Health Plans At Odds with Providers Over Patient Data Standards

Insurance companies are expressing opposition to a proposed rule mandating uniformity in the way that payers handle patient data.

The proposed rule, “Administrative Simplification: Certification of Compliance for Health Plans,” is an Affordable Care Act policy that requires certain insurance companies to certify their compliance with the standards for claim status, electronic funds transfer, and electronic remittance advice. Insurers would then need to prove they have completed certain testing of its electronic transaction capabilities according to standards required by HIPAA. Noncompliant entities would face a penalty of $20-$40 per beneficiary covered by a health plan. The US Department of Health and Human Services estimates that the policy would affect 3,000-5,000 health plans, Modern Healthcare reported.

The rule was posted publicly in January, and the comment period ended April 3.

Health plans, including those represented by the Blue Cross Blue Shield Association and UnitedHealth Group, disagreed with physician and provider groups—including the American Hospital Association and the American Academy of Family Physicians—over the requirement.

In its comments on the proposal, UnitedHealth wrote “If a health plan acts in good faith to implement the appropriate standards and operating rules, identify and correct known gaps, and engage in one of the two validation pathways, it should not be subject to the strict certification penalties when an unforeseen defect occurs.”

UnitedHealth goes on to argue that health plans should be allowed to correct any errors within a reasonable timeframe after being notified of a defect by the Centers for Medicare and Medicaid Services.


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