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HIPAAsuite: The Experts in EDI Healthcare

 Martin Scholl, President
Martin Scholl first encountered HIPAA Electronic data interchange (EDI) in 2001 and saw that a lot of money could be saved by standardizing the most common transactions in the healthcare industry. Now, 15 years later the President of HIPAAsuite sees that EDI has been widely adopted and claims are now 95 percent plus in the electronic form. “It was then when I developed the first HIPAA Claim Printer, a tool to print or display EDI claims as HCFA-1500 or UB92 claim forms. This product allowed numerous entities to deal with 837 claim files, by printing them to paper and manually entering them,” he begins. “Today our company has transitioned to offering an entire suite of HIPAA EDI solutions with several hundred clients throughout the USA.”

According to Scholl, the lack of enforcement has created a fractured healthcare landscape where some providers can do certain aspects of EDI while a few payers are still not able to do more than accept 837 claims. “Many are not able to take advantage of all the new EDI automation offerings owing to the lack of advanced compliance solutions with the CORE real-time requirements. Adding to this hindrance is the cost of solution,” adds Scholl. HIPAAsuite offers the ability to load claims into a database and with the adjudication module of HIPAA Claim Payment Master, users are able to arbitrate and pay claims including the resulting 835, 277CA and receive and respond to 276 in real time with HIPAA RealTime Server. “We can even create the CCD+ transaction to initiate an electronic payment as the Committee on Operating Rules for Information Exchange (CORE) Phase III requires. The complete life cycle of a claim can now be handled in HIPAAsuite and our customers can comply with the ever increasing regulations with a clear path forward,” explains Scholl.

Complete HIPAA Solutions

Scholl knows that at the first glance, an EDI claim is utterly confusing as it is made for electronic data exchange between computers. But through close inspection, it is a highly structured document that contains provider information, patient/subscriber information, the condition and diagnosis of what led to the healthcare incident and lastly the procedures that make up the claim. “Our claim entry/edit screens are build around this data structure and empower the user to see the claim as an event that needs a complete description,” asserts Scholl. The HIPAA Claim Master extracts the claims from an 837 file; it can display claims as a standard healthcare claim form such as the CMS-1500 or UB04, which makes it easy to read the claim for non programmers and case workers. Claims can also be edited down to the smallest detail in the claim master and can be saved to any database and retrieved at any time and packaged as 837 EDI file.

The company assists mainly small to mid-size healthcare payers in achieving HIPAA compliance by acting as a middleware for these organizations’ home grown systems. “We handle EDI data in their full complexity and an existing system takes only what data elements they need.

Our CORE certified HIPAA RealTime Server is a self hosted IP server that listens for SOAP and MIME requests


Conversely, the legacy system feeds adjudication and status information back and HIPAAsuite software creates the follow up transactions like 835, 277, 999,” explains Scholl. Once the interfaces are built, clients can resume to their business without the need to rewrite their system or even change to new software that is in itself HIPAA compliant.

Another key area where the software is used is communications with the Health Insurance Exchanges (HIE), the federal as well as the state exchanges that Obamacare has established. “The communications between HIE and plan provider is mainly EDI. The HIE sends an 834 enrollment transaction with newly enrolled members. The plan provider then enters them in their system and responds with the same 834 plus information from their system back to the HIE,” asserts Scholl. Similarly the premium payments are collected by the HIE, at least the first three months and then passed through to the plan provider. The payments are accompanied by an 820 transaction. “Our HIPAA Enrollment Master and our HIPAA Premium Payment Master handle this information exchange for numerous clients,” explains Scholl.

Recently, CareOregon approached HIPAAsuite as they needed a real time eligibility solution. As a longtime client of HIPAAsuite for claim processing, CareOregon installed the HIPAA RealTime Server solution and within a few weeks their programmers devised a nightly process to export member eligibility into our HIPAA Eligibility Responder software. “We are strictly HIPAA EDI and understand healthcare. We constantly tinker with our products, make them better, stay up with the latest programming techniques and languages,” adds Scholl.

The future of HIPAAsuite

The company is working on an online claim entry app that the customers can brand and deploy. HIPAAsuite’s vision is a browser based app that allows anyone, anywhere to enter a HIPAA compliant healthcare claim. “Anyone with a smart phone will be able to enter a valid and compliant claim that can be exchanged via 837 EDI files,” asserts Scholl. HIPAAsuite’s next business roll out will be a subscription licensing model to ‘rent’ their software. With the roll-out of their new Visual Studio 15 based software they have introduced a new licensing module that tracks use with a central license server. “Now we can offer monthly leases of our software products and we have the ability to turn the usage off in case a contract is terminated,” explains Scholl.

Having built HIPAAsuite from ground up without any financial assistance, Scholl has taken the company to new heights with hard work and determination. “Now we are at a point where the products have been developed, tested, and proven to add value to our customers. We are investing in marketing and sales while automating our systems with CRM integration,” says Scholl. “But this might also be the time to partner with a larger company with better sales support and infra-structure and to invest in HIPAAsuite to further increase our market share.”