WHEN IT COMES to HIPAA transaction standards, healthcare
organizations like to play by their own rules. Although the standards were intended to streamline the transmission of financial
and administrative transactions, such as health plan eligibility
requests and billing claims status checks, they left too much
room for interpretation.
As a result, providers, vendors, clearinghouses, and health
plans have developed their own rules for following the standards when exchanging information. The outcome has been
disorganization and discrepancies between trading partners—
hardly the simplification and efficiency envisioned when the
standards were written.
But a mandate enacted by the Affordable Care Act requires the
industry to adopt operating rules that dictate how HIPAA transaction standards are used. The first two operating rules pertain
to transactions on health plan eligibility and claims status, and
they must be implemented by the end of the year.
Simplification at Last?
The creation of mandatory operating rules for HIPAA transaction standards is years in the making—and will continue to
2016—but it should lead to reduced costs and simplified work
processes within organizations and across the industry.
A History of the Problem
First drafted into HIPAA legislation in 2000, the transaction standards were intended to unify the healthcare industry on ways to
exchange financial and administrative data. But differences in
state laws, individual system complexities, proprietary software,
variances in internal business operations, and a lack of federal
enforcement led to large inconsistencies in how organizations
employed the standards.
There has never been guidance on how to use the standards,
says Dan Rode, MBA, CHPS, FHFMA, vice president of advocacy and policy at AHIMA. Once organizations began adopting
their own ways of using the standards, simplification went out
Trading partners would only use parts of the standard, including information specific to their needs but not other data that
could be used for broader administrative simplification, Rode
says. Health plans would agree to trade different information
with different providers, further varying use of the standards.
Other organizations would disregard the standards entirely and
make up their own rules. One health plan may handle patient
eligibility requests entirely differently than another, causing administrative headaches for providers and their vendors.
That’s why guidelines for employing the standards—or operating rules—are needed to restore order, Rode says.