Some time back i got an opportunity to get involved for automated code set processing. When I look back , I see dependency on many of the common inputs from multiple parties. Just because I was not very business pro. Today while looking back i was able to understand the intent of healthcare code set processing needs. Here is one small attempt to share the same.
What are Standard HIPPA Code Sets?
Code set is a generic terms used in healthcare industry. Each code in code sets denotes some description. HIPPA Code sets determined or decided by HIPPA (Health insurance portability and accountability act 1996). In simple words there is a regulatory body which regulates and define the code sets and associated meaning of those code sets. All the organizations operating in health care space have to ensure that they uses these code sets. So it enables them to share the data with other parties. No one can do business independently right, there are multiple parties involved in one business system. Having HIPPA code sets in place ensure fast data and un ambiguous data exchange. Few samples. We can easily understand that how generic these terms are
- Diseases, Injuries.
- Prevention, Diagnosis.
- Impairments, Treatment.
- disease, Causes of injury, other health-related problems or impairment.
- Health Management ,Health related problems and indicators.
Why do we need standard code Sets ?
Good questions though, and nothing in this world exist without need. Let’s understand this with one very simple real time example. Lets say that you are sick. So now you are a client or patient. You will need to go to physician. He might or might not send you to medico test lab. So now treatment is done and you will need to hit pharmacy, Pharmacy will give you medicines and will engage health agent. Health agent will engage health insurance provider. Now claims has come in picture. If claims are there then adjunction will happen . At last you might / might not get settlement check from bank.. (Thanks !!!!!!! if you could read this much.though it was tiring for me to relate them.) Now you have to think. How many times your Personal (PHI and PII information) shared across the parties in this process (7 times).
Yes, you got it . This is the problem here. You have only 90 days(or any figure) to settle your claims with health insurance providers. And you claims cycle goes through multiple channels. This causes delay and discrepancy as many parties are involved. so government has come up with HIPPA (HIPPO) to help you. Once you are in system your data will get processed like rocket and you will not miss claims adjunction because of 90 days(or any number) cap … happy go lucky now.
Physicians , pharmacist , Pharmacy benefit management, Insurance Providers, Health advisers, Prescription , Drug , Claims, practice and every health care entity need to comply HIPPA norms.
As everyone says that goal of this is to ensure the simple administration of health claims. But there is a bigger second objective as well , that is to protect individual identifiable information and personal health information. So basically HIPPA enables to achieve below
- Transaction regulation
- Privacy and security regulation (PHI and PII data )
How HIPPA code sets helps health care industry / entities ?
It doesn’t help them much. Yes believe me this puts extra burden to safeguard PHI and PII data. In longer run healthcare entities learnt that It Simplify claims submission for health care providers who deal with multiple health plans. Moreover it definitely improves data quality provided you are big enough to spend multi million dollars to effectively utilize the BIG data.
One way HIPPA definitely helped health care entities by Standardizing data. Standardized data later help entities for accurate and efficient electronic data exchange between the many producers and users of administrative health care transactions.
Most benefited entities with this are, Patient, physicians, pharmacy benefit managers. Health insurance providers are still recovering from big shock by utilizing so called BIG data.