In medical billing and credentialing, compliance is a core driver of efficiency and revenue protection. While the Health Insurance Portability and Accountability Act (HIPAA) is best known for safeguarding patient data, its impact extends deeply into operational workflows that affect provider on-boarding and reimbursement.

As a Leading Medical Billing Service Provider, Medical billers and Coders (MBC) integrates HIPAA-compliant practices into every aspect of the revenue cycle—from credentialing services to final claim resolution.

For official guidance, refer to the U.S. Department of Health & Human Services HIPAA Guidelines.

Credentialing Services and HIPAA: First Line of Compliance

Credentialing is the process of verifying that providers are qualified and authorized to treat patients and bill payers. However, it’s also a compliance checkpoint. Incomplete, outdate, or insecure provider data can result in claim denials, payment delays, or regulatory scrutiny.

To avoid these issues, HIPAA-compliant credentialing must include:

• Secure handling of personally identifiable information (PII)
• Encrypted communication with payers and provider networks
• Controlled data access and audit-ready documentation

MBC Insight:

“When credentialing is done right—with HIPAA in mind—providers get enrolled faster and experience fewer disruptions in billing,” says the Credentialing Director at MBC.

Medical Billing Under Regulatory Scrutiny

Medical billing relies on the secure and accurate transmission of health information. HIPAA governs this through strict standards for electronic data interchange (EDI), claim documentation, and payer communication.

Key areas of HIPAA impact in billing include:

• Eligibility verification through secure platforms
• Accurate CPT/ICD coding
• Encrypted claim submission
• Secure storage of remittance advice and EOBs

A non-compliant claim, even with minor errors, can lead to denials, audits, or penalties—directly affecting your revenue.

MBC Insight:

“Our billing teams constantly monitor CMS and payer policy changes to keep clients compliant and prevent billing disruptions,” notes a Compliance Specialist at MBC.

Why Compliance Drives Revenue?

Being HIPAA compliant is more than checking boxes—it enhances payer trust, improves operational speed, and reduces costly errors. Organizations that align billing and Credentialing Service with HIPAA see:

• Fewer claim rejections
• Faster reimbursements
• Greater patient data security
• Lower audit risk

Medical billers and Coders offers end-to-end support, ensuring that all credentialing and billing workflows are HIPAA compliant, accurate, and payer-ready.

Related Links:

• Denials in Medical Billing
• MBC: Leading Provider of Medical Billing and Credentialing Services
• What You Need to Know About Proposed Changes to HIPAA?

FAQs

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Most providers are delivering telehealth services more often now. Due to lots of advantages, a large population of patients has also adopted to telehealth environment. While delivering telehealth services, the provider needs to take some precautions to avoid HIPAA violations. Recently Office of Civil Rights (OCR) has published FAQs on telehealth and HIPAA during the COVID-19 nationwide public health emergency.

We shared some useful content that will help you in avoiding HIPAA violations while delivering telehealth services for your practice. We discussed some basic topics like defining telehealth, healthcare providers, good faith, place of service for telehealth, communication channels, and Protected Health Information (PHI).

Defining Telehealth Services

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What Is HIPAA?

Health Insurance Portability and Accountability (HIPAA) Act of 1996 is a law that intends to protect the privacy of patient information. It establishes national standards for processing electronic healthcare transactions and requires healthcare organizations to implement these.

Why Your Practice Should be HIPAA-COMPLIANT?

Non-compliant of HIPAA regulations can cause a big amount of fines to your medical practice and the Medical Billing Service Company working with you. This also affects the reputation of you and outsourcing medical billing company also it can cost thousands of dollars.

First step to take to become HIPAA compliant is to have a BAA (Business Associate Agreement) in place. BAA need to be submitted to all your vendors such as medical billing service company. This will help your practice to be updated HIPAA compliant practice. As soon as all parties sign the BAA agreement they are liable to follow all HIPAA compliance rules and regulations. If they fail to do so then they are subject to civil and criminal penalties for action not authorized in your BAA.

