Vendors Fall Under Reform EDI Provision

Under the health reform law, health insurers may not be the only entities required to demonstrate that they comply with "operating rules" to make the HIPAA transaction sets more standardized (see story).

Insurers must certify compliance to the Secretary of Health and Human Services. But a provision in Sec. 1104, labeled Service Contracts, requires payers to ensure their transactions processing vendors also are in compliance.

Here's the provision: "A health plan shall be required to ensure that any entities that provide services pursuant to a contract with such health plan shall comply with any applicable certification and compliance requirements (and provide the Secretary with adequate documentation of such compliance) under this subsection."

Some insurers, particularly Aetna and some Blues, already require their clearinghouses and software vendors to support the operating rules that exist today.

The provision in the reform bill will put additional pressure on transactions processing vendors and quicken adoption of the operating rules, says Rachel Foerster, principal at Rachel Foerster & Associates, a Beach Park, Ill.-based consulting firm. "I see it as a cascading impact that drives deeper and broader adoption."

--Joseph Goedert