This reference guide is instrumental for someone to better comprehend the components and the advantages of electronic data interchange (EDI). Some of the areas in which EDI helps are boosting data quality, lessening billing inaccuracies, as well as improving accuracies and reliability. EDI is also significant in cutting costs and improving the quality of healthcare delivery to patients together with the services being provided (Orttung & Linscott, 2015). This paper will explore how EDI enables electronic transactions, and how HIPAA has changed how health care information care information is transmitted in EDI. Finally, the paper will explore the relationship between electronic health records, reimbursement, HIPAA, and EDI transactions.
Definition of Electronic Data Interchange (EDI)
EDI is established standards for organizing information to be electronically shared and transmitted between and within business organizations, government institutions, and other entities. EDI is the standard that Health Insurance Portability and Accountability Act (HIPAA) has recognized deliberately to facilitate the transference of patient’s data (Dicks, Kent, Tripp, Bartlett, & Crosley, 2017). With the promotion of EDI, the requirement to print, store and file papers is eliminated, which again has been confirmed to be more effective (Orttung & Linscott, 2015). With EDI, information is stored in electronic forms as stored within the system, and can be easily shared and used without printing, reducing the costs that could have been spent otherwise.
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Moreover, HIPAA prepared particular standards for EDI that is subdivided into eight various transaction standards. These standards include claims and coordination of benefits (COB), premium payments, benefit inquiry, and response, claim status, enrollment, and de-enrollment in a health plan, eligibility, remittance and payment advice, and coordination of drug benefits. Concisely, EDI is a framework that replaces the processing of a big number of documents, which have in the past proved cumbersome, costly, and inefficient (Dicks et al., 2017). Thus, HIPAA has advocated for transmission of healthcare data through standardized formats, majorly utilizing the EDI protocol (Orttung & Linscott, 2015). EDI transmissions are also instrumental in dealing with security and compliance matters and bridging the gaps created like information inaccuracy and patients’ inability to retrieve information about them.
HIPAA has set eight standardized electronic transactions that EDI utilizes to enable retrieval, storage, and transference accordingly. HIPAA has also incorporated a section on administrative simplification that facilitates the issues of confidentiality and security of health information or records. For example, whenever patients have paid a visit to the physician's office, their claims are reconciled with their health insurance to enable payment of that service. Electronic claim submission, which one of the standardized electronic transactions that EDI enables, will offer a more available, faster manner to process claims (Klann, Abend, Raghavan, Mandl, & Murphy, 2016). Other advantages derived from utilizing electronic transactions in the healthcare industry include raising efficiency, enhance the quality and precision of information and cut the overall costs.
Utilizing the EDI helps a health care provider to facilitate the submission of transactions, sometimes in an instance. As a result, once the transactions have been processed, the payments for the claims can be made. By utilizing EDI, healthcare providers may not find the chance to dodge their responsibilities for protecting their clients’ information as well as the billing services or clearinghouses are safeguarded as these are also utilized to facilitate the transmission of beneficiary data (Dicks et al., 2017). Consequently, the EDI have a framework that allows signing an agreement as a security and confidentiality requirements that makes the provider be obligated, as needed by Centers for Medicare and Medicaid Services (CMS) and HIPAA.
How HIPAA has Changed How Health Care Information is Transmitted in EDI
The objective of HIPPA and the standards that it recommends is to enhance the efficiency of the healthcare system. The terms and conditions set, for electronic transmissions, advocate for privacy and security standards to eliminate fraudulent activities and misuse of a patient’s health information (Dicks et al., 2017). The privacy law has been constituted to shield a patient’s information from being misused or shared by unauthorized persons in any manner. On the other hand, HIPAA’s security law establishes standards so that they can achieve respect, confidentiality, and honesty of patients’ safeguarded health information in healthcare institutions.
HIPAA’s standards for EDI transactions are encoded in place of directing describing the procedure so that only authorized persons can decode the information. For the receiver of the information to recognize the content sent to him, both he and the sender should have similar codes (Klann et al., 2016). The two collections of codes that HIPAA needs are ICD-9-CM for diagnosis, CPT-4 and HCPCS codes for outpatient processes (Orttung & Linscott, 2015). Whenever the above regulations are considered diligently, the general data quality is enhanced considerably, handling and processing time of the transactions is lessened, the risk of losing documents is eliminated, and costs that relate to administrators are reduced for providers.
The Relationship between Electronic Health Records, Reimbursement, HIPAA, and EDI Transactions
All these aspects of electronic health records, reimbursement, HIPAA, and EDI transactions are related in several ways to ensure efficient and health patient care. EHR is a patient’s chart that has detailed medication records, referrals, laboratory outcomes, background history, demographics, and past medical records. The authorized persons can access such information instantly as long as they need to use them (Klann et al., 2016). The past medical story is also helpful for doctors to administer treatment to the patient, as they can carefully do a proper diagnosis without missing any gaps. HIPAA entails almost all the aspects as it recommends standards that healthcare providers have to comply with for efficient delivery of healthcare services.
HIPAA covers the issues of the billing process like medical records storage, the use of codes in the creation of claims, and among others. Claims would comprise information concerning the patient, the health provider they consulted, and the patient’s medical care plans (Klann et al., 2016). It will also incorporate the codes indicating the procedures in attending to the patients. Healthcare claims are the most frequented form of electronic transaction, along with the claims applied for in reimbursement for the providers (Orttung & Linscott, 2015). Reimbursements entail returning money to the patient or the provider accordingly based on the verification that money has been disbursed inappropriately or has not been provided at the time needed. Again, reimbursements are enabled through making reference to the electronic health records and relevant transactions that will inform the situation in question.
Conclusion
Electronic health records, reimbursement, HIPAA, and EDI transactions engage harmoniously and complementarily to provide the patient with quality healthcare. With HIPAA being at the center of all these aspects, EDI does not just enhance the quality of healthcare but also brings down the chances of losing documents, and cuts the costs of the providers. Moreover, the electronic data interchange (EDI) guide effectively suggests the way EDI operates and the benefits of utilizing the system. One of the functions that EDI is so aggressive about is the issue of privacy and security of patients’ records. For the receiver of the information to understand the information sent to him, the sender must give him an access code. This guarantees confidentiality and security of the information so that it is only restricted within the authorized persons. All the components discussed in the paper enhance effectiveness in healthcare delivery and promoting quality as long as the standards set by the HIPAA are followed.
References
Dicks, K., Kent, R., Tripp, R., Bartlett, T., & Crosley, T. (2017). U.S. Patent No. 9,619,621 . Washington, DC: U.S. Patent and Trademark Office.
Klann, J. G., Abend, A., Raghavan, V. A., Mandl, K. D., & Murphy, S. N. (2016). Data interchange using i2b2. Journal of the American Medical Informatics Association , 23 (5), 909-915.
Orttung, M., & Linscott, D. (2015). U.S. Patent No. 9,141,991 . Washington, DC: U.S. Patent and Trademark Office.