Recently in one of the USA state one facility violated HIPAA compliance. A nursing home patient’s physician texted the patient’s lab reports to nurse. Both the physician and nurse were the only authorized medical professionals to see the message. The centers of Medicare and Medicaid Services found the residential facility to be the violation. They used text message for the communication instead of the secure method of communication.

Please find below is the Compliance Checklist (Ref: ComplianceHelper.com)

• Have you formally designated a person(s) or position(s) as your organization’s privacy and security officer?
• Do you have documented privacy and information security policies and procedures?
• Have they been reviewed and updated, where appropriate, in the past 12 months?
• Have the privacy and information security policies and procedures been communicated to all personnel, and made available for them to review at any time?
• Do you provide regular training and ongoing awareness communications for information security and privacy for all your workers?
• Have you done a formal information security risk assessment in the last 12 months?
• Do you regularly make backups of business information, and have documented disaster recovery and business continuity plans?
• Do you require all types of sensitive information, including personal information and health information, to be encrypted when it is sent through public networks and when it is stored on mobile computers and mobile storage devices?
• Have you implemented controls to limit physical access to all devices and areas where PHI is accessed or stored?
• Do you limit access to PHI to only those who need it to fulfill their job responsibilities?
• Have you implemented technical security controls to protect against unauthorized access to electronic PHI?
• Have you identified all your business associates (including subcontractors if you are a BA) and ensured they have signed a BA agreement and follow all HIPAA requirements?
• Do you require information, in all forms, to be disposed of using secure methods?
• Do you have a documented breach response and notification plan, and a team to support the plan?
• If you are a covered entity (CE), do you provide a Notice of Privacy Practices (NPP)  that meets all HIPAA requirements in compliance with the Omnibus Rule changes?
• Have you established processes to document and account for disclosures of PHI?

(Questions developed by Rebecca Herold, CIPM, CISSP, CIPP/US, CIPP/IT, CISM, CISA, FLMI; CEO, The Privacy Professor: http://www.privacyguidance.com )

If you answered ‘NO’ to any of these questions you are not in compliance with HIPAA and are at risk of fines and other penalties. It is important to know that a business partner or regulatory agency can ask you, at any time, to provide proof that you are HIPAA compliant.

If you need to bring your medical practice up to HIPAA’s standards, please contact Medical Billers and Coders today through email: info@medicalbillersandcoders.com or reach us at our toll free number: (888) 357 3226 and we’ll ensure that your medical practice is HIPAA compliant.

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Why HIPAA Automation Tools?

Highly innovative and educated medical billing software’s being used today, streamline workflows with highly secure automated processes that protect patient data, such as secure FTP file transfer functions that use passwords, keys, certificates, SSL/TLS Explicit/Implicit solutions as well as file encryption and decryption protocols with open PGP, PGP certificates, passphrases and keys.

So, the moot question that arises here is what are the next steps, beyond meeting privacy thresholds established by HIPAA?

• Should the features or standards be reshaped to better control and monitor the actions of complaint organizations?
• If HIPAA compliance is just a checkbox item to be crossed off before an IT product release, does it limit or overthrow the purpose of compliance?
• And remembering the spirit of the HITECH Act isn’t it important to strive for better outcomes?
• Most importantly it facilitates physicians/doctors operating out of multi-location and department

Heeding the HIPAA Compliance

Medical billing software automation has become a central part of enforcing HIPAA compliance and other regulations, and most tech-savvy healthcare organizations have already automated core business processes involving private health information of the patients, including validation of insurance information, patient scheduling, and notifications, medical billing, and coding management. As a result, the healthcare industry had to integrate automated processes with legacy systems.

Over the 15 years, healthcare units across the United States have increasingly used technology solutions to optimize workloads, share critical health data and deliver healthier patient care. The federal government encouraged the adoption of Electronic Health Records (EHRs) by healthcare service providers through the Medicare and Medicaid EHR Incentive Programs five years back that provide direct financial incentives to healthcare providers who demonstrate ‘meaningful use’ of certified EHR technology. Ultimately, the end goal is to improve patient care and sustain a financially viable bottom line in tandem with the HIPAA compliances.

