Systems, Data and HIPAA from a Medicaid Perspective Rick Friedman, Director Division of State...
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![Page 1: Systems, Data and HIPAA from a Medicaid Perspective Rick Friedman, Director Division of State Systems Center for Medicare and Medicaid US Dept Health](https://reader036.fdocuments.us/reader036/viewer/2022062504/5a4d1b677f8b9ab0599b16b9/html5/thumbnails/1.jpg)
Systems, Data and HIPAA from a Medicaid Perspective
Rick Friedman, DirectorDivision of State SystemsCenter for Medicare and MedicaidUS Dept Health & Human Services
HIPAA
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HIPAA Overview What -- National standards to be adopted by Secretary
of HHSWho -- All health plans, all clearinghouses, and those providers who choose to conduct
these transactions electronically, are required to implement
When – Oct 2003 for transactions requirements; April 2003 for privacyNote -- does NOT require providers to use EDI
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HIPAA’s Purpose• Improve the efficiency and
effectiveness of the health care system by standardizing the electronic data interchange of certain administrative and financial transactions.
• Protect the security and privacy of transmitted healthcare information.
$
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HIPAA’s Scope • Administrative transactions• Code Sets• Identifiers• Security• Electronic signature• Privacy of individually
identifiable health data
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Additional Provisions• Penalties– $100 per violation of standards (up to $25K total
per year).– $50K to $250K and 1 to 10 years in jail for wrongful
disclosure of individually identifiable health information.
• Expanded HIPAA responsibilities for NCVHS– HHS to “rely” on NCVHS recommendations– Track implementation for Congress– Identify issues/barriers and advise HHS on
mitigating strategies
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Key HIPAA Committees
Designated Standards Maintenance Organizations (DSMO)– ANSI X-12– Health Level Seven (HL7)– Natl. Council for Prescription
Drug Plans (NCPDP)– National Uniform Claims
Committee (NUCC)– National Uniform Billing
Committee (NUBC)– American Dental Assoc. (DeCC)
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DSMO Role in HIPAA Implementation
• Collaborative process to evaluate change requests and develop recommendations
• Substantive changes reviewed by NCVHS with open hearings and recommendations to HHS
• Will be ongoing yearly process (in general Secretary may only make changes yearly)
• DSMO Web Site established to accept change request to mandated standards: www.dsmo.org
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What about the other standards?• Employer ID, Provider ID, Security final rules planned for
release this year (?)– Security especially will be a major challenge
• Claims Attachment and Health Plan ID NPRMs this year (?)– Health Plans need to be comfortable with whatever
is proposed for the Health Plan ID
– Claims Attachments: major opportunity and challenge!
– Opportunity to respond to NPRMs after release
• Electronic Signature TBD
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A Reminder: What Does HIPAA Mean to YOU?
• HIPAA is the law• There are deadlines for compliance• There are civil and criminal penalties• YOU are a covered entity-- buck stops
here• Affects all partners; requires cooperation• Could have major impacts on business
operations• It’s bigger than Y2K• Has impact on future business strategies
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Key PointsWorth Remembering
When Implementing HIPAA1. Address more than compliance aspects;
i.e. recognize this is not an IT problem2. Don’t rush through the planning phase3. Remember Y2K lessons on process:
-- Do your homework -- Plan accordingly-- Find a champion -- Build a committed team
4. Recognize HIPAA as a unique opportunity to improve business practices… using EDI as the enabler
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Medicaid HIPAA-Compliant Concept Model
• Two Views– Enterprise-wide: agency + trading partners– Operational from within an agency
• Interactive CD• Tool Kit – regs, definitions, contacts• Can Be Easily Customized to Meet Your MCO-
specific Needs
NOTE: Check it out at www.mhccm.org or request a copy via e -mail to: [email protected]
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BANK
Health Plan Enterprise Data Exchange Partners View
OTHER PAYER(HEALTH PLAN)
BENEFICIARY(SUBSCRIBER)
CLEARING-HOUSE
PROVIDERS
BUSINESS ASSOCIATE
MEDICAID AGENCY(HEALTH PLAN)
OTHER STATEAGENCY
D0000
BANK
MCO/HEALTH PLAN
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BANK
Health Plan Business Process View
FINANCIALADMINISTRATION
ENROLLMENT &MEMBER SERVICES)
PROVIDER SERVICES
VENDOR CONTRACTADMINISTRATION
PAYER CONTRACTADMINISTRATION
D0000
UTILIZATION MGMT
MCO/HEALTH PLAN