To ensure patients regarding billing procedures, insurance account specialists needs to understand the importance of protecting the confidentiality of patients' personal information (PPI). Because they work with patients medical records on a regular basis, insurance account specialists must understand the laws that govern the use of medical records. The most important legislation regarding the confidentiality of patient information is contained in the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
Initiated by Senators Edward Kennedy and Nancy L. Kassebaum, HIPPA began as a response to public concern about people who were denied health insurance when they changed jobs. The final version enacted by Congress, however, was much broader in its scope and its ongoing impact more than decade after its passage. In addition to protecting the portability of health insurance, the law sets standards for the use of electronic technology by healthcare organizations. It establishes standards for protecting peoples' medical information during electronic exchange. HIPAA also imposes fines and possible prison terms for those who violate its provisions.
Patients medical records are legal documents that belong to the provider who created them. But the provider cannot withhold the information in the records from patients unless providing it would be detrimental to persons health. This information belongs to the patient. Patients control the amount and type of information that is released, except for the use of the data to treat them or conduct normal business transactions. Under HIPAA, only patients or their legally appointed representatives have the authorize the release of information to anyone not directly involved in their care.
HIPAA which became Public Law 104-191 on August 21, 1996, has two parts:
Title I, health insurance reform, is the law related to the continuation of health insurance coverage when individuals change jobs.
Title II, known as Administrative Simplification, affects individuals' private health information.
The U.S. Congress passed an act with provisions for Administrative Simplification because of concern over the rising costs of health care. A significant portion of every health care dollar spent in the United States goes to the overhead associated with administrative and financial transactions.
HIPAA Standard Transactions
1. Filing claims for paymentsHIPAA Standard Transactions
3. Checking Health Care Claim Status
b. 277 - Health Care Claim Status Notification
4. Notifying providers for payments
a. 835 - Electronic Remittance/Payment Advice
I am aware that each office use different types of Practice Management Software. I just want to share what I have found on the internet and
here are some computer tools that are useful everyday for the medical office staff. Click the image to view training videos. - - >
I am aware that each office use different types of Practice Management Software. I just want to share what I have found on the internet and
It is generally agreed that the health care industry could achieve much greater efficiency if common business transactions were standardized and handled digitally.
The Administrative Simplification provisions encourage the use of electronic data interchange (EDI). EDI is the computer-to-computer exchange of routine business information using publicly available standards. People who are working in allied health careers use EDI to exchange health information about patients among physicians and insurance companies.
HIPAA-mandated medical code sets, which are the ICD-9-CM diagnosis code set, the CPT procedure code set, and the HCPCS supply code set.
When a patient comes in to the office and treated, the patient's confidential health informaation is collected and put into the computerized Practice Management System (PMS). The services rendered are assigned a standard code from HIPAA required code sets (CPT - procedure/service codes and ICD-9 or 10-CM - diagnosis codes) When claims are generated for electronic submission, data are compiled and constructed to HIPAA Standard transactions . This EDI is recognized across the health care sector in computers maintained by providers, clearinghouses, and insurance payers. The harmony among the covered entities results in a more efficient claim life cycle.
Who is affected by HIPAA?
Any person or organization that electonically transmits and stores individually identifiable health information is considered a covered entity and is required by law to comply with HIPAA. A covered entity is anyone who submits claim electronically, makes referral or obtains authorization via e-mail messages that contain individually identifiable health information.
HIPAA affects practically all healthcare organizations as indicated by the following list:
What are the types of documents that should be shredded?
HIPAA Alert!!!
When a patient comes in to the office and treated, the patient's confidential health informaation is collected and put into the computerized Practice Management System (PMS). The services rendered are assigned a standard code from HIPAA required code sets (CPT - procedure/service codes and ICD-9 or 10-CM - diagnosis codes) When claims are generated for electronic submission, data are compiled and constructed to HIPAA Standard transactions . This EDI is recognized across the health care sector in computers maintained by providers, clearinghouses, and insurance payers. The harmony among the covered entities results in a more efficient claim life cycle.
