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HIPPA REGULATION: Privacy Overview

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There are three major areas addressed in the Privacy Regulation: 1. Use and disclosure of PHI, 2. Patient rights 3. Security administrative and physical

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Business Associates

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can be held directly accountable by federal or state authority for failure to comply with HIPAA statutory or regulations. ex. IT techs, Janitors, Cleaning Services, Vendors, Collection agencies, Consultants and Billing Services.

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Entities

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ex. doctors, hospitals, pharmacy

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Breach

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unauthorized acquisition access, use or disclosure of protected health information, ex. ALGH issue on breach where health info was spread with no consents from patients.

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What is NOT considered a breach?

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1. Where an authorized person who received the health info. cannot reasonably have been able to retain it. 2. If an unintentional acquisition, access, or use occurs within the scope of employ. and info doesn't go any further. 3. If it is an inadvertent disclosure that occurs within a facility, and the information does not go any further.

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Tiered Increase in Civil Monetary Penalties

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HIPPA violation at $50,000 per violation and an annual maximum of $1.5million.

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What are examples that could not result in HIPPA violation by DHHS?

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-Overheard phone or nursing station conversation -Joint treatment areas -Sign-in sheets -Calling names in reception areas -Hospital rounds Solutions would be to speak quietly, cubicles, curtains, dividers, asking patients to step back, or closing doors.

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Health Information (PHI)

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Any info. whether oral or recorded in any form or medium that is created or received by a health care provider, health, plan public health authority, employer, life insurer, school or university, or health care clearinghouse, and related to the past, present or future physical or mental health or condition.

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Individual Identifiable Health Information (IIHI)

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Information that is a subset of health information, including demographic, information collected from an individual.

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Identifiers

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-Email address -Social Security number -Medical record number -Vehicle identifier -Full face photograph

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The Notice of Privacy Practices should be...

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In a written language, tape, or video that the patient understands, be clearly posted in the practice or facility, and if applicable, on the practice website.

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Fraud

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the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowingly that the deception could result in some unauthorized benefit to himself/herself or some other person. ex. Billing for services that were not furnished and or supplies that were not provided -Billing for services as if performed by a particular entity when they were, in fact, performed by another entity not eligible to be paid by Medicare -Using in incorrect or inappropriate provider number ni order to be paid (using a deceased provider number to defraud Medicare).

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Abuse

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describes practices that either directly or indirectly result in unnecessary costs to the Medicare Program. Acts committed knowingly, willfully and intentionally. ex. Charging in excess for services or supplies Providing medical unnecessary services

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Whistleblower

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or the "qui tam" provision as it is formally called allows a person that has knowledge of a false claim against the government to bring an action against the suspected wrongdoer on behalf of the U.S. government.

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Relator

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a person that files a qui tam suit on behalf of the government and may share a percentage of the recovery realized from a successful action ex. patient, disgruntled former employee or other business contact.

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OIG Compliance Plan

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There are seven steps

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Primary goal of OSHA

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To reduce injuries, illnesses and death, and to provide leadership and encouragement to employees and workers to help recognize and realize the value of safety and health on the job.

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Compliance Safety and Health Officers CSHO

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designated individuals from OSHA who could inspect your facility for one of five reasons: 1. Employee complaints 2. Fatalities 3. Routine inspections for High Hazard 4. Catastrophes (3 or more hospitalized) 5. General inspections (Rare)

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OSHA Penalties and Fines

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up to $7,000 for each violation

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OSHA bloodborne: Exposure Control Plan (ECP)

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At a minimum the ECP is reviewed and updated annually to reflect new or modified tasks and procedures with potential exposure.

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Personal Protective Equipment PPE

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Should be provided to employees in appropriate sizes at no cost and is readily accessible ex. gloves S, M, L

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Hepatitis B Vaccination

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Offered to all employees at risk of occupational exposure at no cost. Vaccines should be given after training and within 10 working days of initial assignment. Those employees who initially decline, but request the vaccine at a later time are provided the vaccine within 10 days of the request.