Focus On Information and Security through Automated Tools

Healthcare service providers and the associated companies that work with them, such as an offshore medical billing and coding organization have to be mindful of protecting patient privacy. If you still haven’t forgotten, the Health Insurance Portability and Accountability Act (HIPAA) that was passed during the Clinton Administration governs privacy protections by requiring that anyone who possesses health-related information protect it.

Specifically, the health data custodians must keep private any critical information related to the health information they possess, including names, phone numbers, email addresses, medical records numbers, driver license information, etc.

Do remember that with the increase in patient payments, payment modes, the payment cards and bank accounts of patients are exposed, which in turn increases the risk of a data breach. A payment card data breach can lead to a high financial and reputational loss for the hospital or physician that can result in loss of business and bad publicity.

In a sensitive industry like healthcare, where the privacy of patients is compromised, it can affect a large number of people. Adherence to rules and regulations laid down by the HIPAA is vital for enhanced security of patient information as fraudulent activity can be effectively prevented by HIPAA before, during, and after the claims are processed.

In the healthcare domain, HIPAA establishes clear guidelines between parties with regard to electronic transactions and electronic record keeping. For improved security, it mandates people who carry out the medical billing undertaking, to make use of EHR systems.

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Title I has been a debated topic with health coverage of many individuals going under constant change looking at the job security of American individuals. Covering individuals under health care policy after significant breaks.

Title II is known as the background regulation of the healthcare industry as the industry moves toward the technologically vibrant sector.  Now with Information becoming the new currency, the law was made to protect the patients’ healthcare information.

According to the law here are some insights about the HIPAA Regulations

U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) takes up the initiative of implementing the HIPAA security and privacy laws. OCR checks the following during the investigation process

1. Investigating complaints filed with it.
2. Conduct a compliance audit to determine whether the covered entities are in compliance.
3. Educating and reaching out to foster compliance.

In the case of non-compliance where the doctor’s office is not resolving the matter satisfactorily, OCR may decide to impose monetary penalties.

In some cases, the Office of Civil Rights (OCR) has taken the way of approaching criminal liabilities just to cope with violations.

The criminal violations of HIPAA are currently handled by DOJ. The person or organization that obtains and discloses individually identifiable health information can face a fine of up to $50,000 and imprisonment of up to 1 year.  Offenses committed under false presentence increased to a $100,000 fine with up to 5 years in prison. Finally, offenses committed with intent to sell or use for commercial advantage, personal gain, or malicious harm are fines of $250,000 and imprisonment of up to 10 years.

In most cases, the patient’s data is stolen from the hospitals to demand money or use the patient’s details for payment. In most cases, the offenders get away with the crime as the patients affected don’t pursue the matter to a higher level. It’s imperative for healthcare providers to understand the effect that any leak can underestimate the patients from different regions.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We can assist you in Medical billing to receive accurate reimbursements from private and government payers. To learn more about our HIPAA Regulation Services, contact us at info@medicalbillersandcoders.com/ 888-357-3226.

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In connection with enabling billing data portability, HIPAA also created certain privacy procedures and measures that all covered entities, and now physicians are supposed to follow.

The law is intended to help physicians hence; it is important that they follow HIPAA Compliance risk analysis. Failure to comply with this wide-reaching piece of healthcare policy could put your organization’s future in serious jeopardy — to the tune of crippling financial penalties or can get deeper like criminal charges.

Thus, it’s important that you and your staff are not only regulating all HIPAA requirements but ensuring full compliance within your organization.

Here’s how HIPAA Compliance Risk Analysis Can Be Helpful to The Physicians In 2017. All you have to do is:

Ensure that your technology toes HIPAA Line

This goes beyond certifying your electronic records system i.e. your practice’s EMR or EHR has HIPAA and PHI on lock.

