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Regulatory Compliance
We are fully aware of and compliant with the numerous and complex federal and state regulations affecting the administration of health plans. We are continually making modifications to our systems and seeking education to become compliant with any new regulations that are implemented. The following represents a few of the major regulations that we are addressing:
Health Insurance Portability and Accountability Act of 1996 (HIPAA):
This is one of the most extensive and comprehensive regulations affecting the health care industry in its history. It has four major sections being Portability, Electronic Data Interchange, Privacy and Security. The following represents a brief overview of our actions to address each of these areas:
Portability - The general purpose of this section of the law was to ensure people could change jobs without losing health coverage due to a pre-existing condition. In accordance with this law, we provide each participant who loses coverage with a Certificate of Creditable Coverage. The individual can present this certificate to a subsequent provider of health coverage to reduce or eliminate any pre-existing exclusion condition period.
Electronic Data Interchange - This is the portion of the law that has had the most impact on health plans as it requires them to be capable of accepting and sending certain data in a specific electronic format. There are seven different transaction sets that health plans must be able to transmit and receive electronically. We have invested a considerable amount of resources to become fully compliant with the HIPAA EDI standards. It is anticipated that over the next few years, there will be a savings from handling transactions electronically instead of in paper form as health care providers become more comfortable with this process.
Privacy - The HIPAA Privacy rules impose restrictions on disclosures of health information that are not related to a patient's treatment, claims payment or health plan operations. We have implemented numerous changes in our operations to address these rules including a more secure method of records destruction, training staff on the rules to ensure there are no inappropriate disclosures, submission of a health plan's privacy notice to each new participant in the plan, computer access restrictions, and enhanced facility security. Please click here to see our privacy notice.
Security - This portion of HIPAA takes effect in April 2005 (or 2006 for small health plans). It requires a security assessment to determine any flaws that could allow inappropriate disclosures electronically of an individual's health information. The assessment will concentrate in three main areas to ensure there are adequate administrative, technical and physical safeguards. After having the security assessment performed, we will need to address the recommended remedial actions to become fully compliant with the Security regulations. We are scheduling a security assessment in the fall of 2004 to be performed by a firm highly skilled in this area.
Employee Retirement Income Security Act (ERISA) Claims and Appeals Procedures
We have the capacity to administer ERISA-mandated claims and appeals procedures including the various timely filing and notification requirements for pre-service, urgent, concurrent and post-service claims or appeals. In addition, we can administer any client-specific claims and appeals procedures for those clients not subject to ERISA.
Consolidated Omnibus Reconciliation Act (COBRA)
COBRA allows health plan participants to extend their coverage when it would otherwise be lost for various reasons. This requires a health plan to timely notify a participant of his/her COBRA rights and to continue such coverage for specific periods of time, subject to timely receipt of COBRA continuation payments. We have a comprehensive method of COBRA notification, receipt and billing process to comply with these requirements, or we can work with any other client's COBRA administrator.
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