How to Secure EDI Transactions in Healthcare Effectively?

The health industry consists of many different components and processes. We often do not talk about data, but it is undoubtedly an integral part of practice management. Processing the high volume of health informatics needs a standardized system.   

Electronic data interchange (EDI) transactions securely transfer data across healthcare institutions, insurers, and patients with established message formats and standards. The EDI system addresses conversion errors, improves healthcare interoperability, and reduces data exchange and interpretation costs. Health plans, clearinghouses, and healthcare providers who exchange medical records electronically are obliged to implement uniform standards for all EDI transactions in healthcare HIPAA-compliant. EDI solutions ensure the security and accuracy of electronic health records. To integrate medical EDI, all entities must follow particular data specifications. For instance, if the information is transmitted to a receiver computer, it is converted into non-human language with the software for electronic data exchange. All documentation sets utilized by electronic data solutions are assigned standard codes.  

The Importance of EDI in Healthcare

Research indicates that 88% of hospitals constantly engage in health data exchange. However, the variability of information systems and lack of data standards generally becomes an obstacle   for the hospitals, causing them to miss out on leveraging public health data effectively. Electronic Data Interchange (EDI) enables secure and standardized data exchange between healthcare stakeholders, establishing a common language and format for transmitting information. For example, EDI transactions for healthcare like EDI 837 allow healthcare providers to electronically submit comprehensive claim information, eliminating the need for manual paperwork, thus reducing errors. EDI healthcare integration solutions also improve claim processing and adjudication, leading to quicker reimbursement and improved financial management.

Healthcare EDI Types

Healthcare organizations use ten types of HIPAA-compliant electronic data interchange software:  

• Healthcare claim transaction – allows providers and patients to submit claim information and access and share the data.  
• Retail pharmacy claim transaction– enables healthcare professionals and regulatory agencies to submit retail pharmacy claims. Additionally, this EDI software solution transmits claims for retail pharmacy services and medical billing payment information to payers.  
• Insurers utilize the healthcare claim payment/advice transaction to make payments to healthcare providers.  
• Benefits enrolment and maintenance- This healthcare EDI software is used by unions, government agencies, insurance agencies, associations, or healthcare organizations paying claims.   
• Payroll deducted and other group premium payments for insurance products- This EDI transaction in healthcare makes premium payments for insurance products. Providers use the electronic data interchange in healthcare to share information with financial organizations.  
• Healthcare eligibility/benefit inquiry- The electronic data interchange system helps healthcare organizations to send inquiries for healthcare benefits and subscriber eligibility to financial institutions and government agencies.   
• Healthcare eligibility/benefit response- The primary purpose of this electronic data interchange solution is to respond to request inquiries about the healthcare benefits and eligibility associated with a subscriber or dependent.   
• Healthcare claim status- This EDI healthcare allows healthcare providers to request or verify the status of healthcare previously submitted to a payer, such as an insurance company.  
• Healthcare claim status notification- The healthcare EDI enables reporting on the status of claims previously submitted by providers. Healthcare payers and insurance companies use this EDI in healthcare.  
• Healthcare service review Information- Hospitals use the EDI in medical billing to request authorization from a payer, such as an insurance company.

Navigating Challenges in Healthcare EDI

The implementation of healthcare EDI claims can be beneficial, but it also presents certain challenges. Effective solutions are needed to ensure seamless integration, regulatory compliance, and robust data security.

1. Complex Regulations

Organizations must navigate HIPAA and Administrative Simplification regulations, which require stringent requirements for Electronic Data Interchange healthcare transactions. Compliance can be challenging, therefore staying updated with evolving ASC X12 protocols is crucial. To ensure compliance, a dedicated team with programming expertise and HIPAA knowledge should be assembled to monitor updates and to build a strong foundation for successful EDI implementation while meeting healthcare industry standards.

