Corporate Compliance

HIPAA and home care

Compliance Monitor, January 20, 2005

Q: Do the HIPAA regulations apply to private duty nurses hired privately by the patient to care for him or her at home and who do not work for an agency?

A: It's important to understand that HIPAA's definition of a covered healthcare provider is not based on the type of provider. It is based on the business practices of the specific provider, and whether certain transactions are performed electronically.

In this case, if the private duty nurse accepts payment from the patient and does not interact with the patient's health plan, then the nurse is not covered by HIPAA. However, according to HHS' Web site, HIPAA's administrative simplification regulations apply to "healthcare providers who conduct certain financial and administrative transactions electronically. These electronic transactions are those for which standards have been adopted by the secretary under HIPAA, such as electronic billing."

If the private duty nurse bills the patient's health plan (i.e., Medicare, an insurance company, etc.) electronically, or electronically checks the patient's eligibility to receive services under such a plan, then the nurse would be covered by HIPAA. The nurse would also be a covered entity if he or she uses a billing service that submits claims electronically.

This question was answered by Kate Borten, CISSP, CISM, president and founder of The Marblehead Group, Inc., a national healthcare consulting firm based in Marblehead, MA.

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