Filing frenzy: What to do to become HIPAA-compliant

The extension of the deadline on making electronic claims buys time to meet the CMS standards. Here are some things you need to know.

By Tyler Chin, AMNews staff. Nov. 10, 2003.

Under the new electronic health care transactions standards of the Health Insurance Portability and Accountability Act, Medicare and private insurers cannot pay doctors a cent if they submit non-HIPAA-compliant electronic claims.

But what is a HIPAA-compliant claim?

It's a claim meeting the standard format specified by the HIPAA implementation guide for that transaction. The format specifies content, what data should be captured and where the fields for those data elements should be on the claim. Simple, right?

Except that you can't look at a claim and say, "Yeah, that's HIPAA-compliant." The standards are about the technology behind the claim, making it difficult for physicians to determine if their process is producing compliant claims.

Oct. 16 was supposed to be the deadline for physicians to file HIPAA-compliant claims, but the Centers for Medicare & Medicaid Services extended that deadline because most physicians and other entities covered under the HIPAA electronic claim standards weren't ready. So there's still some time for you to figure it out, although CMS hasn't said how much time.

Can I buy some new, off-the-shelf system and be HIPAA-compliant?

Not necessarily. That's because there's no guarantee an insurer's system will accept the transaction out of the box from the physician's system, said Christine Stahlecker, a consultant at CTG Healthcare Solutions, Cincinnati.

A major reason is that the physician's and insurer's software vendors could have interpreted the HIPAA implementation guides differently. Other reasons could be that the doctor's software isn't capturing the required HIPAA data elements and the situational data elements that insurers require to adjudicate a claim, she said. Thus, submitting a HIPAA-compliant claim involves extensive communication, work and testing among the physician office, the physician's practice management company, billing service or claims clearinghouse, and insurers.