OCR Reveals HIPAA Audit Protocol
The U.S. Department of Health & Human Services’ Office for Civil Rights (OCR) has made public its long-awaited HIPAA audit protocol, posting it on its website June 26.nnThe Health Information Technology for Economic and Clinical Health (HITECH) Act, which amended the Health Insurance Portability and Accountability Act in 2009, required OCR to conduct a pilot audit program to assess HIPAA compliance. OCR established the audit protocol, which is searchable and organized around modules, to conduct the audits. The first 20 preliminary audits have been conducted; in all, 115 covered entities will be audited in the pilot program, which will end in December 2012.nnThe audit protocol covers the following requirements:n
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- The Privacy Rule requirements for (1) notice of privacy practices for PHI, (2) rights to request privacy protection for PHI, (3) access of individuals to PHI, (4) administrative requirements, (5) uses and disclosures of PHI, (6) amendment of PHI, and (7) accounting of disclosures.
- The Security Rule requirements for administrative, physical, and technical safeguards.
- The requirements for the Breach Notification Rule.
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nThe goal of the audits is to analyze trends, improve overall compliance and identify best practices, according to Linda Sanches, senior advisor for health information privacy at OCR, reporting on the audits at an OCR/NIST conference in early July. OCR does not plan to penalize auditees found in violation, though it will do so if it uncovers “serious compliance issues,” she said.nnSource: www.fierceemr.com; Marla Durben Hirsch; June 27, 2012.nn
Recently, the United States Supreme Court issued its long-awaited decision on the constitutionality of the Patient Protection and Affordable Care Act (the “Act”). In a 5 – 4 decision, with Chief Justice Roberts writing for the majority, the Court upheld the constitutionality of the controversial individual mandate and, thus, the remainder of the Act, with one exception discussed below. The Court upheld the individual mandate on the grounds that it was within Congress’ taxing power to require those who choose to not purchase health insurance to, in essence, pay a tax. A majority of the Court did not agree that the individual mandate was a valid exercise of Congress’ power to regulate interstate commerce.nnImportantly, the Court overturned the provision of the Act that would have allowed the federal government to take away all Medicaid funds from states that chose to not extend Medicaid coverage to all individuals under the age of 65 with incomes below 133% of the federal poverty level. This could mean that a number of states will opt out of the Medicaid expansion thereby reducing the number of currently uninsured who will receive coverage in 2014.nnThe Court’s decision means that all of the other provisions of the Act will remain in place including guaranteed issue, no lifetime caps, no exclusions for preexisting conditions, payment and delivery system reforms such as ACOs, and enhanced fraud and abuse enforcement powers.nnThe decision does not necessarily mean that the Act cannot be repealed by congress or a new president. Congressional Republicans have stated they will continue their efforts to defund the Act, and to repeal it if Gov. Romney becomes President and Republicans take control of both houses of Congress.nnSource: http://www.supremecourt.gov/
The health plans are increasingly putting pressure on providers (especially surgeons) to utilize IN-network providers, vendors, facilities, etc.nnOne Example: For years, it has become common place for Out Of Network (OON) surgical assists (many of whom are SA’s or C-SA’s) to get a hold of the surgeons bill for a surgical case and send out claims for 100% of the surgeon’s fee (the total fee prior to any contractual discount or even multiple procedure discounting) on the cases where they participate as first or even second assist. Some states have laws that force the health plan to hold the patient harmless to bills if the surgeon and the facility (or some combination) is IN-Network. The SA’s and some “creative” billing services are capitalizing on this loop hole to send in OON bills at 100% of charges. In many cases they actually get paid these amounts. Making it more profitable to be the SA than the actual surgeon! Imagine having virtually no-risk, no overhead, no staff to pay. You just show up for the case and get up to 5 -10 times what the actual surgeons gets for the case!nnWell, as we have always suspected, the health plans are finally saying NO MORE. In addition, many patients are not aware that there is an OON provider taking part in their case until they (the patient) gets a surprise, a huge bill – if even just the OON Co-Pay from someone they don’t know, never met, didn’t know was going to be in the case. The other un-intended consequence is that the total cost of a case (something that one surgeon is measured against others by) has astronomically gone up due to this practice. The surgeon, who is IN-Network gets a black mark because the overall cost of his/her cases is affected by the charges and network status of everyone involved.nnSome health plans are filing suit, others are forcing their In-Network surgeons (in the case of the OON SA assists) to make their patients aware of the use of an OON provider. We recently have seen United institute this for the use of OON facilities.
THIS WEEK — The Supreme Court of the United States should be ruling on four separate issues:n
Credentialing is NOT just filling out paper work…nCredentialing IS an increasingly complex and time sensitive process where the right information has to get to the right place, correctly, (even in the right color ink) and on-time in order for you to be paid correctly and consistently!nnFailure to properly fill out the “paper work” will cause, and has been causing disruptions in payment, inability to obtain referrals, improper co-pay and deductibles being applied and even regulatory audits (when a provider is mis-categorized and loaded improperly in the payer’s system!).nnIf your practice is experiencing:n