WEDI Comments on Launch of Health and Human Services Compliance Review Program

April 23, 2019

This month, the Department of Health and Human Services (HHS) will launch itsCompliance Review Program, an audit to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) rules for electronic healthcare transactions. WEDI, the nation’s leading nonprofit authority on the use of health IT to create efficiencies in healthcare information exchange and a statutory advisor to the U.S. Department of Health and Human Services (HHS), today issued the following statement on behalf of its President and CEO, Charles Stellar, lauding the department on initiating the audits:

“WEDI commends the launch of the Compliance Reviews. In general, the industry as a whole − providers, health plans and clearinghouses − have encouraged HHS to take steps to ensure compliance with HIPAA electronic transaction standards and operating rules. The Compliance Reviews are a good step toward greater adoption of standard administrative electronic transactions which means greater cost and time savings for all parties involved with healthcare billing and payments. Ultimately, greater use of electronic transactions in healthcare will mean lower healthcare costs for consumers.”

The audits will evaluate the most common administrative transactions that health plans conduct with providers. Health plans and clearinghouses will be audited for compliance with standardized formats and operating rules that have been adopted under the HIPAA Administrative Simplification provisions.

Starting in April, nine HIPAA-covered entities will be randomly selected for compliance review.  Any clearinghouse or health plan, including fully and self-insured plans, may be chosen, regardless of whether they work with Medicare or Medicaid.

Transactions that may be reviewed include the healthcare electronic funds transfer (EFT) and remittance advice, and responses to eligibility for benefits requests and claim status requests.  CMS will test these transaction files and ask entities to attest to whether the transactions comply with operating rules.  

In the coming weeks, WEDI will host a webinar for members to discuss these audits and their implications on healthcare. For more information on the Compliance Reviews, read the FAQs and “Prep Steps” from CMS.

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