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Chapter 5


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Chapter 5

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