These days, medical billing provider uses different types of software programs and several high-tech electronic devices as part of their clinical practice from wearable’s to telehealth platforms and they are supposed to be complete HIPAA-compliant.

The technology developed specifically for healthcare purposes was built keeping HIPAA standards in mind.

Have NPI for your organization and each HIPAA covered provider on your staff

HIPAA requires any entity that condenses healthcare services to have a unique 10 digit which we know as NPI- National Provider Identifier.

Basically, there are 2 types of NPIs:

• NPIs are for individual practitioners
• NPIs are for organizations

This is important when physicians with similar names are practicing in the same city and under the same NPI 2 type.

Secure your PHI by practicing proper technical and non-technical safeguards

In this ever-evolving electronic age, data storage and transmission are at great risk in nearly every industry and that means consumer identities are more vulnerable to hackers. In fact, there are more chances to happen in the health care industry, and that is the reason electronic PHI storage and transmission should be greatly regulated.

You can eliminate the by identifying the risks to unlawful access to electronic PHI in their organization. Assess the security measures including administrative, technical, and physical safeguards that currently exist in the organization. Address any gaps in the organization’s security program.

Conducting HIPAA Compliance Risk Analysis Will Result In:

• Greater privacy and security of patients
• Personal health information provider and health plan overhead cost reductions through standardization
• Constant processes among health plans as electronic formats and values will be uniform throughout the health care industry
• Interpretation of data submission through standardized transactions and code sets
• Accessibility of a new option for submitting authorizations and referrals that let transmission of multiple referrals and authorizations in uniform formats

Bottom Line

The best way to ensure that your office is always HIPAA compliant is to make patient privacy a part of your business practice, and embed it into the workflow. Practice this, and your internal audit will be a breeze, and if OCR does show up, you don’t have to take the stress.

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Under this Act, healthcare providers are required, to protect and keep confidential any personal health information of patients. The Rule also gives patients rights to their health information, including rights to obtain a copy of their medical records, and request corrections. In this blog we will discuss, How Your Staff can be your Biggest HIPAA Vulnerability?

Healthcare breaches can happen due to a number of reasons, the paramount being potential economic gain. Moreover, due to the digitization of records and wearable devices, the healthcare industry faces the biggest threat to patient information by cybercriminals.  But, they face the biggest challenge of security of sensitive information not just from third-party vendors but also from within the organization itself.

Today with third-party vendors employed to handle the processing and workflows, that include verification and eligibility of patient information for insurance coverage that helps in reducing claim dismissal, the need to maintain confidentiality and security goes a notch higher. However, very often it is employees within the industry itself who can inadvertently leak information and be your biggest HIPAA vulnerability.

Given the statistics, as per the Protenus Breach Barometer, November 2016 saw the most breaches committed this year so far. With 57 reported incidents, 54 percent was caused by employees(insiders) itself (see inbox for more stats).

Added to this significant incident, the report stated that 60 percent of the breached parties took longer than the 60-day window required to report breaches to the department of Health and Human Services.

Let us see how the healthcare staff inside our own organizations can be the biggest HIPAA vulnerability factor:

Manual maintenance of Medical records

Given that the practice of Electronic Medical record keeping is yet to be streamlined, mishandling of patient records is seen as a common HIPAA violation. When a practice uses written patient charts or records, a physician or nurse may accidentally leave a chart in the patient’s exam room available for another patient to see. Hence it is very essential to initiate the EMR– Electronic medical record system as early as possible.

Vulnerabilities in the IT system

Laptops & Mobile devices are the most vulnerable to theft. Very often doctors and administrators carry patient information in their mobile devices or their laptops.  If such devices are not password protected and data not encrypted then access to patient-specific information is very easily available.

The quick communication channel

Although it may seem easy and simple to text patient information this confidential information can be easily accessed. Not everyone, be it the doctors or even the patients realize that this is confidential information, be it blood test results or any other patient-related information. And, both parties need to have encryption on their devices, which may not always be the case.