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Recordkeeping

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Training records contain the dates of training, sessions, summary of training, names and qualifications of the trainers, names and job titles of the trainees and are maintained for 3 years.

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Medical Records are kept for...

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duration of employment, plus 30 years thereafter.

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OSHA Illness and Injury and Sharps Logs

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for employers with 11 or more employees at any time in the previous year, forms should be kept for 5 years from year represented.

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Automated Reviews RAC Audit

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when there is certainty that an overpayment or underpayment exists, but there is no written policy, article or guideline. For example, duplicate claims or pricing mistakes.

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Complex Reviews RAC Audit

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RACs will make claim determinations utilizing a "human review" of the relevant medical records and there is high probability that the service is not covered by Medicare policy or coding guideline exists.

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Administrative Simplification

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Provisions of HIPPA mandate that the federal government adopt national standards for the electronic exchange, storage and handling of health care data between health care payers, plans and providers.

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Fair Labor Standards Act (FLSA)

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requires employers to keep records on wages and hours worked.

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Payroll Violation

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Willful violation can carry a fine up to $10,000

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Exempt

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paid salary. ex. Administrative assistants, personnel directors, office managers, and laboratory supervisors.

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Non-exempt

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meet requirements for overtime pay. After working there 40 hours a week and will get pay one and a half times there regular pay. ex. Nurse aides, LPN, Janitors, Clerical work, Lab tech assistants.

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Training Records

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retain for 3 years.

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Wage records

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retain for two years

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Posters required to post by employers under federal law..

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Age Discrimination Child Labor Family and Medical Leave Polygraph Testing Safety Requirements

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Sexual Harassment

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consists of making an employee "uncomfortable" in the workplace based on sex.

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"Quid Pro Quo"

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cases in which the employee is threatened or suffers job detriment or retaliation for refusing to concede to sexual demands.

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Anti-Discrimination Rules for the American Workplace

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law requires employer to provide reasonbile accommodation to employee or job applicant with a disability.

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Disability

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those who have an impairment that "substantially limits" one or more major life activities.

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Undue Hardship

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a business is not required to provide accomodations to disabled individuals, this definition woulc cause a significant difficulty or expense ex. -nature and cost of accommodation -size, type and financial resource -type of operation

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HIV+Employee

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An employee can be required to submit to an HIV test unless it is a bona fide occupational requirement.

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Pregnancy Discrimination Act

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makes it unlawful to discriminate on woman based on their pregnancy, childbirth or related medical condition. Unlawful not to hire or promote if ability exists.

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Polygraph Protection Act

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requires that a notice be posted where all employees can see the protections listed under the act ex. -To written notice prior to testing -To refuse or discontinue the test -Not to have disclosure of the results to unauthorized persons.

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Key person insurance or "Key man"

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can be anyone directly associated with the business whose loss can cause financial strain to the business.

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Provider Patient-Relationship

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it continues until it is ended by one of the following circumstances -The patient has no need for further care -The patient terminates the relationship -The provider formally terminated the relationship

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Patient Termination Guidelines

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1. Send patient certified return letter, termination may or may not be stated on the letter 2. if termination is due to noncompliance say so clearly on the letter 3. Avoid stating reason in writing if there's a personality conflict, an unpaid bill, or for a reason not to be made public. 4. Keep the receipt for the certified letter in patients chart with a copy of the letter.

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Jousting

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never criticize or make derogatory comments about another healthcare professional or organization to the patient or in the medical record.

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Electronic Health Record

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primary purpose of an EHR adoption should be to make a medical practice more efficient by reducing the costs and the time it takes to perform a specific task.

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ICD-10 Major Changes

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-Alphanumeric codes -Expanded injury codes, grouped according to site rather than type of injury -Combination of diagnosis/symptom codes

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Common employee barriers to ICD-10

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1. Resistant to change 2. Comfortable with old system 3. Opt for retirement 4. Need to spend money for learning new coding system 5. Coding of numerous medical records may be time consuming.

