Lesson 4.
1
HIPPA , Compliance and Reimbursement Guidelines
u Health coverage portability
Health information privacy
HIPAA-Health
u
u Administration simplification
Insurance u Medical savings accounts
Portability and u Long term care insurance
u Security requirements
Accountability u Privacy requirements
Act u National Identifier requirements
u Electronic transactions and code set
standard requirements
Also known as PHI
Protected Need to know basis only
Health Restricted information among
Information providers, nurses , healthcare staff
Conversations
Password protected
Training and procedures updated and done
yearly
Security Violations must be reported
Disciplinary action / loss of job
Financial implications
What constitutes a violation
u Impermissible disclosures of protected health information (PHI)
u Unauthorized accessing of PHI
u Improper disposal of PHI
u Failure to manage risks to the confidentiality, integrity, and availability of PHI
u Failure to implement safeguards to ensure the confidentiality, integrity, and availability of PHI
u Failure to maintain and monitor PHI access logs
u Failure to enter into a HIPAA-compliant business associate agreement with vendors prior to giving access to
PHI
u Failure to provide patients with copies of their PHI on request
u Failure to implement access controls to limit who can view PHI
u Failure to terminate access rights to PHI when no longer required
u The disclosure more PHI than is necessary for a particular task to be performed
u Failure to provide HIPAA training and security awareness training
u Theft of patient records
u Unauthorized release of PHI to individuals not authorized to receive the
information
u Sharing of PHI online or via social media without permission
u Mishandling and miss mailing PHI
u Texting PHI
u Failure to encrypt PHI or use an alternative, equivalent measure to prevent
unauthorized access/disclosure
u Failure to notify an individual (or the Office for Civil Rights) of a security
incident involving PHI within 60 days of the discovery of a breach
u Failure to document compliance efforts
Penalties
u Tier 1. Lack of awareness where a covered entity or individual was unaware that
the act in question was a violation. Fines start at $100 and go up to $50,000 per
violation, topping out at $1.5 million each year.
u Tier 2. Reasonable cause to believe the individual or entity knew about the rule or
regulation. Issues at this tier are considered a lack of due diligence. The fines
range from $1,000 to $50,000 per violation. The maximum fine is $1.5 million per
year.
u Tier 3. The HIPAA violation was performed with willful neglect. The party then
corrected the violation within the required time period of 30 days after discovery.
Fines at this tier start at $10,000 and go to $50,000. The maximum penalty is $1.5
million per year.
u Tier 4. At this tier, the violation was made with willful neglect of HIPAA Rules.
Further, the entity made no effort to correct the violation. There is a standard
$50,000 fine per violation at this tier with a maximum fine of $1.5 million each
year.
Criminal Acts
u Unknowingly or with Reasonable Cause. The person may receive a jail
sentence of up to one year.
u False Pretenses may result in a five years’ maximum jail sentence and a fine
increase to $100,000 per violation.
u Personal Reasons or to Commit Fraud or a Crime. Malicious intent such as data
breaches may lead to a jail sentence of up to 10 years and a fine up to
$250,000 per violation.
u Intentional deception or mispresenting
that an individual knows is false or
does not believe to be true .
u Billing for services that were not
furnished
Fraud u Misrepresenting a diagnosis code to
justify payment
u Soliciting, offering or receiving a kick
back
u Routine waiver of copay
u Unbundling
OIG- Office of the Inspector General
Run in conjunction with Department of Human Services
Annual work plan targeting areas of abuse
[Link]
Starks Law
u The original statute was quite simple. It sought to ban physician self-referral
for designated services when a patient was covered by Medicare or another
government payer. Self-referral occurs when physicians refer patients for
designated health services to hospitals, labs and other entities from which
they or an immediate family member benefit financially.
u Stark Law has numerous exceptions, each of which carries its own detailed
requirements. Many of the exceptions require compensation paid to a
physician to not take into account the value or volume of a physician's
referrals or other business generated between the parties to a gainsharing
agreement. Many exceptions also require the arrangement to be commercially
reasonable and compensation to be at fair market value.
