HIPAA: Reinventing Healthcare Business Processes to Benefit Consumers

Congress is taking major steps toward incremental healthcare reform. The Healthcare Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to provide portability of insurance coverage for consumers and to improve the efficiency and effectiveness of America’s complex healthcare system. By simplifying and streamlining administrative processes, the system will be able to respond faster, more accurately and overall, provide better service to consumers. This legislation serves as the catalyst to reinvent healthcare business processes. Simplifying and standardizing healthcare transactions are significant steps forward for consumers with major benefits for healthcare providers, payers, and the entire healthcare industry.

How do you comply with HIPAA?

HIPAA requires virtually every healthcare provider to make changes in the way its internal business processes are performed. Some will need only to make small changes while others will have a major task to comply in order to include electronic data transmission. Current provisions include requirement for national standards for medical code sets and electronic health transactions (including claims, enrollment, eligibility, payment and benefits coordination) standard identifiers for providers, payers and individuals, and security and privacy standards. Every HIPAA-defined administrative transaction between providers and payers exchanged electronically also will be subject to healthcare data security and privacy standards. These standards, in addition, will apply to intermediaries and clearinghouses operating on behalf of providers and payers.

The Sensibill Approach:

Complying with Administrative Simplification & Improving Patient Communication.

Sensibill helps our client’s comply with HIPAA regulations to simplify administrative processes and provide HIPAA-ready electronic information transmission.

  • Electronic Healthcare Claims Processing (835 Transactions)
  • Eligibility verification
  • ERA (Electronic Remittance Advice)
  • Credit Card Processing
  • Web- enabled reporting

Coding audits to ensure accuracy accelerate reimbursement, and improved documentation. Sensibill partners with A-Life Medical for additional solutions.

Why have a Compliance Program?

The Federal government has begun to increasingly investigate fraud and abuse in the healthcare industry. They believe the best way to protect public health care dollars is through a Compliance Program that acts to prevent fraud and abuse in healthcare, promotes a culture of integrity & high ethical standards, promotes ethical leadership, establishes a standard set of guidelines, and provides a reporting mechanism for concerns.

Compliance Officer

The Compliance Officer is responsible for coordinating, overseeing, monitoring, and assisting the Billing Service’s compliance and quality improvement efforts.

Standards of Conduct - General

Responsible for treating all people with fairness, respect and courtesy. We will strive to create a challenging productive and safe working environment. We will promote equal opportunity and encourage career development consistent with the needs of our business.

Sensibill's Compliance Program

Our Compliance Program encourages a forward thinking culture that recognizes compliance as the responsibility of every employee. It provides education and training in billing and regulatory guidelines, implements and maintains mechanism to assure the accuracy of the claims submission and reimbursement process, monitors and assures the effectiveness of the compliance program, embeds the compliance function within business operations to the greatest extent possible by recognizing the specific risk areas identified by the OIG for billing companies.

Some of the key items focused on are:

  • Billing for items or services not actually documented
  • Duplicate billing
  • Unbundling
  • Upcoding
  • Inappropriate Failure to properly use modifiers
  • Routine waiver of co-payments
  • Inappropriate balance billing
  • Inadequate resolution of overpayment's
  • Lack of integrity in computer systems
  • Failure to maintain the confidentiality of information/records
  • Knowing misuse of provider identification numbers
FACTA Compliance

Sensibill has established our standards for the recognition, identification, and actions required to comply with the Federal Trade Commission “Identity Theft Red Flags Rule”. Entities that have access to credit data have a duty to monitor for the potential that patient data may be compromised and take appropriate safeguards and corrective actions. We have policies in place for the recognition and identification of red flags, and we train and retrain every employee annually on our procedures. Here are some of the items we watch for:

  • A bill for a service the patient denies receiving
  • A bill from a provider the patient has not received services from
  • An EOB for services not received
  • A treatment billed for that is incorrect for the medical condition reported
  • Receipt of a collection notice for services never received
  • An insurance report that benefits are exhausted or a life-time cap has been reached when the patient denies that responsibility
  • Any dispute of identity theft
  • Incorrect credit report information regarding services
  • Mail theft
  • Patient denies receiving any statements