The State of Electronic Healthcare Transactions in Workers’ Compensation

Tina Greene
Tina Greene

Tina Greene, Senior Regulatory Affairs Consultant, Casualty Solutions Group, Regulatory Affairs and Compliance at Mitchell International.

The Administrative Simplification provisions of the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) include requirements that national standards for electronic health care transactions be established. These standards were adopted to improve the efficiency and effectiveness of the nation’s health care system by encouraging the widespread use of electronic data interchange in health care.

In the final rule, it’s recognized that:

“Non-HIPAA entities such as workers’ compensation programs and property and casualty insurance accept electronic healthcare transactions from providers, however, the Congress did not include these programs in the definition of a health plan under section 1171 of the Act.

The statutory definition of a health plan does not specifically include workers’ compensation programs, property and casualty programs, or disability insurance programs, and, consequently, we are not requiring them to comply with the standards. However, to the extent that these programs perform healthcare claims processing activities using an electronic standard, it would benefit these programs and their healthcare providers to use the standard we adopt.”

“Health Insurance Reform: Standards for Electronic Transactions; Announcement of Designated Standard Maintenance Organizations; Final Rule and Notice.” Federal Register 65:160 (17 August 2000) p. 50319.

In an effort to realize the effectiveness of electronic data interchange, some states have adopted regulations requiring electronic healthcare transactions for billing and payment. Early implementers of EDI for workers’ compensation in various states identified issues such as payer ID (claim administrator identification), claim filing indicator code and claim number, and worked with stakeholders to find resolutions. These issues have since been addressed in industry standards.

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Property and Casualty Alignment with HIPAA

Tina Greene
Tina Greene

Guest post by Tina Greene, senior regulatory affairs consultant, Mitchell International.

There are major healthcare regulatory mandates going in effect, at the federal and the state level, which will significantly impact property and casualty (P&C) insurance medical bills payers. The Administrative Simplification provisions of the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II), state mandates for property and casualty eBilling and more regulatory initiatives are forcing payers to understand these regulation’s requirements and be prepared to implement new processes and technologies in order to be compliant. Federal healthcare administrative simplification offers payers an opportunity to prepare for compliance while meeting cost containment and operational efficiency objectives, empowering property and casualty payers to prepare for an all-electronic American healthcare future.

The concepts of eBilling and ePayment for medical bills are gaining traction throughout the healthcare arena, along with the adjacent P&C insurance industry. Medical providers and P&C payers are increasingly taking advantage of the benefits associated with electronic billing and payments, which include substantially lower transaction costs, increased efficiency for call centers, adjusters and finance departments.

Non-legislative organizations are collaborating and recommending changes that could accelerate the impact on the P&C industry.

Other non-legislative organizations are collaborating and recommending changes that could accelerate the impact on the P&C industry. For instance, the Workgroup for Electronic Data Interchange (WEDI), the International Association of Industrial Accident Boards and Commissions (IAIABC), the American Medical Association (AMA), and the Accredited Standards Committee of the American National Standards Institute (ASCX12) are all working to ensure standards to facilitate eBill exchange and adoption. The National Committee on Vital and Health Statistics (NCVHS), a public advisory body to the Secretary of Health and Human Services (HHS), periodically holds meetings to review health statistics and trends. And while the NCVHS does not set policy, they do provide analysis, insight and recommendations to HHS, with eBilling as a topic of likely review in the future. These organizations have collectively laid a path for how to participate in this new environment.

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