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Management

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means to "bring about" to have charge of or responsibility for; conduct.

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Leadership

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is to influence and establish personal, professional, and practice goals.

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Equity Theory

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each person responds to his surroundings based on their own subconscious judgment of equality.

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Level One: Maslow's Hierarchy of Need

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Physiological, the most basic need air, water, sleep, food.

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Staff Meetings Benefit

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-pay off -increase productivity -generate better decisions -there the best vehicle for effective communication

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Average Active Listener

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retainer only about 50% of a conversation

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Questions NOT legally asked in a interview

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-Race -Religion -Sex or age -Martial status -Arrest records -Place of birth -Number of children

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People Pleaser

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this type of person may tend to be fickle and unreliable

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Troublemakers

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investigate the reasons for any inappropriate behavior.

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Freeloaders

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a person that talks a lot and does very little

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Silent employees

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ask for elaboration, typically a poor listener so summarize main points to make sure they heard you and understood

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Formal Budget

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allows for determining what must be accomplished financially at least a year in advance

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Formalized Budget

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forces the office supervisor to analyze expenditures and eliminates many unnecessary purchases.

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Budget

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assists the practice in measuring projected financial goals with the actual financial performance

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Budget information should be shared...

answer

with the staff so they can participate in effective cost controls.

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Actual Status

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report indicating financial operations of the last reporting period that can be for a period of one, three, six or twelve months and can also be obtained from past reports.

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Projected Status (soft data)

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report indicating the financial situation for the next reporting period.

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Accounts payable A/P

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bills that the practice owes to vendors

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Accounts receivables A/R

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are the amounts owed to you by your patients

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Average Billing per Patient

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Total Billing per month or year/Number of patients by month or year

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Average Cost per Patient

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Total variable expenses per month or year/Total patients by month or year

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Average Net Charges per Patient

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Total net collection per month or year/Total number of patients by month or year

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Charge off

answer

accounts receivable that will likely remain uncollectable and will be written off as collection or bad debt. (Appears as an expense to the practice income statement, thus reducing net income.

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Credits

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increase liabilities and equity and decrease assets.

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Direct Expense

answer

are directly related to a cost center

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Expense to Earnings ratio

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called overheard ratio. Total expenses/total collection

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Fixed Expense

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do not very with the volume of services. Examples would be rent, insurance, loan payment, etc. (Will always be every month).

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Gross Monthly Collection ratio

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Total Collections/Gross or net charges (percentage answer)

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Income Statement

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a record of the financial "performance" of a business (ability to make money) over a period of time. Also called a P&L, profit or loss statement.

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Indirect Expense

answer

expense that is NOT directly related to the service. Examples, clinical lab and the space occupied, utilities and cleaning services.

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Net Monthly Collection Ratio

answer

Total collections/total charges-adjustments

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Overhead

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the ongoing administrative and clinical expenses of the medical practice necessary for the business to function.

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Ratio

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the number resulting from one number being divided into another number (division)

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Total Expense per patient

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Total expense/number of patients

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Variable Expenses

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expenses that are incurred directly proportional to the number of patients seen and services rendered. Examples, medical, office supplies and medications.

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Budget Planning

answer

for optimum results evaluate the past 3 years of income and expense in order to prepare your projected budget. Hint*A good manager will plan a budget a year in advance.

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What influences your budget?

answer

-Inflation (barrier) -HIPPA (to be compliant) -OSHA (Providing that annual training being compliant) -Having a billing compliance plan -New Services (Medicine changes) -Labor Costs (finding qualified people) -Competition (Location, Services, Marketing)

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Forecasting

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to make an estimate of the number of new patients visits over the past 3-4 years.

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High overhead

answer

suggests at least some -low patient volume -excess expense -overstaffing or inefficient staffing -poor managed care contracts

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Low overhead

answer

normally seen as a "positive" indication it can indicate an underlying problem for the future -inequitably high fees -lack of proper patient management -failure to deliver high quality medical care -understaffing or low salary

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Strategic Plan

answer

working with outside consultants is vital. An up-to-date plan helps the owners/physicians ascertain the current position of the practice, and hopefully where it is going in the future.

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Flash report

answer

should be short and straight to the point its an excellent method of communicating patient stats and financial information.

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Net charges

answer

Gross-adjustments=net charges

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Why Dollars Lost?

answer

4 main reasons why dollars get lost in practices -Poor financial management -Incorrect coding -Lack of third party payer knowledge -Lack of employee education

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Collecting co-pay for divorced cases

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the adult seeking treatment is responsible for the bill. The person bringing the child is still responsible to you for payment, the patient can bill their estranged, but not responsibility of the practice.

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Contract Law*

answer

in order to bill insurance there needs to be a SSN in place as an identifier of the patient and to improve on identity theft.

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Federal Fair Credit Billing Act

answer

"to protect the consumer against inaccurate and unfair credit billing"

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Fee Schedule Changes to consider...

answer

competition is a factor to consider when making changes to a fee schedule

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Embezzlement

answer

occurs when someone fraudulently signs or alters documents, usually checks, with change to the financial obligations of the practice.

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Managed Care Accrediting Organizations

answer

-National Committee for Quality Insurance (NCQA) -Joint Commission on Accreditation of Healthcare (JCAHO) -American Accreditation HealthCare Commission (AAHCC) -Medical Quality Commission (MQC)

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Preferred Provider Organization PPO (In Network and Out of Network)

answer

In Network: contracted providers. Patients will have, -Low Co-pay -Low Deductible -Little out-of-pocket expense Out of Network: go outside of the contract physician list. -High deductible -High Co-pay -High out-of-pocket expense

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Silent PPO

answer

plan that has two ways to access your contracted discount fee. behind the scenes take your info and give a less reimbursement.

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Health Maintenance Organizations (HMO)

answer

Typically have a co-pay that there responsible for and require referral for specialists, typically every three months.

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Types of HMO's

answer

Group Model-private practice physicians, including hospitals Network Model-contracts with one or more multi-specialty clinics Staff Model-providers are employees of HMO and they provide services to those HMO beneficiaries

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Independent Practice Associates IPA

answer

a separate legal entity that can either organize physicians and contact on their behalf with MCOs to provide services

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Medical Service Organizations MSO

answer

-Target small practices -own employees for the practice -they can lease equipment -the docs will pay some monthly fee for the service

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Capitation

answer

known as per member per month. form of reimbursement used most commonly by HMOs to compensate primary care physicians for their services.

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Fee for Service

answer

form of reimbursement is the most familiar type of to physicians. A physician agrees to provide a specific service for a fee lower than his/her regular charge

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Authorization

answer

approval for services, including diagnostic services and inpatient or outpatient treatment.

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Concurrent Review

answer

involves the ongoing evaluation of treatment for appropriateness and necessity during the course of that treatment.

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Claim filing questions to ask...

answer

-What are the time limits for claim submissions? -Can you track your charges and payments? -How long does it take to pay a "clean claim"

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General Contract Provisions (Hold Harmless)

answer

2 Types a) The patient is held harmless financially if the plan goes bankrupt ex. cannot bill the patient b) The plan is held harmless for outcomes due to treatment decisions made by the provider.

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Withhold

answer

relation to risk pool. Dollars that are set aside that may be returned to the doctor if other docs included in risk pool watches utilization and cost of providing services

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Payer Reinsurance

answer

purchased by primary insurers to protect against excessive claim

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Resource-Based Relative Value Scale (RBRVS)

answer

value scale was developed for CMS for Medicare reimbursement

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Stop-Loss

answer

insurance coverage in the event of unexpected financial loss to the plan or provider

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PECOS

answer

Medicare's internet-based provider enrollment is also known

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SOAP

answer

Subjective, Objective, Assessment, Plan

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