The National Standards Group (NSG) released an updated Compliance Review Program Findings report identifying the most common violations of standards and operating rules from compliance reviews. The report expands on the report released in July 2021 and includes insights from 19 additional reviews.
The Compliance Review Program aims to promote compliance with HIPAA Administrative Simplification rules for electronic healthcare transactions. Since the program launched in April 2019, NSG has initiated 39 compliance reviews with 35 health plans and four clearinghouses.
The Centers for Medicare & Medicaid Services NSG, on behalf of the US Department of Health and Human Services, administers the Compliance Review Program. The US healthcare system could save an estimated $20 billion a year if all covered entities complied with required standards and operating rules for electronic transactions.
In July 2021, NSG released a Compliance Review Findings report summarizing common violations identified in the 15 compliance reviews that completed the assessment process between April 2019 and March 2021. An additional 19 compliance reviews completed the assessment process between April 2021 and March 2022.
While the specific violations identified in the report vary slightly from those identified in prior report, the three most common transaction types experiencing violations remained constant.
The most common 2021 violations involved:
- The N1 Payee Identification segment in Loop 1000B and the NM1 Service Provider Name segment in Loop 2100. Covered entities used an invalid National Provider Identifier (NPI) number.
- The LQ segment in Loop 2110. Covered entities failed to include an appropriate Remark code in segment LQ when using a Claim Adjustment Reason Code (CARC).
- The SVC Service Payment Information segment in Loop 2110. Covered entities used invalid Healthcare Common Procedures Coding System (HCPCS) codes and modifiers in sub elements SVC01-02 and SVC01-03.
To read the report, visit the CMS website.