The Health Insurance Portability and Accountability Act (HIPAA) had a big impact on Billing and Coding. This was a significant law passed in 1996 and phased in over several years:
HIPAA Administrative Simplification established requirements for protecting patient health information in three categories:
When communicating verbally make sure conversations are private and cannot be overheard. Any discussions involving Protected Health Information (PHI) should involve only those authorized to know.
When communicating electronically – systems should have appropriate physical, administrative, and technical safeguards in place to protect the confidentiality, integrity, and availability of the ePHI.
When communicating by fax any documents containing PHI, be very careful. It is recommended faxing protected information only when there is an immediate need to obtain records for treatment authorization. Recommend a confidentiality notice on fax cover page.
Locate printers or fax machines used for PHI in secure areas that are only available to those with a need to know.
Patient information may not be disclosed or released unless authorized by the patient.
Health care providers, their staff, and any business associates or contractors may remotely access electronic health information. This includes the use of mobile devices to access electronic protected health information (ePHI).
The appropriate physical, administrative, and technical safeguards must be in place to protect the confidentiality, integrity, and availability of the ePHI on the mobile device and in the cloud.
Business Associate agreements must be in place with any third party service providers for the device and/or the cloud that will have access to the e-PHI.
Fraud is defined by federal government as anyone who knowingly or willingly executes, or attempts to execute, a scheme to defraud any healthcare benefit program.
Fraud is intentional deception or misrepresentation of the services or procedures performed by a provider in an attempt to obtain or increase payment. Fraud can be punishable by criminal conviction of fines.
Abuse is not considered as serious because it typically results from an ignorance or lack of awareness of proper coding and billing guidelines. When abuse is detected, it typically results in recovered or adjusted payments, possible suspension form the insurance payers programs, or in more severe cases financial penalties.
HIPAA set fines for of $20,000 per claim for false claims plus triple damages.
Another federal law that impacts billing and coding is the Health Information Technology for Economic and Clinical Health Act (HITECH).
Fraud and abuse can be prosecuted under a variety of federal and state laws.
Medicare frequently investigates and prosecutes providers who abuse or manipulate the system.
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