Web-based applications, CPOE systems and remote access for physicians—the security standards in HIPAA were developed for two primary purposes:
To protect certain electronic health care information that may be at risk To protect individual health data while permitting appropriate access to that information—and promote the use of electronic health information in the industry
HIPAA security standards are divided into administrative, physical, and technical safeguards.
Administrative safeguards include assignment or delegation of security responsibility to an individual and security training requirements. Physical safeguards are the mechanisms required to protect electronic systems, equipment and the data they hold, from threats, environmental hazards and unauthorized intrusion. They include restricting access to EPHI and retaining off site computer backups. Technical safeguards are the automated processes used to protect data and control access to data. They include using authentication controls to verify that the person signing onto a computer is authorized to access that EPHI, or encrypting and decrypting data as it is being stored and/or transmitted.
Each set of safeguards comprises a number of standards, which in turn comprise implementation specifications that are either required or addressable. Required specifications must be implemented; addressable specifications must be assessed to determine if they’re reasonable and appropriate in your environment.

HIPAA Benefits Significant resources need to be invested over the next several years to achieve compliance with the HIPAA legislation and to realize the long-term benefits. The benefits of HIPAA include:
Lowering administrative costs Improved efficiency for patients and providers Increasing customer satisfaction Improved security and privacy of information
HIPAA Covered Entities
Health Plans Health Care Providers who use certain electronic transactions Health Care Clearinghouses
HIPAA Provisions
Transaction Standards and Code Sets Privacy Security National Standard Identifiers Provider Employer Health Plan Individual
HIPAA Transactions and Code Sets (TCS) The rules for Transactions and Code sets were published on August 17, 2000 and with modifications published in May 2002. The compliance date was October 16, 2002. On December 27, 2001 President Bush signed HR3323, which provides for a delay in the implementation of the TCS rules of HIPAA. This extended the compliance due date to October 16, 2003, if a compliance extension is requested. Further modifications to the final rule were published in February 2003. This rule finalizes provisions applicable to electronic data transaction standards from two related proposed rules published in the May 31, 2002 Federal Register. It adopts proposed modifications to implementation specifications for health care entities and for several electronic transaction standards that were omitted from the May 31, 2002 proposed rules. The purpose of these regulations is to standardize the electronic exchange of information (transactions) between trading partners. These transactions are mandated to be in the ANSI ASC X12 version 4010 formats. The covered transactions include:

270 = Eligibility Inquiry 271 = Inquiry and Response 276 = Claim Status Inquiry 277 = Claim Status Inquiry and Response 278 = Authorization Request and Authorization Response 820 = Health Insurance Premium Payment 834 = Beneficiary Enrollment 835 = Remittance / Payment 837 = Claim or Encounter
The HIPAA Code Set Regulations establish a uniform standard of data elements used to document reasons why patients are seen and the procedures performed during health care encounters. HIPAA specified code sets to be used are:

Diagnoses - ICD 9 Procedures - CPT 4, CDT Supplies/Devices – HCPCS Additional Clinical Data - Health Level Seven (HL7)
HIPAA specified administrative codes set for use in conjunction with certain transactions and HIPAA eliminated local codes.

HIPAA National Standard Identifiers These regulations establish standard numerical identifiers for health plans, providers, and employers to simplify administrative processes, such as referrals and billing, to improve accuracy of data, and reduce costs. The final rule for the Employer Identifier, which became effective in July 2002, establishes a standard for a unique employer identifier and requirements concerning its use by health plans, health care clearinghouses, and health care providers. The health plans; health care clearinghouses, and health care providers must use the identifier, among other uses, in connection with certain electronic transactions. Final rules are pending for the National Standard Health Care Provider Identifier, the National Individual Identifier, and Standard Unique Health Plan (Payer) Identifier. Penalties for Failure to Comply with HIPAA The legislation carries heavy civil and criminal penalties for failure to comply. US DHHS Office for Civil Rights will enforce civil penalties that may include penalties from $100 per violation to $25,000 per calendar year. US Department of Justice will enforce criminal penalties which may include up to 10 years imprisonment and a $250,000 fine. An interim final rule on Enforcement was published in April 2003. It establishes rules of procedure for the imposition, by the Secretary of Health and Human Services, of civil money penalties on entities that violate standards adopted by the Secretary under HIPAA. The Interim Rule is effective until September 16, 2004. EDI Transactions with HIPAA Compliance With a tremendous interchange of information between resources, the security measures that enable the interchange of information are guided by the HIPAA. Below mentioned are some features of the EDI transactions through HIPAA.

Features
Links to those Chapters of the Medicare Claims Processing Manual (pub.100-04) that contain further information on Health Insurance Portability and Accountability Act (HIPAA) contingency plans. The Administrative Simplification Compliance Act (ASCA) requirement that claims be sent to Medicare electronically as a condition for payment. How you can obtain access to Medicare systems to submit or receive claim or beneficiary eligibility data electronically.