HHS Compliance Review Program is coming soon… WEDI offers support

April 12, 2019

This month, the Department of Health and Human Services (HHS) will launch its Compliance Review Program, an audit to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) rules for electronic healthcare transactions. WEDI, the nonprofit organization that industry turns to for information on using health IT to improve efficiencies in healthcare information exchange, praised the move in an April 11 press announcement.

“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,” said President and CEO, Charles Stellar in the statement. WEDI is also and a statutory advisor to the U.S. Department of Health and Human Services.

WEDI said 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 said it will host a webinar for members to discuss the audits and their implications on healthcare and has suggested that interested parties read the “Prep Steps” from CMS.

“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,” said Stellar.  “Ultimately, greater use of electronic transactions in healthcare will mean lower healthcare costs for consumers.”