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Medical Claims Processing: Medical Claims Processing Laws

Between dealing with physician, patient, and insurance data, staff in your billing department will be handling a lot of sensitive information. This is why it’s important for everyone in your billing department to understand the laws protecting that information and what they and the practice are responsible for, when it comes to the laws surrounding medical claims processing. Here are just two of the most important medical compliance agencies that medical billing specialists should be aware of.


HIPAA Regulations documents on a desk apex edi

Many people are at least aware of the existence of HIPAA, a set of guidelines that governs the way that medical information is protected. While HIPAA covers many aspects of patient protection, the part that applies most pressingly to those working with medical claims is found in Title II, which governs how and with whom patient data can be shared. HIPAA simplified the process of medical billing by providing universal identifiers for providers, employers, and patients, and by standardizing the requirements for electronic claims processing software.

Billing staff will be required to stay in compliance with HIPAA by protecting patient information and not sharing it with unauthorized parties. Medical practice employers should review HIPAA with all of their employees during the onboarding process.


The OIG was established to enforce HIPAA and prevent medical fraud. To remain in compliance with OIG, it’s important that medical billing staff refrain from activity that may be considered fraudulent. Fraudulent activity is generally classified as purposely falsifying information for benefit. At its worst, this involves practices providing false information on a patient’s medical record for financial gain. The OIG investigates and prosecutes practices that are found guilty of this type of behavior.

Best practices as outlined by these guidelines will help you keep yourself, your patients, your employees, and your practice safe.

At Apex EDI, we’re dedicated to making the medical claims process easier and helping medical practices get back to helping patients. We’re experts in medical claims processing policies and laws. We can help you better manage this confusing but important part of your practice.  We provide your practice with the tools and assistance necessary to cut down on claim denials and simplify medical claims filing.  Want to learn more? Request a demo today.

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Apex EDI, Inc.
556 E Technology Ave
Orem, Utah 84097
Support: (800) 840-9152
Sales: (801) 383-0388
Fax #: (801) 642-0333
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