Use of Social Media

Even giving examples of diseases by showing a patient’s photo on a social media site even if the intention is to throw light or make people aware of the problem, is and can be considered a HIPAA violation.

Accessing patient information on home computers

More often than not, clinicians will often use their home computers or laptops from home to access patient information to record notes or check on follow-ups – this too is a HIPAA violation.

Resource crunch

Smaller clinics may not have the resources to put certain IT measures into place like encryption etc. But, even carrying a patient’s Medicare card in a wallet by a doctor is considered a HIPAA violation, as it contains the patient’s Social Security Number (SSN).

Water cooler or break room gossip

Simply just talking about patient’s to friends and co-workers is known to be a HIPAA violation that can cost a practice a significant fine. Employees must be mindful of their environment, restrict conversations regarding patients to private places, and avoid sharing any patient information with friends and family.

Thus, unless we bring in certain measures and protocols within our own systems to enlighten our own staff about HIPAA violations, just handing over certain workflows and processes to third-party vendors and assuming that security measures are in place will not help.

Regular training and audit checks of the various in-house systems and processes are a must to ensure that HIPAA violations are not being broken. Moreover, certain IT security measures too must be included in the audit to enhance security measures and Patient Health Information (PHI) from being hacked and lost.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. To know more about our medical billing and coding services, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.

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This type of unregulated data has the potential to paint a detailed health profile of an individual. It can also describe whole communities based on factors such as health conditions and location. Using this type of unregulated information, it becomes easy for data brokers to build reports on individuals and sell to marketers. In majority of such cases, consumers are left with no recourse to obtain or rectify their data.

• According to MobiHealth News, the data obtained by check-ins on Foursquare at fast food restaurants or wearable devices such as FitBit are not protected under HIPAA
• Health scores are not covered by these regulations too. These scores act like credit scores for a patient’s health that is not controlled by HIPAA
• Combination of different types of information such as consumer-generated data and historical claims data can be easily combined and used for health or financial-risk profiling. This type of information is purchased by hospitals, hedge funds, pharmaceutical companies, payers and large provider networks

Unfortunately, majority of consumers are not vigilant about their data protection. They are willing to share data in order to help hospitals, pharmaceutical companies or large provider networks serve goals related to public health.

Recently, a survey was conducted on more than 21,000 patients with medical health conditions in the US, asking their opinion on sharing personal health data through social media in the wake of HIPAA regulations.

• It was found that they were very open to the idea of online sharing of health information if it helped improve their health
• They were not reluctant in letting researchers learn more about their disease and come up with better treatment options
• Approximately 84% patients were ready to share health information with drug companies to help them make safer and effective products
• 94% patients were glad to share the information to improve care provision for future patients who may suffer from similar health conditions

The survey results give an indication that a new age in medicine has started. People are ready to share personal health data even after knowing that some of it is not covered under HIPAA regulations. This will surely help researchers come up with breakthroughs in medicine.

HIPAA-compliant Medical Billing Services

Not just patients but the providers also need to be careful about HIPAA compliance. In order to streamline billing and avoid HIPAA audits, many practices outsource their billing requirements to companies like Medical Billers and Coders (MBC).

MBC is one of the largest consortiums of certified coders and billers well-trained in handling HIPAA-compliant medical billing. The company serves 42 specialties spread all over the 50 states in the US, helping providers sail through reimbursement challenges.

The post Does HIPAA Cover All the Personal Health Data? appeared first on Medical Billing and RCM Blogs.

Many states in the US will expand and extend their Medicaid program to everyone under 133% of the federal poverty line in this year. The federal government will support this program for approximately three years by providing complete funding. Due to this, optometrists seeing Medicaid patients will witness a significant rise in number of people seeking treatment.

