Know Your Patient (KYP) Regimes – Bringing Amendments To Verification Process

By | June 7, 2022

The healthcare industry has a complex structure mainly because it deals with the most sensitive information. Criminals once they get their hands on this information, can easily manipulate it for personal benefits. For instance, fraudsters use the insurance details of legitimate patients to pay for their treatments. Furthermore, they use fake information to commit prescription fraud. 

Therefore, healthcare providers and other subsidiaries need to employ robust patient verification solutions. This is so to keep the legitimate patients’ data secure and restrict fraudsters from onboarding in the first place.

Regulatory authorities enforce laws like HIPAA, HITECH, and EMTALA in the healthcare sector to verify patients prior to giving any assistance. The blog covers major regulations that the healthcare sector is obliged to abide by. 

Patient Identity Verification – Global Regulations for Healthcare Sector 

The healthcare sector does not only refer to hospitals, it also involves clinics, nursing care centers, pharmacies, and others. All of these subsidiaries face medical scams at any stage. For instance, prescription fraud in the pharmaceutical industry and identity theft in hospitals.

This is why it has become necessary for every medicare provider to adhere to the Know Your Patient (KYP) standards. Firstly to verify patients, secondly, to keep the data updated, and thirdly to secure the information. 

Criminals use the information of other patients to apply for health-related benefits. Similarly, they avail insurance benefits and buy drugs by using forged prescriptions. Keeping all this view, regulatory authorities are enforcing the following strict regulations of the healthcare sector:

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA came into effect in 1996 as federal law for the healthcare sector to safeguard the patients’ records. Furthermore, it mandates all medicare providing centers to identify patients and get their consent before disclosing their information. HIPAA was followed by the Privacy Rule. 

This rule’s main purpose was to implement the standards set by HIPAA. As per the Rule, the healthcare sector should briefly inform the patients regarding their right to use and control personal information. Also, the medicare providers should protect this data from external breaches to ensure the legit patients are getting the treatment. 

The Health Information Technology for Economic and Clinical Health Act (HITECH)

The HITECH standardizes electronic health records keeping in the medicare sector. This type of Know Your Patient (KYP) act came into effect in 2009. Its main aim is to address the increasing patients’ concerns regarding information safety and security.

Furthermore, this act also maps the guidelines for healthcare providers concerning how to make use of technology in electronic data keeping and patient verification. 

HITECH not only provides these insights but also strengthens the US’s HIPAA act. Also, it obliges the Health and Human Service Office for Civil Rights (OCR) to keep the patients’ data secure and not share it with anyone without consent.

It further mandates OCR to make audits and impose hefty penalties on the medicare providers who fail to comply with identifying patient set standards. The maximum fine OCR can impose is up to $1.5 million per year. 

Centers for Medicare and Medicaid Services (CMS)

CMS falls under the jurisdiction of the Department of Health and Human Services (HHS). As per the guidelines CMS’s responsibility is to administer the healthcare providers. It is further responsible to monitor and supervise the Medicare center. 

CMS mandates healthcare centers to strictly incorporate the general health regulations and build patient identity verification in line with them. It further emphasizes the Electronic Health Records (ENR) program. This very initiative will minimize the need for paper-based health records.

Shufti Pro Funding indicates that patients can simply access their records online without having to face the chances of inaccurate entries. 

The Emergency Medical Treatment and Labor Act (EMTALA)

The Healthcare sector is the most complex among the rest of the other industries. Any breach or criminal exposure can leave the whole health of citizens at stake.

Previously, the regulations were focused on the patient’s age verification, validation of identities, treatments, and record-keeping. However, regulatory authorities have also enacted regulations to address emergency situations. 


As per Shufti Pro News, the EMTALA from the Know Your Patient (KYP) standards focuses on emergency treatments. It allows patients to access healthcare services even if they are unable to pay for insurance coverage. However, the healthcare providers should verify the patients and screen their records before providing the treatment.

Furthermore, the EMTALA mandates healthcare providers and medical coverage facilities to offer a screening of patients during the treatment. 

In Summation

The Healthcare sector is widely experiencing an increase in medical scams like identity theft, prescription fraud, and false insurance claims. Therefore, the regulatory authorities are imposing strict regulations on the medicare providers and their affiliates.

As per the laws, hospitals, pharmacies, and other subsidiaries should perform accurate patient verification prior to their onboarding and facilitation. Furthermore, the healthcare centers should keep the patients’ information secure from external breaches. Hence, the AI-powered Know Your Patient (KYP) solutions are the healthcare sector’s go-to options. 

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