u Stark Law applies to the following designated health services:
u Clinical laboratory services
u Physical therapy services
u Occupational therapy services
u Outpatient speech-language pathology services
u Radiology and certain other imaging services
u Radiation therapy services and supplies
u Durable medical equipment and supplies
u Parenteral and enteral nutrients, equipment and supplies
u Prosthetics, orthotics and prosthetic devices and supplies
u Home health services
u Outpatient prescription drugs
u Inpatient and outpatient hospital services
Anti Kickback
u The Federal Anti-Kickback Statute prohibits the knowing and willful
solicitation, offer, payment or acceptance of any remuneration, directly or
indirectly, overtly or covertly, in cash or in kind in return for:
u referring an individual to a person for the for the furnishing or arranging for
the furnishing of any item or service for which payment may be made in
whole or in party under a Federal health care program; or
u purchasing, leasing, ordering, or arranging for or recommending purchasing,
leasing, or ordering any good, facility, service, or item for which payment
may be made in whole or in party under a Federal health care program.
u In a nutshell, the Anti-Kickback Statute prohibits a person or entity from
paying another individual or entity to induce that individual or entity to refer
items or services which may be reimbursed by a Federal health care program.
Do you look good in Orange ?
u Connecticut Rheumatologist Sentenced to More Than 3 Years in Federal Prison
for Defrauding Medicaid
u Encompass Health Corporation Agrees To Pay $4 Million To Resolve Allegations
Of Improperly Billing Medicare
u Sanford Health Entities to Pay $20.25 Million to Settle False Claims Act
Allegations Regarding Kickbacks and Unnecessary Spinal Surgeries
u Mandeville Nurse Charged With Conspiracy to Alter or Falsify Records in a
Federal Investigation
u Long Island Chiropractor Sentenced to 18 Months' Imprisonment for Multi-
Million Dollar Health Care Fraud Scheme
Types of Insurance
MEDICARE MEDICAID COMMERCIAL VETERANS WORKERS
COMP
LIABILITY
Signed Contract
Agreed fee schedule on each
procedure
Network
Providers Sets regulations on timely filing
Required to collect copays at time of
visit
u Part A : Hospital Insurance
u Part B : Physician Services
u Originally designed for people 65 and
older
u Later added eligibility to included
disabled , and end stage renal disease
Medicare u Can be primary or secondary insurance
u Highest fraud percentage
u MAC Jurisdictions based on where
services rendered
u Florida is Jurisdiction N
u Maine is Jurisdiction K
An ABN is a written notice from Medicare
ABN – u
(standard government form CMS-R-131),
given to patient before receiving certain
Advanced items or services, notifying you: Medicare
may deny payment for that specific
beneficiary procedure or treatment. You will be
personally responsible for full payment if
Notice Medicare denies payment.
u Employer Based and Market Place Plans
u Coverage varies per plan
u HMO
Commercial u PPO
Insurance u 80% of plans have deductible over
$2000 per year
u Aetna, Blue Cross, Cigna, Harvard,
United Healthcare
Workers Comp
u Injury happened while working or direct result of your work
u Required to advise employer and file first report of injury
u Employer files claim with their Workers Comp carrier
u Investigation
u Claim #
u If service related to Workers Comp then you can not bill health insurance
Coding Process
Charge Entry
Missed Charges = Lost Revenue
HCFA Claim Form
Included into New patient paperwork
at each providers office
Gives permission for insurance
company to pay provider directly
Assignment
of Benefits Coordinates with a Box checked off in
a claim
If not done, payments from insurance
will go to patient
Contractual Obligation
u Providers have their own contracts with health insurance companies. When
you agree to these terms, you agree to meet certain billing requirements.
Denial due to a contractual obligation means that you’ve failed to jump
through one of the insurer’s hoops. Some common issues include:
u Not filing the claim in a timely fashion.
u The claim was already paid.
u The submitted claim does not support the necessity of the service, or the
provider provided too many services. For instance, doing too many
unnecessary diagnostic tests may result in a claim denial or adjustment.
u The provider wasn’t certified to provide the covered service at the time it
was provided.