2. Protecting Patient Data

Healthcare organizations must prioritize protecting sensitive patient data during Electronic Data Interchange (EDI) transactions to prevent data breaches. This involves establishing privacy protocols, conducting regular risk assessments, and keeping audit trails updated. Comprehensive security measures, including encryption, robust privacy protocols, and thorough risk assessments, are crucial. Collaborating with cybersecurity service providers can further strengthen defenses against cybercriminals accessing private information.

3. Interoperability and Legacy Systems

Healthcare organizations face the challenge of integrating Electronic Data Interchange (EDI) into their existing IT infrastructures, often including legacy systems. These systems may not be compatible with modern EDI development services, leading to potential disruptions or data degradation. To overcome this, healthcare organizations should invest in robust EDI solutions, either customizing software to work with legacy systems or gradually phasing out outdated systems. A well-planned integration strategy ensures EDI implementation enhances workflows and data management processes.

4. Training and Vigilance

Regular training is crucial for employees handling confidential data and accessing systems vulnerable to cyber threats. It’s essential to stay updated with evolving cybersecurity protocols and maintain a proactive stance against potential threats. Training sessions should emphasize the importance of adhering to established protocols to safeguard digital assets. By revising plans and staying updated with the latest cybersecurity developments, organizations can maintain a robust defense against cyber threats.

How EDI Works?

EDI transactions in healthcare involve a couple of steps, and let’s look at them. 

1. EDI Mapping

EDI mapping refers to transforming business files like PDFs, Excel, and Google Sheets created in healthcare admin applications into formats for EDI transactions in healthcare. EDI mapping and translation are important because EDI documents would not be readable and would be difficult to use without them. Healthcare EDI transactions come with built-in EDI mapping and translation connectors for HIPAA and HL7 documents, saving time invested in custom scripting.  

2. Testing and Validation

When EDI documents are created, they must be tested and validated to ensure accuracy. EDI transactions demand rigorous testing that uses a system known as Snip Levels. It involves verifying files across seven levels to ensure that every document contains all the essential data.   

3. B2B File Transfer

Standard EDI healthcare documents are sent from one partner to another, say the provider to the payer, pharmacy, or government agency. HIPAA regulations insist that EDI documents be exchanged to reach only the intended partner and no one else. Transfer of EDI files emphasizes encrypting, authenticating, and robustly securing file transfers.  

4. EDI Integration

Care providers and partners utilize electronic billing transactions with EDI software to translate them into usable formats through healthcare automation. This automation is a crucial ingredient of integrating EDI transactions because it promotes streamlined, end-to-end EDI data flows, reducing manual errors, improving accuracy, and saving time.

How to Make Your Healthcare System EDI Compliant

1. System Infrastructure and Process Assessment

Assessing healthcare system infrastructure and operational processes helps identify gaps and improve areas, laying the groundwork for implementing necessary changes for effective EDI compliance.

2. Integrating EDI-Capable Software

Selecting and integrating software solutions that support EDI functionalities is crucial for seamless data exchange, ensuring compatibility with existing infrastructure, streamlining processes, and facilitating efficient communication between healthcare stakeholders.

3. Staff Training on EDI Protocols

Educating staff on healthcare EDI solutions, protocols and procedures is crucial for successful implementation and compliance. Training programs should cover data security, transmission methods, error handling, and regulatory requirements, empowering staff with the necessary knowledge for smooth EDI for healthcare operations.

4. Compliance Monitoring

Continuous monitoring and evaluation are essential for ensuring long-term EDI compliance in healthcare systems. Regular audits and reviews help identify non-compliance issues, allowing timely resolution and adherence to EDI standards and regulations.

Conclusion

EDI transactions in healthcare are crucial to improving patient care quality, including integrated care or collaborative care services. EDI integration may seem complex, but it requires a high level of programming skills and practical knowledge of HIPAA compliant software development regulations. Team OSP has the necessary experience and skillset to build a custom EDI software that would perform well and comply with HIPAA regulations. We can help you successfully implement EDI transactions in healthcare.