A Healthesystems publication

Fall 2011

HIPAA Standards in Workers’ Compensation

On November 18, 2011 the National Committee of Vital and Health Statistics (NCVHS) will conduct hearings on Section 10109 of the Affordable Care Act (ACA). The hearings will focus on health information data exchange and standards — an emerging area of attention for many workers’ compensation payers, their vendors, clearinghouses and state agency policymakers. The upcoming hearings have already generated significant discussion and preparation amongst industry groups who are slated to testify about the impact of the ACA and associated HIPAA regulations on workers’ compensation payers and providers.

Today, electronic data exchange is becoming more the norm in a workers’ compensation system which was at one time primarily driven by paper processes. The technology to provide real time claim adjudication adds significant efficiency to the system, but also presents unique challenges for system participants. For example, nationally adopted electronic health exchange standards allow providers to check on patients’ eligibility and coverage in group health or government sponsored health insurance programs. But the terms “eligibility” and “coverage” have different meanings in the world of workers’ compensation, and this presents an obstacle for allowing medical providers to conduct “real time” eligibility checks, as they can for other types of insurance programs. State workers’ compensation policymakers understand this nuance, and are working to educate federal and state agencies on the differences between workers’ compensation programs and other types of insurance programs.

Right now, there are only a handful of state workers’ compensation programs which have adopted the electronic data exchange standards which are already widely implemented outside of the Property and Casualty lines of insurance. Texas’ workers’ compensation agency was the first to adopt electronic requirements for billing, and several other states including Minnesota and California have followed suit by adopting e-billing standards. Many other states currently have advisory committees which are in the process of exploring e-billing rules for future consideration. Healthesystems staff continues to serve on several of these advisory committees to educate state policymakers about the benefits and challenges of adopting national standards in workers’ compensation. For more information on the hearings, or for information on HIPAA standards, visit http://www.ncvhs.hhs.gov/.

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