1 Health Insurance Portability and Accountability Act of 1996 IS&C Expo October 16 & 17, 2002 John Wagner Governor’s Office of Technology
Time to Learn about Administrative Simplification
3 Health Insurance Portability and Accountability Act HIPAA Public Law 104-191 To improve the efficiency and effectiveness of the health care system.
4 And Why are We Doing This? To improve the efficiency & effectiveness of the health care system by standardizing the format content and data elements in electronic health care transactions Assure portability & continuity of healthcare Combat fraud and abuse Promote medical savings account Improve Long Term Care access & coverage Simplify the administration of health care
5 Biggest Problems for States Implementing New Security Procedures Implementing New Privacy Procedures Implementing Transactions & Code Sets Renovate? Replace? Translators? Clearinghouse? Multiple Waves of Implementations End-to-End Testing (+ Multiple Waves)
6 And More Big Problems for States Not Enough Time for Implementation(s) Contracts with Data Exchange Partners Penalties Resources: Money & Personnel Selecting Translators & Chasing a Moving Target
7 HIPAA standards will regulate: Format Privacy Security Content Any health care entity public or private that creates, stores or transmits health care data in any format, must comply within 2 years of standards adoption (there are exceptions for certain plans based on size).
8 HIPAA EFFECTS THE ENTIRE HEALTH CARE INDUSTRY! Healthcare entities include: Health Care Plans Health Care Providers Clearinghouses Business Associates Trading Partners
We are in this together and everything is connected
10 The Thigh Bone’s Connected to the Knee Bone… TITLE II: Preventing Health Care Fraud and Abuse Subtitle A: Fraud and Abuse Control Program Subtitle B: Revisions to Current Sanctions for Fraud and Abuse Subtitle C: Data Collection Subtitle D: Civil Monetary Penalties Subtitle E: Revisions to Criminal Law Subtitle F: Administrative Simplification Subtitle G: Duplication and Coordination of Medicare-Related Plans Subtitle H: Patent Extension Title II
11 The Knee Bone’s Connected to the Leg Bone … Sub. F Section 262: Transactions, Codes, and Identifiers Section 264 Privacy
12 Questions for States Who is responsible for HIPAA compliance? What is the State’s timetable? Which implementation solution is best for the State? What options are available in the limited time available? How do we address Privacy & Security? How do we address TCS requirements?
14 Standards for Electronic Transactions Claim and encounter Payment and remittance advice Third Party Liability (claim format) Claim status inquiry and response Enrollment and disenrollment in a health plan Eligibility (inquiry and response) Health plan premium payments Authorization for service request and response
15 Standards, Rules, and X12 Cross Reference Standard Transaction Claim -Professional Claim - Institutional Claim - Dental Remittance Claim Status Enrollment Eligibility Premium Payment Referral First Injury Report Attachments 45 CFR Part 142 K, M L N O P Q R Implementation Guide (v.4010) X098 X096 X091 X093 X095 X092 X061 X094 X12 Standard 837 835 276 and 277 834 270 and 271 820 278
16 Implementation Strategies for Transaction & Code Sets OPTIONS: Replace Systems Renovate Systems Install EDI Translators Use Clearinghouses Combination
17 More Questions for States Criteria for validating data conversions and mapping when using translators and Clearinghouses How to deal with more and more delays (get started now with X12 assessment?) How can we standardize Policy and Security Where do we get the money and resources?
19 What is the purpose of HIPAA? To improve the efficiency and effectiveness of the health care system by standardizing the format content and data elements in electronic health care transactions and provide privacy protection for protected health information.
20 Who must implement HIPAA? Any health care entity public or private that creates, stores or transmits health care data in any format.
21 Health care entities include: Health Care Plans Health Care Providers Clearinghouses Business Associates Trading Partners
22 What is covered by HIPAA? You!! Personal Health Information (PHI) is protected by HIPAA
23 What are the components that have been identified by DHHS for implementation of HIPAA Administrative Simplification? Transaction and Code Sets Privacy Security Training
24 Is information available on the Web about HIPAA? Yes, information can be found at: WWW.WVDHHR.ORG/HIPAA
25 Where can I ask questions regarding HIPAA? The WV HIPAA Project Management Office is staffed and ready to answer your questions. You may reach the PMO at 558-5164.