Regulating Healthcare - Lecture E

1. Introduction to Health Care
and Public Health in the U.S.
Regulating Health Care
Lecture e
This material (Comp 1 Unit 6) was developed by Oregon Health & Science University, funded by the Department
of Health and Human Services, Office of the National Coordinator for Health Information Technology under
Award Number 90WT0001.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Regulating Health Care
Learning Objectives - 1
• Describe the role of accreditation,
regulatory bodies, and professional
associations in health care in the U.S.
(Lecture a)
• Describe the basic concepts of law in the
United States: the legal system, sources of
law, classification of laws, the court
system, and the trial process. (Lecture b)
2

3. Regulating Health Care
Learning Objectives - 2
• Describe legal aspects of medicine
involving the Affordable Care Act,
professional standards in health care,
medical malpractice, Tort reform, and
Medicare and Medicaid Fraud and Abuse
(Lecture c)
3

4. Regulating Health Care
Learning Objectives - 3
• Describe key components of the Health
Insurance Portability and Accountability Act
(HIPAA) and describe efforts to promote patient
safety in the U.S. (Lecture d)
• Discuss the need for quality clinical
documentation for the use of the health record
as a legal document, communication tool and a
key to prove compliance for health care
organizations. (Lecture e)
4

5. The Health Record
• Summarizes a patient’s health conditions
and care activities
• Historically existed on paper but have
become increasingly digitized
• Serves as a
– Communication and quality enhancement tool
– Legal record of the care provided
5

6. The Health Record as
Tool for Patient Safety
• Providing care based on a full
understanding of a patient’s current and
past conditions is a key element of safe
care
• Information in the health record is
monitored for accuracy and completeness
• The health record is used to manage risk
and improve care
6

7. The Health Record
as a Legal Record
• Considered the business record for a
health care organization
• Also a legal record
– Admissible in a court of law
– Substantiates quality of care provided
7

8. Governance of Health Record
• Federal and State Laws, Regulations, and
Rules
• The Joint Commission and other voluntary
accreditation
• Medical staff bylaws
8

9. Quality Clinical Documentation
for Legal Purposes
• Hand-written documentation
– Illegibility introduces malpractice risk
• Electronic documentation
– Mistakes can be made, but the legibility of
health record content is improved
– More detailed notes
• “What isn’t documented isn’t done”
9

10. Quality Clinical Documentation to
Avoid Fraud and Abuse Accusations
• Clinical documentation improvement
programs support high-quality
documentation
– Train providers
• High-quality documentation supports
accurate coding and reimbursement
• Accurate coding is needed to avert
accusations of fraud and abuse
10

11. OIG Compliance Program Tips - 1
• The Seven Fundamental Elements of an
Effective Compliance Program
1. Implementing written policies, procedures and
standards of conduct
2. Designating a compliance officer and
compliance committee
3. Conducting effective training and education.
4. Developing effective lines of communication
11

12. OIG Compliance Program Tips - 2
• The Seven Fundamental Elements of an
Effective Compliance Program
5. Conducting internal monitoring and auditing
6. Enforcing standards through well-publicized
disciplinary guidelines
7. Responding promptly to detected offenses and
undertaking corrective action
• OIG compliance education videos:
http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp
12

13. Corporate Integrity Agreements - 1
• A comprehensive CIA includes
requirements to:
– Hire a compliance officer/appoint a
compliance committee
– Develop written standards and policies
– Implement a comprehensive employee
training program
– Retain an independent review organization to
conduct annual reviews
13

14. Corporate Integrity Agreements - 2
• A comprehensive CIA includes
requirements to:
– Establish a confidential disclosure program
– Restrict employment of ineligible persons
– Report overpayments, reportable events, and
ongoing investigations/legal proceedings
– Provide an implementation report and annual
reports to OIG on the status of the entity's
compliance activities
14

15. Compliance Beyond
Fraud and Abuse
• HIPAA Privacy and Security Rules
– What is the plan for appropriate release of
PHI?
– How is the tracking of release occurring?
– Who is responsible for breach notification?
– What training is being done?
– Is there a team reviewing policies and
procedures?
15

16. Regulating Health Care
Summary – 1 – Lecture e
• The health record is the business and
legal record for a health care organization
• The health record is the communication
tool for the health care team
• Clinical documentation is used to assure
high quality care of the patient, as well as
to provide information for decision-making,
reimbursement and medical coding
16

17. Regulating Health Care
Summary – 2 – Lecture e
• Thorough and complete clinical documentation
protects health care organization from the risk of
fraud, abuse, and malpractice claims
• Compliance programs are important to assure
correct procedures to follow related to
regulations, rules, laws, accreditation, and
internal policies
• HIPAA privacy and security rules need to be
included in compliance plans
17

18. Regulating Health Care
Summary - 1
• Health Care accrediting and certification
organizations
• The U.S. legal system
• Laws governing health care privacy and
security rules
18

19. Regulating Health Care
Summary - 2
• The clinical documentation in the health
record supports quality health care,
administrative and business operations of
the organization, and provides the basis
for legal proof of care that assures
compliance with laws, rules, and
regulations as well as professional
standards of care
19

20. Regulating Health Care
References – 1 – Lecture e
References
American Health Information Management Association. http://www.ahima.org/topics/ehr.
Accessed January 30, 2017.
American Health Information Management Association. http://www.ahima.org/topics/cdi.
Accessed January 30, 2017.
American Health Information Management Association. http://www.ahima.org/topics/psc.
Accessed January 30, 2017.
Bayes, N., Newby, J, Seggern, J, Valerius J. Medical Insurance An integrated claims
process approach 5th edition, 2012. McGraw Hill Companies: New York
Davis, N. Revenue Cycle Management Best Practices, 2011, AHIMA Press: Chicago
Health Care Compliance Program Tips http://oig.hhs.gov/compliance/provider-
compliance-training/index.asp. Accessed January 30, 2017.
LaTour & Eichenwald, Health Information Management, concepts, Principles, and
Practice, Third Edition, 2010 AHIMA Press: Chicago
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21. Regulating Health Care
References – 2 – Lecture e
References
Office of the Inspector General.
http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp. Accessed January 30,
2017.
Office of Inspector General. A Roadmap for New Physicians: Avoiding Medicare and
Medicaid Fraud and Abuse. http://oig.hhs.gov/fraud/PhysicianEducation. Accessed
January 30, 2017.
Centers for Medicare and Medicaid. http://www.cms.gov/default.asp. Accessed January
30, 2017.
Corporate integrity agreements. http://oig.hhs.gov/compliance/corporate-integrity-
agreements/index.asp. Accessed January 30, 2017.
21

22. Introduction to Health Care
and Public Health in the U.S.
Regulating Health Care
Lecture e
This material was developed by Oregon
Health & Science University, funded by the
Department of Health and Human Services,
Office of the National Coordinator for Health
Information Technology under Award
Number 90WT0001.
22