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  • The health insurance specialist must know about the different guidelines and regulations for maintaining patient records and processing health insurance claims Federal laws and regulations affect health care in government programs like Medicare, Medicaid, TRICARE, and Federal Employees Health Benefit Plans. State laws regulate recordkeeping practices and provider licensing of insurance companies and state workers’ compensation plans.
  • Privacy right of individuals to keep their information from being disclosed to others Confidentiality restricting patient information access to those with proper authorization and maintaining the security of patient information Security – safekeeping of patient information by Controlling access to hard copy and computerized records Protecting patient information from alteration, destruction, tampering, or loss Providing employee training in confidentiality of patient information Requiring employees to sign a confidentiality statement that details the consequences of not maintaining patient confidentiality Breach of confidentiality – the unauthorized release of patient information to a third party Discussing patient information in public places Leaving patient information unattended Communicating patient information to family members without the patient’s consent Publicly announcing patient information in a waiting room or registration area Accessing patient information without a job-related reason
  • Medicare Administrative Contractors Oversee the processing of Parts A and B to consolidate claims processing by one carrier. False Claims Act Regulates the behavior of any contractor who submits claims for expense to the federal government for any program. Federal Anti-Kickback Law Protects patients from fraud and neglect by curtailing the corrupting influence of money on health care choices Utilization Review Act Facilitated ongoing assessment and management of health care services; Required hospitals to perform continued-stay reviews; To determine medical requirement and appropriateness of Medicare and Medicaid inpatient hospitalizations McKinney Act Provides health care to the homeless OBRA 1989 Physician self-referral law (Stark I) Prohibited physicians from referring Medicare patients to clinical laboratory services in which the physicians or their family members had a financial ownership/investment interest or compensation arrangement OBRA 1989 1994 added waiving of copayments, deductibles, and coinsurance as unlawful—results in False claims; Violations of the anti-kickback statute; Excessive use of items/services paid by Medicare PATH Audits implemented to examine billing practices at teaching facilities; Focus was on two issues: Compliance with Medicare rules affecting payment for physician services provided by residents and whether level of service was coded and billed properly CCI Developed by CMS to trim down Medicare program expenditures by detecting out-of-place codes on claims and rejecting payment for them HIPAA Mandated administrative simplification regulations that govern privacy, security, and electronic transaction standards for health care information SCHIP Health insurance program for newborns, children, and youth ; covers health care services such as physician visits, prescription medicine, and hospitalizations Medicare Prescription Drug, Improvement, and Modernization Act Provides Medicare recipients with prescription drug savings and additional health care plan choices
  • Limiting exclusions for preexisting medical conditions Providing credit for prior health coverage Providing new rights to enroll for health coverage when health coverage is lost Prohibiting discrimination in enrollment and premiums Guaranteeing availability of health insurance coverage Preserving, through narrow preemption provisions, the states’ traditional role in regulating health insurance Creates national standards to protect individuals’ medical records and other personal health information Gives patients greater access to their own medical records and more control over how their personal health information is used Adopts standards and safeguards to protect health information that is collected, maintained, used, or transmitted electronically
  • HIPAA also mandates that health insurance claims be retained for two years after a patient’s death
  • HIPAA defines fraud as “an intentional deception or misrepresentation.” The difference between fraud and abuse is individual’s intent. Examples of abuse include: Excessive charges for services Services not medically necessary Improper billing practices A person found guilty of fraud can face civil penalties, imprisonment and/or administrative sanctions
  • If reimbursed funds exceed the amount a provider or beneficiary were supposed to receive Waiver of Recovery Overpayment discovered subsequent to the third calendar year after the payment year Overpaid physician is found to be without fault or is deemed without fault
