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HIPAA Consult: Answers to your questions about . . .


Transaction compliance; other payers' policies; non-HIPAA-compliant upgrades; documenting compliance plans


HIPAA Consult

Answers to your questions about . . .

By Ronald Sterling, CPA

Transaction compliance

Q: I've heard that the Oct. 16 deadline for submitting HIPAA-compliant claims to Medicare was extended. Is that correct?

A: Technically, the Centers for Medicare & Medicaid Services didn't free providers from the HIPAA transaction requirements. Congress set the deadline, and CMS can't change that. CMS has simply devised a temporary contingency plan for accepting noncompliant transactions. As long as you can show that you're working toward compliance, you can continue to use existing formats for claims and other transactions. So in effect, you have an extension. But you don't know how long it will last.

Other payers' policies

Q:Will other payers accept claims that don't meet the transaction standards?

A: If they have their own contingency plans for accepting noncompliant claims, yes. Besides Medicare, the Blue Cross Blue Shield companies, many Medicaid plans, and a number of other payers have said they'll support contingency plans.

Non-HIPAA-compliant upgrades

Q:Have most software vendors supplied the necessary upgrades?

A: The major vendors have. But some aren't providing all the tools you need. For instance, the system might allow you to enter only one number for the covered person and his family members, whereas HIPAA requires separate numbers for subscribers and patients. So if you use that system, you're not collecting the information you need to submit a compliant claim. You may be able to get away with it for now. But as payers tighten the screws, they'll start coming back to you with these problems. And you'll be scrambling to fix old claims that went through fine before, but aren't allowed anymore.

To mitigate this risk, you can test the format and data content of your claims with a clearinghouse or with Claredi ( www.claredi.com), which charges doctors $600 a year for HIPAA transaction testing.

Documenting compliance plans

Q:How can I prove that I'm working toward compliance?

A: Put together a contingency plan to show how you're going to move toward HIPAA-compliant transactions. First, get your practice management software vendor to specify in writing the features it has added to your system to make it HIPAA-compliant. Also, list your payers and their HIPAA status: Are they offering contingency plans? Can your clearinghouse send HIPAA-compliant transactions to all of them?

Note how you're trying to overcome obstacles to compliance. For example, if your clearinghouse can't send HIPAA-compliant transactions to a payer, document the problem and say you're going to wait until the payer is available to the clearinghouse before you submit HIPAA-complaint claims to that carrier. In the meantime, you can say, "I'm going to make sure my staff is completing the new screen fields that my product uses to generate a HIPAA-compliant claim, even though those fields weren't necessary under the old format." That may help if CMS starts going after noncompliant practices.


Ronald Sterling, CPA, is president of Sterling Solutions Ltd. in Silver Spring, MD. He can be reached at rbsterling@aol.com. This department answers common HIPAA-related questions. It isn't intended to provide specific legal advice.


Ronald Sterling. HIPAA Consult: Answers to your questions about . . .. Medical Economics Oct. 24, 2003;80:19.

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