Who is affected by HIPAA?
Any person or organization that electonically transmits and stores individually identifiable health information is considered a covered entity and is required by law to comply with HIPAA. A covered entity is anyone who submits claim electronically, makes referral or obtains authorization via e-mail messages that contain individually identifiable health information.
HIPAA affects practically all healthcare organizations as indicated by the following list:
a. Healthcare providers
b. Healthcare plans
c. Healthcare clearing houses
c. Healthcare clearing houses
d. Public health authorities
e. Self-insured employers
f. Life insurers
g. Information systems vendor
h. Various service organizations
i. Universities
It is important to know that many aspects of your job revolve around the certainty that your medical office is 100 percent HIPAA compliant. As a healthcare employee, there are duties that you will perform regularly that will require you to send , receive or discuss patient information.
The following is a list of electronic transactions that are covered by HIPAA:
a. Healthcare payment and remittance advice (RA)
b. Coordination of benefits
c. Eligibility for health plan
d. First report of injury
e. Referral certification and authorization
f. Healthcare claims or equivalent encounter information
g. Healthcare claim status
h. Enrollment and unenrollment in a health plan
i. Health plan premium payments
Consequences of unethical and illegal behavior
HIPAA calls for severe and criminal penalties for non-compliance, including fines of up to $25,000 for multiple violations of the same nature of the calendar year. There could also be fines up to $250,000, or imprisonment of up to 10 years for knowingly mishandling health information or both fines and imprisonment. Less severe penalties consist of exclusion from participating Medicare and Medicaid program.
What are the types of documents that should be shredded?
It is common for billing offices to have a shredder or shredder bins strategically place in the office. It is important to be aware of where these receptacles are. Any paper documents that have Protected Heath Information (PHI) should always be disposed of regularly by putting all documents with patient health, financial, or legal information in shredder bins and not in waste baskets.
Advantages of Using EDI:
1. Paper claims are much slower to process but doing it electronically is much faster.
2. EDI can almost error free, with increase claim acceptance rates because its scrubbing information capabilities.
3. Lower administrative, postage, and handling costs than those paper claim submission.
4. On-line receipt or acknowledgement.
5. Claim status and eligibility information in 24 hours or less.
6. Faster payment, with electronic claims generally being paid after 13 days, while paper claims cannot be paid for at least 27 days.
7. Faster deposit of payments for account receivable through electronic funds transfer (EFT); payments can be at provider's bank, while paper checks can take long as a week to process.
What is a Clearing House?
A clearinghouse is a business that receives electronic claims. It sorts, edits and checks the claim for accuracy. After the data in the claim is reformatted to fit the requirements of the individual insurance carrier, it is electronically transmitted. If there is an error on the claim that has been submitted to the clearinghouse.
Benefits of using a clearinghouse include the following:
1. Turnaround time is quicker. Claims are paid in days (7 to 14 days) rather paper claim that are paid in months.
2. Fewer claims get denied, down-coded or lost due to mistakes. The auditing services of the clearinghouse reduce the number of paper problem claims from 35% to only 3%.
3. Filing claim is faster. An electronic claim normally requires 5 minutes to submit versus 15-20 minutes for paper claim.
What is carrier-direct claim submission?
Carrier-direct claim submission allows physicians and billing services to transmit insurance claim directly to the insurance carrier without having to go through a clearinghouse.
Medicare, Medicaid, and Blue Cross/Blue Shield use a carrier direct system. Many other carriers use this system and should be contacted to obtain more information on their submission requirements. Sometimes, carriers who participate in carrier-direct claim submission have a particular software that may be used to submit claims. Some carriers provide a software at no charge. Contact these carriers directly to find out more about the software requirements.
Some billing services choose to file the majority of their claims directly to the carrier to avoid the clearinghouse fees. It may be less costly to choose this route, but more time-consuming. So deciding wisely which is the best option needed for a medical practice is important.