Patient Obligation
u When a denial is coded as a patient obligation, it can mean many things. In
most cases, the denial should specify which specific contractual issue gave
rise to the denial. Some of the most common include:
u The patient has not met their deductible.
u The patient was required to seek a referral.
u The service is not covered.
u The claim lacks the information necessary to determine whether it was
covered.
u The care is covered by another insurer. Check with the patient to see if they
have another plan.
u No Coverage
u Non-covered services
u Missing information
Common u Duplicate claim or service
denials u Not covered by payer
u Limit for filing expired
u Lack of authorization
u Lack of referral
CODING ISSUE
u If a bill isn’t correctly coded, it won’t be paid. Long strings of numbers, however,
can easily be transposed. Consider how the code 87621, for an abnormal pap
smear that suggests the need for further testing, can become irrelevant nonsense
if the numbers shift locations. Other coding issues include:
u Not including a code.
u Including the wrong code.
u Using the wrong coding system for the insurer.
u Not following the standard of care associated with the included codes.
u Many coding issues are simple errors that can easily be fixed–and compensated–
with a bit of detective work. Yet the process can be a frustrating one that wastes
lots of time you might otherwise spend with patients.
BILLING THE WRONG COMPANY
u In the era of Obamacare, many consumers change health insurers every year,
as rates change, and new providers enter or leave the marketplace. So it’s
increasingly common for bills to go to the wrong company. The insurance a
patient had last year might not be the insurer they use this year. Check
coverage and service dates carefully to ensure the bill goes to the right
company.
u Another insurance is prime such as workers comp
u Birthday Rule : Under the birthday rule, the health plan of the parent whose
birthday comes first in the calendar year is designated as the primary plan,
according to the National Association of Insurance Commissioners. It doesn't
matter which parent is older. The year of birth isn't a factor. Thus, if your
birthday is July 15, 1965, and your spouse's is Sept. 17, 1963, your health plan
would be considered primary because your birthday comes first in the
calendar year.
DUPLICATE BILLING
u Duplicate billing is incredibly common, especially as medical practices switch
to payment automation services that automatically generate bills. For
example, if you see a patient for a consultation and bill for this, but then
your billing software automatically generates a consultation fee associated
with a service you provided, this is duplicate billing for which you can’t be
paid. In other cases, a duplicate bill might appear to be a duplicate when it’s
actually not. These billing issues can be tough to untangle, so insurers simply
reject bills when there’s any doubt.
MISSING INFORMATION
u An incomplete claim will almost always be denied. Even when a claim form is
filled out in its entirety, however, it may still lack information. Insurers
construct complex requirements for their insureds and the doctors who serve
them. You might need to document that a patient received a referral for a
service, that another treatment was tried first, or that the patient underwent
testing for a specific medical condition. Without specific documentation
showing that the treatment is medically necessary and covered under the
plan, it could be denied.
No referral / No authorization
u HMO policies ALWAYS need referral from PCP and must be on the claim
u Check benefits before patient seen to prevent no auth denials
u Provider responsibility to do these
u Most can be done online
Online or on paper
Most insurance companies have a specific
form
Know the payment policy
Appeals/ Time limit
Reconsideration State your case
Attached your evidence
Medical notes
Copy of original denial (EOB)
Modified Claim after processed or paid
Adding procedures, Diagnosis Code
Corrected Adding referring name
Claims Normally done on paper
Form
Overpayments
u Insurance
u Two insurance companies pay as primary due to a lack of coordination of benefits
(COB).
u The provider bills incorrectly or in excess of actual charges.
u Duplicate submission of the same claim resulting in a duplicate payment.
u Patient
u Overpaid copay at time of visit and it was less
u Received a bill and paid then insurance reprocessed
Identifying and Returning
Overpayments
u In 1998, the OIG issued specific compliance guidance for billing companies. In
it, the OIG assigned to billing companies the responsibility for identifying and
assisting your clients in the return of overpayments. As a billing company, you
are tasked with working with your clients to investigate anything you know to
be amiss, which includes the investigation of overpayments. If evidence of
misconduct (e.g., unreported overpayments) is found on the part of one of
your clients, the OIG outlines a proper initial response:
u Refrain from submitting those claims that appear questionable.
u Notify your client in writing within 30 days of discovering the questionable
payment.
u Work with your client to satisfactorily resolve the suspected misconduct.
