HIPAA Transaction Adoption Rates

CAQH (Council for Affordable Quality Healthcare) conducts an annual study of the adoption rates for commonly used HIPAA transactions in the healthcare industry.  A copy of this study can be obtained through this link:


This data is for the 2013 calendar year.  Based on the comments provided in the report, it is apparent that they feel that there has been significant progress in the implementation of these transactions.  As a vendor that provides systems that use them in revenue cycle management, the growth seems painfully slow.

The summary table on page 4 of the report shows the adoption rates for calendar year 2013 by transaction type.  The highest being claims at 92% and the lowest being prior authorization at 35%.  However, this study includes web portals provided by health plans to providers for the entry of these transactions.  In my opinion, these systems are not truly HIPAA transaction processing systems since the provider side of the system is still completely manual.

I believe that the actual adoption rates of claim status, eligibility and prior authorization systems is significantly lower than these rates, probably less than half, if you only count systems that are automated at each end.   The claim and remittance statistics are probably accurate since there aren’t many health plan portals for claim entry and electronic remittance data is provided one way, health plan to provider, in batch mode using the 835.

The unique feature of this study is that it has a predecessor.  They did the same study in 2013 for the 2012 calendar year.  If you compare the two, it is especially depressing.  Here are some numbers from Table 2 on page 5:

Claims Submission 2012 – 90.2% 2013 – 91.8%
Eligibility 2012 – 64.7% 2013 – 65.3%
Prior Authorization 2012 – N/A  2013 – 6.7%
Remittance Advice 2012 – 42.7% 2013 – 46.4%

This is especially concerning when you take into consideration that Medicare conducts 100% of their claims, eligibility and remittances using the HIPAA electronic standard, which further pads these stats.

Through the ACA, plans are in place to introduce deadlines for health plans to conduct these transactions through fully automated systems that will process them in a HIPAA compliant format and be fully automated at each end, like CMS.  These standards have been in place for nearly twenty years now, it is obvious that market forces and the mutual cost/benefit promised through HIPAA legislation is not enough to make adoption happen.

Providers became fully compliant when they became capable of conducting these transactions with CMS for Medicare claim processing.  This technology can be easily applied to every other health plan by provider system vendors.  It is time for the insurance industry to step up, bite the bullet and accommodate these provider systems capable of dealing with them directly, without a “portal”.  The full benefits for health plans and providers won’t begin until they all start using them.


By Kalon Mitchell, President – MEDTranDirect

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