Overview of HIPAA and Administrative Simplification

Transcription

1 Overview of HIPAA and Administrative Simplification Denise M. Buenning, MsM, Director Administrative Simplification Group Office of E-Health Standards and Services Centers for Medicare & Medicaid Services Baltimore, Maryland

2 Topics To Be Covered The changing face of HIPAA Update on HIPAA Classic initiatives Version 5010 ICD-10 The Affordable Care Act and HIPAA Operating Rules Health Plan Identifier Electronic Funds Transfer and Remittance Advice HIPAA Certification Claims Attachments

3 The Changing Face of HIPAA The Health Insurance Portability and Accountability Act of HIPAA Then Brought the word standard into our health care vocabularies Held the promise of a more streamlined, efficient and economic way of conducting the business of health care Demanded an open and prescriptive process for adoption And let s not forget privacy and security issues ( Please Stand Behind This Line at the pharmacy counter)

4 The Changing Face of HIPAA HIPAA Now: Impacts are greater, stakes are higher than ever before According to the U.S. Healthcare Efficiency Index, more than 5 billion health care transactions today are conducted electronically, at a cost savings of more than $23.5 billion versus paper the magic ROI with room for more savings an additional $29 billion if all transactions were conducted electronically As industry s business needs change, now more than ever there is a need for transparency and collaboration between government and industry We can do it better, faster, cheaper but still maintain quality

5 Version 5010 Update CMS is on track for Version 5010 implementation Medicare Fee for Service Medicare Fee for Service already accepting both Version 5010 test and production claims Testing volume continues to grow State Medicaid Programs Only 5 state Medicaid programs indicating possible non-compliance; CMCS is working closely with them to mitigate risks

6 Version 5010 Update There is NO CHANGE in the compliance date: it remains JANUARY 1, CMS will return claims submitted in old Version 4010A1 format, and conduct usual HIPAA enforcement process Those who anticipate non-compliance should take risk mitigation steps NOW Clearinghouse/clearinghouses Medicare FFS offers free Version 5010 compliant software Look for vendors that offer all payer software

7 ICD-10 Refers to the diagnosis and procedure code sets Replaces ICD-9 code sets and includes updated medical terminology and classification of diseases. CPT coding for outpatient and office procedures is not affected by the ICD-10 transition More logically organized, more detailed and specific, and more clinically accurate

8 Benefits of ICD-10 More accurate payments for new procedures Fewer miscoded, rejected, and improper reimbursement claims Improved ability to measure healthcare services Increased sensitivity when refining grouping and reimbursement methodologies Decreased need to include supporting documentation with claims

9 Transitioning to ICD-10 Identify your current systems and work processes that use ICD-9 codes Communicate implementation plans between providers, payers and vendors Identify potential changes to work flow and business processes Budget for time and money related to the implementation Allow enough time to test transactions Assess staff training needs

10 Resources to Help You Prepare CMS ICD-10 Web site: CMS ICD-10 Listserv: 10_Industry_ _Updates.asp Professional, clinical, trade associations

11 ICD-10 Decisions at CMS CMS ICD-10 Executive Steering Committee currently meets on a bi-weekly basis Internal policy, process, and systems issues are discussed CMS maintains and updates an internal log of decisions to be made, which are addressed on a rolling basis. As change requests are issued to our contractors, we will publish FAQs regarding our ICD-10 most frequently raised issues. Once Version 5010 is implemented, expect increased emphasis/responses to ICD-10 issues

12 The Affordable Care Act and HIPAA The Affordable Care Act changed the face of HIPAA: Accelerates the timelines for adoption of standards for acknowledgements, claims attachments, health plan identifier Brings operating rules into the mix Provides for health plan HIPAA compliance and increases penalties for health plans that do not certify compliance to CMS

13 The Affordable Care Act and HIPAA Operating Rules Must be adopted for all transactions for which the Secretary has adopted a standard First Operating Rules IFC for eligibility and health claim status published in Federal Register on July 8, 2011, with comments closed on September 6, 2011 CMS is reviewing comments and will issue a final rule if necessary

14 The Affordable Care Act and Health Plan Identifier HIPAA Would provide for all heath plans as defined under the HIPAA to obtain and use a health plan identifier for use in standard transactions. Regulation is in final CMS clearance Compliance date is January 1, 2014 for health plans, and January 1, 2015 for small health plans

15 The Affordable Care Act and HIPAA Electronic Funds Transfer (EFT) and Remittance Advice (RA) standard Adopts a standard for EFT between a health plan and the plan s bank or financial institution Regulation is in final CMS clearance Compliance date is January 1, 2014

16 The Affordable Care Act and HIPAA HIPAA Compliance Certification Health Plans must certify to CMS that they are compliant with ALL HIPAA transactions, code sets and operating rules Significant penalties for plans for failure to certify Compliance date is January 1, 2014 Regulation currently being drafted

17 The Affordable Care Act and Claims Attachments HIPAA Adoption of a standard for Claims Attachments Background information gathering is underway NCVHS, testifiers will weigh in Compliance date is January 1, 2016

18 Future of HIPAA and Health Care Reduce the cost, burden and complexity of administrative electronic health care transactions Recognize that solutions may exist outside the health care arena and learn from other industries experiences and expertise Respond to the industry s call to streamline, when possible, the lengthy standards adoption process, but also be mindful of industry s capacity to respond

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