  • Providers are responsible for reimbursement of overpayment when Incorrect reasonable charge determination Provider received duplicate payments Receiving a payment after accepting a assignment and beneficiary receives payment and remits to provider Provider receives two payments: One from Medicare and another from a workers’ compensation or automobile carrier Liability Overpayment was made because of a mathematical or clerical error. Provider does not submit documentation to substantiate services. Overpayment for rental of DME billed under the one-time authorization procedure Medically Unlikely Edits Established by Medicare for CPT or HCPCS level II codes Maximum number of units of service (UOS) under most circumstances allowable by the same provider for the same beneficiary on the same date of service
  • Unbundling occurs when one service is divided into its component parts and a code for each component part is reported as if they were separate services A code for the separate surgical approach (e.g., laparotomy) is reported in addition to a code for the surgical procedure
  • General penalty for failure to comply: Wrongful disclosure of individually identifiable health information: Wrongful disclosure offense Offense under false pretenses Offense with intent to sell information
  • Electronic Health Care Transactions Establishes a uniform language for electronic data interchange (EDI) HIPAA required payers to implement


  • 1. Legal and Regulatory Issues Chapter 5
  • 2. Privacy and Security Standards
    • Privacy
    • Confidentiality
    • Security – safekeeping of patient information by
    • Breach of confidentiality – the unauthorized release of patient information to a third party
  • 3. Federal Laws
    • Medicare Administrative Contractors
    • False Claims Act
    • Federal Anti-Kickback Law
    • Utilization Review Act
    • McKinney Act
    • OBRA 1989
    • PATH
    • CCI
    • HIPAA
    • SCHIP
    • Medicare Prescription Drug, Improvement, and Modernization Act
  • 4. Health Insurance Portability and Accountability Act (HIPAA)
    • Improves portability and continuity of health insurance coverage in the group and individual markets
    • Combats waste, fraud, and abuse
    • Supports use of medical savings accounts
    • Long-term care services and coverage
    • Unique identifiers for providers, health plans, employers, and individuals
    • Standards for electronic health information transactions
    • Create privacy standards for health information
  • 5. Record Retention
    • Storage of documentation for an established period of time usually mandated by federal and state law
    • Medicare Conditions of Participation mandate the retention of patient records in their original or legally reproduced form (e.g., microfilm) for a period of at least five years.
    • HIPAA mandates the retention of health insurance claims and accounting records for a minimum of six years.
  • 6. Common Forms of Medicare Fraud
    • Billing for services that were not performed
    • Misrepresenting diagnosis to justify payment
    • Kickbacks
    • Unbundling codes
  • 7. Overpayments Include
    • Payment based on a charge that exceeds the reasonable charge
    • Duplicate processing of charges/claims
    • Payment made to the wrong payee
    • Payment made for an item or service not covered
    • Incorrect application of deductible or coinsurance
    • Payment during a period of nonentitlement
    • Payment for which another entity is the primary payer
    • Payment made after the beneficiary’s date of death
  • 8. Provider Liability for Overpayments
    • Providers are responsible for reimbursement of overpayment when
    • Provider receives two payments:
    • Provider was paid and did not accept assignment.
    • Provider furnished erroneous information.
    • Submitted a claim for services that were not medically necessary
    • Put in a claim for something that is not qualified for Medicare reimbursement
    • Items or services furnished by provider who is not qualified for Medicare reimbursement
  • 9. National Correct Coding Initiative (NCCI)
    • Analysis of standards for medical and surgical practices
    • Coding conventions included in CPT
    • Coding guidelines made by national medical specialty societies
    • Local and national coverage determination
    • Review of current coding practices
  • 10. Unbundling CPT Codes
    • Unbundling occurs when
      • one service is divided into its component parts and a code for each component part is reported as if they were separate services
      • A code for the separate surgical approach (e.g., laparotomy) is reported in addition to a code for the surgical procedure
    • NCCI edits determine appropriateness of CPT code combinations.
    • NCCI edits are designed to detect unbundling.
  • 11. Administrative Simplification
    • Improve efficiency and effectiveness of the health care system by standardizing the interchange of electronic data for specified administrative and financial transactions
    • Protect the security and confidentiality of electronic health information
    • General penalty for failure to comply
    • Wrongful disclosure of individually identifiable health information:
  • 12. Unique Identifiers
    • National Health PlanID
    • National Individual Identifier
    • National Provider Identifier
    • National Standard Employer Identification Number
  • 13. Steps in Identifying Risk Areas
    • Perform periodic audits to monitor billing
    • Develop written practice standards and procedures
    • Designate a compliance officer
    • Conduct training and education classes
    • 5. Respond by investigating allegations and disclosing to appropriate entities
    • Develop open lines of communication
    • Have disciplinary standards and enforce them