Even though states will receive monetary help for covering this population it will not translate into increased reimbursements for providers. The expansion is set to create a new patient dynamic, decrease in payment per transaction for optometrists. However, there will be a possibility of more transactions. Optometry practices may face some common challenges as other small practices in the healthcare industry. This will affect their staff as well as the treatment procedures.

Optometrists have increased inflow of patients because of health care reforms. Various services are being added to the care package and this has made optometry billing complicated. Some of the billing challenges faced by optometry practices are as follows:

• Lack of trained staff for data recording is one of the major billing challenges for optometrists. Since electronic health records (EHR) and electronic medical records (EMR) have become popular, your staff needs to be capable of recording patient data at real time. They must know how to collect the required information and record it with appropriate codes.

• Millions of Americans will get covered under Medicare by 2015 and a large number of patients are likely to come to your clinic. Billing and coding challenges will increase for  Medicare and Medicaid patients.

Practices need to check on their clearinghouse for rejections and improve their Accounts Receivable (AR) reports to ensure timely payments. Everything from patient access and opportunities to reimbursements are bound to change for optometrists due to the Act.

However, it will depend on the individual optometrist to understand what value he adds to the system and how he can prepare his practice for the potential challenges. The need is to capitalize on opportunities and manage the risks related to billing.

Bad debts, not adhering to the reforms of HIPAA for protected health information (PHI) are some additional challenges that can affect billing for optometrists. Since ACA will bring a lot of changes to optometry practices, it would be a good idea for providers to outsource their billing and coding requirements to companies like Medical Billers and Coders.

MBC is the largest consortium of coders and billers who are well-trained in handling billing and coding changes for optometry specialty. The expert team at MBC makes use of the latest software and technology to ensure timely payments, maximize revenue and minimize claims denials

The post Affordable Care Act Changes to Affect Optometry Billing in 2014 appeared first on Medical Billing and RCM Blogs.

Coders and billers are also responsible for ensuring secure electronic and physical transfer of sensitive data between these parties. If they make errors in this procedure, it can lead to federal investigations.  Therefore, providers need to streamline their medical billing process in order to avoid HIPAA violations.

Medical billing specialists should adhere to federal healthcare laws and regulations if they don’t want to get into legal hassles. In order to implement Electronic Healthcare System by the end of 2015, providers will have to let go of paper claim forms and handle electronic transactions. However, to do so, they will have to meet the privacy and security standards required by HIPAA.

• With electronic data transfer, all information related to patients finds its way into data files. If providers don’t maintain high standards of security, confidential patient information can reach wrong hands

• Providers will also have to create a compliance implementation plan and keep tracking the progress of the plan on a constant basis

• A staff should be assigned the work of ensuring that computers are password protected and sensitive areas are secure

• Coders should stay updated about Medicare policies, including compliance issues. They should act as the best resource for staying abreast compliance regulations

As a provider, you need to understand the importance of hiring coders and billers who are not only skilled in billing but also have extensive knowledge of medical terms, anatomy, computer skills and above all, knowledge of HIPAA regulations. If the billers and coders are not certified or experienced, it creates room for errors and HIPAA violations.

The role of coding and billing in today’s healthcare industry cannot be denied. Unless you have skilled staff, mistakes caused in billing and coding can slow down claim submission, causing delays in payment and data breaches. Such errors will not only prove to be costly for your practice but also affect your reputation among patients.

How to streamline your billing procedure?

Today, medical practices lack the time, money and resources to streamline billing tasks, comply with HIPAA, strengthen financial performance or enhance the quality of patient care. However, outsourcing has proved to be a boon for such providers who don’t want to give up their practice due to pressure caused by healthcare reforms.

Medical Billers and Coders (MBC) is the largest consortium of billers and coders in the US, offering effective HIPAA-compliant medical billing to practices. Our team performs medical billing operations, keeping your patient information confidential and secure.

MBC works with the aim to help practices eliminate the pain of hiring or training coders and billers, implementing EHRs and complying with HIPAA and other reforms. While we handle your medical billing requirements, you can concentrate on offering quality patient care.

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