Administrative Simplification Rules Affect Health Care Providers

As you know, the Health Insurance Portability and Accountability Act's (HIPAA) various regulations are being implemented in stages. Title I of HIPAA, in place now for several years, affects health insurance companies, essentially regulating the portability of health insurance from plan to plan, exclusions and pre-existing conditions. Title II of HIPAA, however, impacts both health insurance companies and physicians and will require considerable time and training to implement.

Section F of Title II, called the Administrative Simplification rules, establishes requirements that directly affect not only insurers, but health care providers as well. It covers three areas: electronic data interchange (EDI), privacy and security. The purpose of the EDI portion is to standardize claims, referrals, authorizations, encounters and other common health care related electronic transactions.

"If you plan to do any of the required electronic transactions with Humana, you have to do them in the standardized format," said Betty Giarth-Haynes, Humana's HIPAA program director. "If physicians are currently doing electronic transactions, they need to check with their practice management system to see whether it will comply with these standards. If not, medical practices should make the necessary system changes in order to communicate with Humana."

The privacy provisions specify that an individual's identifiable health information must be kept confidential. "Identifiable information can only be used and disclosed by Humana for purposes of treatment, payment and health plan operations," said Giarth-Haynes. Further, she explained that the rules establish member rights in relation to their information and how it is used, as well as control who has access to the information.

The security provision specifies the minimum levels of security that will be acceptable to safeguard an individual's identifiable health information from loss or inappropriate disclosure. This includes when a provider is in the process of conducting electronic transactions or storing and discussing the information verbally or in writing.

To find additional information, visit www.ama-assn.org or www.aha.org. Both Web sites have tools to help physicians and other health care professionals bring their practices into compliance.

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