The CMS National Standards Group, on behalf of HHS, administers the Compliance Review Program to ensure compliance among covered entities with HIPAA Administrative Simplification rules for electronic health care transactions.
In April 2019, HHS randomly selected 9 HIPAA-covered entities—a mix of health plans and clearinghouses—for compliance reviews. HHS piloted the program with health plan and clearinghouse volunteers to streamline the compliance review process and identify any system enhancements. In 2019, providers were able to participate in a separate pilot.
More information on the Compliance Review Program
The 2021 Compliance Review Program Findings report includes updates to the lists of common violations of standards and operating rules from Compliance Reviews.
The Compliance Review Program Findings report includes common violations of standards and operating rules from Compliance Reviews.
Watch the CMS video about the Compliance Review Program to learn about why compliance reviews are important for the health care industry and how they are conducted.
Learn the process CMS uses to conduct compliance reviews in this infographic.
Why Compliance Reviews?
Health care providers, health plans, and clearinghouses have encouraged HHS to take proactive steps, including reviews, to ensure compliance with Administrative Simplification transaction standards, which reduce the administrative burden on the health care industry.
HHS’s proactive approach implements a progressive penalty process with the goal of remediation. If an organization isn’t compliant, HHS will work with the entity to resolve any issues. Corrective Action Plans are commonly used to address non-compliance. In cases of willful and egregious noncompliance, monetary penalties may be assessed and calculated on a case by case basis.
Provider Pilot Program
The CMS National Standards Group, on behalf of HHS, launched a volunteer Provider Pilot Program to test the compliance review process and to gain insight on compliance with HIPAA Administrative Simplification rules among providers. This followed a successful pilot program for health plans and clearinghouses completed in 2018.
In April 2019, HHS selected 3 health care providers from the pool of volunteers to participate.
Learn more about the Provider Pilot Program: