CMOM-Practice Management Institute

HIPPA REGULATION: Privacy Overview
There are three major areas addressed in the Privacy Regulation: 1. Use and disclosure of PHI, 2. Patient rights 3. Security administrative and physical
Business Associates
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.
ex. doctors, hospitals, pharmacy
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.
What is NOT considered a breach?
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.
Tiered Increase in Civil Monetary Penalties
HIPPA violation at $50,000 per violation and an annual maximum of $1.5million.
What are examples that could not result in HIPPA violation by DHHS?
-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.
Health Information (PHI)
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.
Individual Identifiable Health Information (IIHI)
Information that is a subset of health information, including demographic, information collected from an individual.
-Email address
-Social Security number
-Medical record number
-Vehicle identifier
-Full face photograph
The Notice of Privacy Practices should be…
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.
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).
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
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.
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.
OIG Compliance Plan
There are seven steps
Primary goal of OSHA
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.
Compliance Safety and Health Officers CSHO
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)
OSHA Penalties and Fines
up to $7,000 for each violation
OSHA bloodborne: Exposure Control Plan (ECP)
At a minimum the ECP is reviewed and updated annually to reflect new or modified tasks and procedures with potential exposure.
Personal Protective Equipment PPE
Should be provided to employees in appropriate sizes at no cost and is readily accessible ex. gloves S, M, L
Hepatitis B Vaccination
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.
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.
Medical Records are kept for…
duration of employment, plus 30 years thereafter.
OSHA Illness and Injury and Sharps Logs
for employers with 11 or more employees at any time in the previous year, forms should be kept for 5 years from year represented.
Automated Reviews RAC Audit
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.
Complex Reviews RAC Audit
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.
Administrative Simplification
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.
Fair Labor Standards Act (FLSA)
requires employers to keep records on wages and hours worked.
Payroll Violation
Willful violation can carry a fine up to $10,000
paid salary. ex. Administrative assistants, personnel directors, office managers, and laboratory supervisors.
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.
Training Records
retain for 3 years.
Wage records
retain for two years
Posters required to post by employers under federal law..
Age Discrimination
Child Labor
Family and Medical Leave
Polygraph Testing
Safety Requirements
Sexual Harassment
consists of making an employee “uncomfortable” in the workplace based on sex.
“Quid Pro Quo”
cases in which the employee is threatened or suffers job detriment or retaliation for refusing to concede to sexual demands.
Anti-Discrimination Rules for the American Workplace
law requires employer to provide reasonbile accommodation to employee or job applicant with a disability.
those who have an impairment that “substantially limits” one or more major life activities.
Undue Hardship
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
An employee can be required to submit to an HIV test unless it is a bona fide occupational requirement.
Pregnancy Discrimination Act
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.
Polygraph Protection Act
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.
Key person insurance or “Key man”
can be anyone directly associated with the business whose loss can cause financial strain to the business.
Provider Patient-Relationship
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
Patient Termination Guidelines
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.
never criticize or make derogatory comments about another healthcare professional or organization to the patient or in the medical record.
Electronic Health Record
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.
ICD-10 Major Changes
-Alphanumeric codes
-Expanded injury codes, grouped according to site rather than type of injury
-Combination of diagnosis/symptom codes
Common employee barriers to ICD-10
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.
means to “bring about” to have charge of or responsibility for; conduct.
is to influence and establish personal, professional, and practice goals.
Equity Theory
each person responds to his surroundings based on their own subconscious judgment of equality.
Level One: Maslow’s Hierarchy of Need
Physiological, the most basic need air, water, sleep, food.
Staff Meetings Benefit
-pay off
-increase productivity
-generate better decisions
-there the best vehicle for effective communication
Average Active Listener
retainer only about 50% of a conversation
Questions NOT legally asked in a interview
-Sex or age
-Martial status
-Arrest records
-Place of birth
-Number of children
People Pleaser
this type of person may tend to be fickle and unreliable
investigate the reasons for any inappropriate behavior.
a person that talks a lot and does very little
Silent employees
ask for elaboration, typically a poor listener so summarize main points to make sure they heard you and understood
Formal Budget
allows for determining what must be accomplished financially at least a year in advance
Formalized Budget
forces the office supervisor to analyze expenditures and eliminates many unnecessary purchases.
assists the practice in measuring projected financial goals with the actual financial performance
Budget information should be shared…
with the staff so they can participate in effective cost controls.
