Enforcement The general and transaction-specific rules provide the tools needed for the industry to achieve uniformity and the associated savings. Since these HIPAA administrative simplification regulations increase efficiency and reduce business costs for health plans and physicians, it is generally in a plan’s best interest to adhere to the regulations. In order to ensure such adherence, the HIPAA regulations establish Oftentimes, the quickest and easiest way to resolve a health plan compliance issue is to contact the health plan representative with whom the practice traditionally interacts regarding the claims process. a complaint-driven process for the resolution of any HIPAA standard transaction violations. In accordance with these rules, practices should follow this two-step process to address perceived noncompliance with the standards: 1. Contact the health plan. Oftentimes, the quickest and easiest way to resolve a health plan compliance issue is to contact the health plan representative with whom the practice traditionally interacts regarding the claims process. This allows physicians to explain their concerns and work directly with the plan to ensure the proper handling of future transactions. Physicians may also contact the health plan’s compliance officer, as adequately following HIPAA standards is an issue of regulatory adherence. 2. File a complaint with the Office of E-Health Standards and Services (OESS). If a practice is unable to satisfactorily address health plan noncompliance through direct contact with the health plan, it may seek to file a formal complaint. The HIPAA regulation establishes a complaint process that allows practices to report noncompliance to the Centers for Medicare & Medicaid Services (CMS) OESS, the government agency responsible for investigating and resolving standard transaction violations. The OESS Administrative Simplification Enforcement Tool (ASET), which is available through the CMS website, walks users through a process of gathering all relevant information. The submitted information is then combined into a report that is subsequently investigated by the OESS. 26 HBMA BILLING • MARCH.APRIL.2015 AMA Resources for Physicians In order to truly realize the intended efficiencies and savings of the HIPAA standard transactions, health plans must become and remain compliant with the regulations. Due to the complaint-focused enforcement process, physician practices need an adequate understanding of the health plan responsibilities and adherence enforcement avenues created by the regulation. The AMA offers multiple resources and an archived webinar designed to convey the necessary information to physician practices. For additional information and to access the AMA resources, please visit www.amaassn. org/go/transactioncompliance. More information on practice automation, including electronic transaction toolkits, is available at www.ama-assn.org/go/electronictransactions. ■ The AMA offers a variety of other tools to assist physicians and their billing partners in electronic transaction implementation. Visit the AMA Administrative Simplification Initiatives website at www.ama-assn.org/go/simplify for additional information and resources. QUICK TIP! FILING A HIPAA COMPLAINT If a health plan is noncompliant, and your contact with the health plan’s compliance officer ends unsuccessfully, you can file a formal HIPAA complaint at https://htct.hhs.gov/aset. Having trouble with the link? Search for “OESS Administrative Simplification Enforcement Tool.”
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