HHS Optimization Project Pilot

Providers and health plans use a variety of different formats for conducting electronic transactions. HIPAA Administrative Simplification transaction standards work towards reducing the variable formats, making it easier for data to be shared and transferred.

The 2016 CAQH Index estimates that industry-wide compliance with the adopted standards could save providers nearly $8 billion annually, with overall savings to the industry projected at more than $9 billion. The report analyzed the financial impact for the following transactions:

  • Claim submission/receipt
  • Eligibility and benefits verification
  • Prior authorization
  • Claim status inquiry
  • Claim payment (electronic funds transfer)
  • Claim remittance advice
  • Claim attachments (standards not yet adopted)

Achieving the full benefits of Administrative Simplification requires industry-wide compliance. To that end, HHS will pursue proactive compliance reviews of health plans and clearinghouses for compliance with Administrative Simplification transaction standards. We intend that our compliance reviews for use of the HIPAA Administrative Simplification transaction standards will result in an environment that requires minimal government intervention because entities are conducting electronic transactions in adopted standard formats.

Why Compliance Reviews?
Health care providers, health plans, and clearinghouses have encouraged HHS to take proactive steps, including reviews, to ensure compliance with Administrative Simplification transaction standards, which will:

  • Reduce the burden on compliant entities of needing to exchange health care information with trading partners that are not compliant with the adopted standards
  • Improve efficiency across the health care system by streamlining communications about billing and insurance related matters, which allows providers and health plans to spend less time on these tasks

Our proactive approach implements a progressive penalty process with the goal of remediation, not punishment. Enforcement actions such as corrective action plans (CAPs) and HHS technical assistance are possible and may be included.

Health Plans and Clearinghouses: Volunteer for the HHS Optimization Project Pilot
Health plans and clearinghouses can verify compliance by volunteering for the HHS HIPAA Administrative Simplification Optimization Project pilot.

HHS is seeking a total of 6 volunteers—3 health plans and 3 clearinghouses. Volunteers will undergo reviews of their transactions for compliance with adopted standards, code sets, unique identifiers, and operating rules. Reviews will be conducted beginning January 2018.

Volunteers will submit electronic transaction files for review and testing by HHS, as well as attest to compliance with operating rules. Transaction submission should take less than 10 hours total. Participants that are selected will be notified and will receive a compliance review package with step by step details of the process.

Upon completion, HHS will provide volunteers with a report that flags any issues that need to be addressed for full compliance. During the pilot, HHS will identify compliance issues and areas for optimization, and volunteers will develop a corrective action plan to remedy areas of noncompliance.

Volunteers that achieve successful reviews will receive a dated certificate to that effect from HHS. Volunteers may choose to share their certificate with potential business associates, the public, and other stakeholders.

This pilot will inform the rollout of the Administrative Simplification Optimization Program, where HHS will begin conducting proactive reviews of health plans and clearinghouses.

Health plans and clearinghouses that take part in the pilot project won’t be subject to random selection for an assessment for one year following HHS’s launch of the optimization program.

Volunteers for the pilot can send an email now to the HIPAAcomplaint@cms.hhs.gov mailbox. Any HIPAA-covered health plan or clearinghouse may volunteer.

HHS will choose volunteers from emails received by December 13, 2017. HHS will inform you by December 27, 2017, whether or not you’re selected to be part of the pilot.

Sign up now to volunteer for our optimization project pilot. Write to HIPAAcomplaint@cms.hhs.gov today!