Actual Status
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.
Projected Status (soft data)
report indicating the financial situation for the next reporting period.
Accounts payable A/P
bills that the practice owes to vendors
Accounts receivables A/R
are the amounts owed to you by your patients
Average Billing per Patient
Total Billing per month or year/Number of patients by month or year
Average Cost per Patient
Total variable expenses per month or year/Total patients by month or year
Average Net Charges per Patient
Total net collection per month or year/Total number of patients by month or year
Charge off
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.
increase liabilities and equity and decrease assets.
Direct Expense
are directly related to a cost center
Expense to Earnings ratio
called overheard ratio. Total expenses/total collection
Fixed Expense
do not very with the volume of services. Examples would be rent, insurance, loan payment, etc. (Will always be every month).
Gross Monthly Collection ratio
Total Collections/Gross or net charges (percentage answer)
Income Statement
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.
Indirect Expense
expense that is NOT directly related to the service. Examples, clinical lab and the space occupied, utilities and cleaning services.
Net Monthly Collection Ratio
Total collections/total charges-adjustments
the ongoing administrative and clinical expenses of the medical practice necessary for the business to function.
the number resulting from one number being divided into another number (division)
Total Expense per patient
Total expense/number of patients
Variable Expenses
expenses that are incurred directly proportional to the number of patients seen and services rendered. Examples, medical, office supplies and medications.
Budget Planning
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.
What influences your budget?
-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)
to make an estimate of the number of new patients visits over the past 3-4 years.
High overhead
suggests at least some
-low patient volume
-excess expense
-overstaffing or inefficient staffing
-poor managed care contracts
Low overhead
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
Strategic Plan
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.
Flash report
should be short and straight to the point its an excellent method of communicating patient stats and financial information.
Net charges
Gross-adjustments=net charges
Why Dollars Lost?
4 main reasons why dollars get lost in practices
-Poor financial management
-Incorrect coding
-Lack of third party payer knowledge
-Lack of employee education
Collecting co-pay for divorced cases
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.
Contract Law*
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.
Federal Fair Credit Billing Act
“to protect the consumer against inaccurate and unfair credit billing”
Fee Schedule Changes to consider…
competition is a factor to consider when making changes to a fee schedule
occurs when someone fraudulently signs or alters documents, usually checks, with change to the financial obligations of the practice.
Managed Care Accrediting Organizations
-National Committee for Quality Insurance (NCQA)
-Joint Commission on Accreditation of Healthcare (JCAHO)
-American Accreditation HealthCare Commission (AAHCC)
-Medical Quality Commission (MQC)
Preferred Provider Organization PPO
(In Network and Out of Network)
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
Silent PPO
plan that has two ways to access your contracted discount fee. behind the scenes take your info and give a less reimbursement.
Health Maintenance Organizations (HMO)
Typically have a co-pay that there responsible for and require referral for specialists, typically every three months.
Types of HMO’s
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
Independent Practice Associates IPA
a separate legal entity that can either organize physicians and contact on their behalf with MCOs to provide services
Medical Service Organizations MSO
-Target small practices
-own employees for the practice
-they can lease equipment
-the docs will pay some monthly fee for the service
known as per member per month. form of reimbursement used most commonly by HMOs to compensate primary care physicians for their services.
Fee for Service
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
approval for services, including diagnostic services and inpatient or outpatient treatment.
Concurrent Review
involves the ongoing evaluation of treatment for appropriateness and necessity during the course of that treatment.
Claim filing questions to ask…
-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”
General Contract Provisions (Hold Harmless)
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.
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
Payer Reinsurance
purchased by primary insurers to protect against excessive claim
Resource-Based Relative Value Scale (RBRVS)
value scale was developed for CMS for Medicare reimbursement
insurance coverage in the event of unexpected financial loss to the plan or provider
Medicare’s internet-based provider enrollment is also known
Subjective, Objective, Assessment, Plan

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