What Medical Billers and Coders Should Know About HIPAA’s Confidentiality Rules

By Karen Smiley

The Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, set a national standard for protecting health data and protecting the patient’s rights. HIPAA does more than simply deal with confidentiality.

  • Title I of HIPAA protects health insurance coverage for workers and their families who change or lose their jobs. Under HIPAA, a new group health insurance must accept most of the medical conditions that were covered by a patient’s previous group policy.

    When an individual enrolls in a new group health plan, the plan may refuse to cover certain defined conditions for a period of 12 to 18 months. This exclusion is reduced by the amount of time that the patient had coverage under his or her previous group health plan. As the biller or coder, you must know this rule so that you can challenge an unlawful pre‐existing denial by a commercial payer.

  • Title II of HIPAA requires a national stand­ard for electronic transactions and national identifiers for providers, insurers, and employers. These identifiers are known as Tax ID numbers (similar to an individual’s Social Security number) and National Provider Identification (NPI) numbers. Payers have payer identification numbers called payer IDs, 5‐digit numbers that identify to which payer a claim is to be sent electronically.

    As a medical biller or coder, you must know and follow these standards to avoid violations for which your employer will be held accountable. (This is also the clause that contains the standards used to ensure the privacy of health information.)

  • Title III of HIPAA addresses the way employers handle medical savings accounts, which are tax‐deferred savings accounts that are used only to cover medical expenses.

  • Title IV of HIPAA mandates that ­employers must allow employees to continue their health insurance when leaving their employ.

  • Title V of HIPAA provides employers with ways to offset the cost of compliance, such as deducting life‐insurance premiums from their tax returns.