The claims process involves the exchange of sensitive patient information, including protected health information (PHI), between healthcare providers, payers, billing companies, and other business associates. HIPAA was specifically enacted to protect the privacy and security of such information, especially as healthcare has transitioned to predominantly electronic forms of communication and record-keeping. HIPAA compliant email systems are designed to address the multifaceted requirements set forth by both the HIPAA Privacy Rule and Security Rule.
In a process where delays can be detrimental, the reliability and traceability of HIPAA compliant email are extremely useful. It doesn't come with the issues associated with traditional methods, which are prone to interception, data leakage, or unauthorized access. According to an Applied Clinical Informatics study titled ‘Evaluation of Secure Messaging Applications for a Health Care System: A Case Study’ noted concerns with using text messaging, “Accidental or unintended disclosure of ePHI through insecure text messaging located on portable devices puts health care organizations at risk for monetary penalties in addition to the direct risk to patient privacy.”
HIPAA compliant email provides encryption and ensures that unintended recipients cannot read messages containing PHI. It is particularly beneficial given the increasing frequency of healthcare data breaches, which often result from the use of noncompliant communication tools. HIPAA compliant email also supports the administrative simplification goals of HIPAA by easing communication between multiple parties involved in claims processing.
According to a journal article published in PRS Global Open ‘Revenue Cycle Management: The Art and the Science’ provided the following perspective on the revenue cycle, “Even though reimbursement rates for service codes are preset, and the service is documented, this apparently straightforward process is complicated by insurance payors, negotiated contracts, coding requirements, compliance regulators, and an ever-changing reimbursement environment.”
The revenue management process typically begins with patient preregistration, during which demographic, medical, and insurance information is collected to verify coverage, identify deductibles, and secure necessary referrals or preauthorizations. Accurate preregistration leads to downstream claim denials or payment delays. The next step is patient data verification. This step helps to avoid claim rejections due to mismatched or incomplete data.
Following verification, the charge capture phase commences immediately after care delivery. Concurrently, patient co-pays may be collected or recorded. The subsequent coding step requires the prompt and accurate assignment of standardized codes to ensure claims are correctly interpreted by payers and to avoid billing errors. Once coding is complete, claims are prepared and submitted to insurance payers using standardized forms, such as the CMS-1500 for outpatient services.
Before submission, claims are often scrubbed to detect and correct errors in formatting, coding, or documentation. After submission, the remittance processing phase begins, where payers review the claim and issue an explanation of benefits (EOB) or electronic remittance advice (ERA) detailing covered services, payment amounts, and reasons for any unpaid items. Payments are then posted to the provider’s accounts, and any discrepancies between expected and actual payments are reconciled.
The patient collections step follows, focusing on collecting any outstanding balances from patients through reminders, statements, or electronic communications. Finally, a process review is conducted to identify gaps, inefficiencies, or recurring issues within the revenue cycle.
According to the HIPAA Privacy Rule, PHI includes a broad array of data elements that can be used to identify a patient or their relatives, employers, or household members. The rule enumerates 18 identifiers that constitute PHI, such as names and geographic information smaller than a state.
In the claims process, PHI is routinely present in admission profiles, billing records, patient profiles, prescription records, referrals, discharge summaries, and follow-up appointment details. The process also involves the exchange of information regarding diagnoses, procedures, treatments, and payment details, all of which are considered PHI if they can be linked to a specific individual.
An excerpt from StatPearls ‘Patient Confidentiality’ does, however, note, “HIPAA broadly defines PHI as any health information transmitted or maintained in electronic media. It is also important to know that PHI is restricted to transmission not only on electronic media but also in any oral communications of identifiable health information that constitutes PHI.” Discussing a patient’s medical condition or billing details in a public area where unauthorized individuals could overhear constitutes a potential HIPAA violation.
One of the most pressing risks is the potential for unauthorized access, use, or disclosure of protected health information (PHI), which can occur when sensitive data is transmitted via unsecured channels such as standard email, SMS, or unencrypted messaging applications. These platforms lack the robust encryption and access controls mandated by the HIPAA Security Rule, making them vulnerable to interception, hacking, or inadvertent sharing with unauthorized parties.
The consequences of such breaches are multifaceted. From a legal and regulatory standpoint, violations of HIPAA can result in substantial monetary penalties, corrective action plans, and reputational damage. The Office for Civil Rights (OCR), which enforces HIPAA, has levied multimillion-dollar fines against organizations found to have failed in their duty to protect PHI, particularly in cases involving unencrypted devices or the absence of business associate agreements.
An example of this is when, on February 20, 2025, OCR fined Warby Parker $1.5 million for allowing hackers to access customers’ protected health information. A cyberattack exposed ePHI for nearly 200,000 individuals, including names, insurance details, and treatment data. OCR finds Warby Parker fails to implement adequate technical safeguards, violating the HIPAA Security Rule. OCR requires a corrective action plan to shore up security controls and prevent future breaches.
An email is considered HIPAA compliant when it incorporates a series of technical, administrative, and physical safeguards that collectively ensure the confidentiality, integrity, and availability of protected health information (PHI) during both storage and transmission. An Applied Clinical Informatics case study ‘Evaluation of Secure Messaging Applications for a Health Care System: A Case Study’ provided on the topic of compliance in messaging platforms, “To meet the basic security and usability requirements, the application must encrypt the message during transit and protect the message from unauthorized access.” The HIPAA Security Rule establishes clear requirements for the protection of electronic PHI (ePHI). The factors that make an email compliant include:
The claims process involves the frequent exchange of sensitive patient information, diagnoses, treatments, billing details, and insurance data between providers, payers, and business associates. The use of HIPAA compliant email ensures that this information is safeguarded against unauthorized access, interception, or disclosure. The protection is not merely a regulatory checkbox; it is the foundation upon which the reliability and effectiveness of the claims process rest.
By employing robust encryption, access controls, and audit mechanisms, HIPAA compliant email systems prevent data breaches that could result in harm. The secure and efficient transmission of claims-related information accelerates the reimbursement cycle, reduces administrative burdens, and minimizes the risk of claim denials or payment delays due to data loss or corruption.
Staff should receive training on how to identify and handle PHI, proper email encryption practices, recognize phishing attempts, and follow internal email policies.
HIPAA risk assessments for email systems handling PHI should be conducted at least annually, and more frequently if there are major changes in systems or workflows.
Patients can communicate with providers via HIPAA compliant email, but providers must obtain and document patient consent before starting email communication and ensure all security safeguards are in place.
Penalties for a HIPAA violation involving email communication can include fines up to $50,000 and imprisonment for up to one year for basic violations, with higher penalties for offenses committed under false pretenses or for personal gain.