Any healthcare provider that exchanges patient data electronically will have 26 months, starting this week, to comply with rules on how to format and transmit that information.
After more than two years of delays, HHS Secretary Donna Shalala last week signed final regulations requiring healthcare organizations to adopt national standards for electronic transactions such as claims submission, eligibility verification and referral authorization.
An agreement reached between HHS and the White House Office of Management and Budget will be detailed in the final rules published in the Federal Register this week. The rules become effective 60 days after publication, and most healthcare organizations have 24 months from that point on to achieve compliance.
The rules implement provisions of the Health Insurance Portability and Accountability Act of 1996 that require standard transaction formats and billing codes for documenting medical services and dealing with claims submissions.
Healthcare organizations now use about 400 different formats to electronically submit and adjudicate claims. The rules Shalala approved last week aim to boost the industry's efficiency and reduce its costs through standardization.
"The intent (of HIPAA) is to move healthcare to the 21st century in terms of really utilizing information technology to drive down operational costs and streamline how we share administrative and financial information about patients," said Russell Jones, practice director of information security for Science Applications International Corp., a La Jolla, Calif.-based research and engineering firm.
Final versions of the transactions and code sets rules initially were to be published by February 1998 and be in force by now. But HHS repeatedly delayed the first drafts of those rules and others dealing with data security, privacy and identity. Once the proposed rules began to roll out in waves starting in 1998, HHS had to consider thousands of public comments before issuing final regulations.
The most recent delays, said the Washington-based Association for Electronic Health Care Transactions, had to do with disagreements between HHS and the OMB over which agency would be responsible for reviewing the rules before they became final.
The new rules do not require providers to submit claims electronically, but require standard formatting for those that do. Payers, on the other hand, must have the capability to send and receive electronic transactions using the designated standards.
Also included in the final rules are standard code sets for data tied to medical diagnoses and procedures. Some of the defined code sets include ICD-9-CM codes for classifying diseases, CPT-4 codes for physician billing and DRG codes for hospital billing.
Other final rules are pending on standard identification numbers for providers, payers and employers. A controversial HIPAA requirement for national patient identification numbers is stalled indefinitely.