GOVERNMENT REPAYMENTS
u When the Affordable Care Act was passed in 2010, it created an express duty
that individual and institutional healthcare providers report and return
"overpayments" received from Medicare or Medicaid to the government "by
the later of" 60 days after the date on which the overpayment was "identified"
or by the date on which a corresponding cost report was due.
This reporting requirement became commonly known as the 60-Day Rule, but
there were a number of unanswered questions relating to the concepts of
"identifying" an overpayment and what a person must do when it became
aware of an overpayment.
u Intentional deception or misrepresentation is
known as ________.
u A. Abuse
Review Question u B. Fraud
u C. RVU
u D. PPO
Rational u Answer : B Fraud
Lesson 4.2 The next step
Most companies want certificate to
validate your skills
Certified coders receive 20% higher
salary than noncertified
Certifications
and testing Ongoing training and yearly CEU’s
Networking
u Certified Professional Coder (CPC®)
Which one is u
u
Certified Outpatient Coding (COC™)
Certified Inpatient Coder (CIC™)
for you ? u Certified Risk Adjustment Coder (CRC™)
u Specialty Coding Certification
What Is the CPC Exam?
u The CPC exam is a test of medical coding proficiency consisting of 150
multiple-choice questions that assess 17 areas of knowledge. Most questions
present a coding scenario to test proper application of CPT® procedure codes,
HCPCS Level II supply codes, and ICD-10-CM diagnosis codes—all of which
medical providers use to submit claims to payers. During the test, you will
reference approved coding books—the AMA’s CPT® Professional Edition, as well
as your choice of ICD-10-CM and HCPCS Level II code manuals. You must
complete the CPC exam within five hours and forty minutes and answer 70%
of the questions correctly to pass.
Preparing for your Exam
u Manuals are ONLY materials allowed in the test area
u Write notes in books per chapter
u Use sticky notes
u Highlight rules
u They will check your books for loose papers or notes
u AAPC American Academy of
Professional Coders
[Link]
Accreditation u AHIMA American Health Information
Management Association
u [Link]
Employment Opportunities
u Certified Medical Biller and Coder – assign codes to patient records using ICD, CPT, and HCPCS
codebooks for different diagnoses and medical procedures for in-patient and out-patient settings
u Health Information Technician or Manager – prepare and scan medical record documents, ensuring
accuracy and timeliness, retrieve records and releases information for patient care purposes
u Medical Records Technician – work to organize, monitor, update and maintain healthcare providers’
electronic medical records
u Medical Secretary – patient intake, insurance verification, and medical record creation
u Medical Office Administrator – responsible to keep the healthcare organization running smoothly
and efficiently by directing and coordinating operations
u Quality Improvement Analyst – responsible for core measures such as patient safety, patient
satisfaction and employee utilization while performing necessary database and statistical analyses
for improving patient outcomes and reducing costs
u Insurance Claims Analyst – review insurance policy to determine coverage, prepare insurance claim
forms, calculate claim amounts, and transmit claims for payment or further investigation
u Reimbursement and Insurance Manager – responsible for the day-to-day management of the
reimbursement department.
Attractive Employers
u Hospitals
u Physician Offices
u College Health Departments
u Military and VA Facilities
u Home Health Agencies
u Mental Health Facilities
u Public Health Agencies
u Insurance Companies
u Physician Offices
u Nursing Home Facilities
u Rehabilitation Facilities
u Urgent Care Clinics
u Surgery Centers
Free resources
u [Link]
u [Link]
u [Link]
u [Link]
u Local AAPC meeting – [Link]
u Insurance specific websites
References
u [Link]
u [Link]
u [Link]
u [Link]
u [Link]
u AAPC ICD CM Expert
u AMA CPT Manual
u [Link]
u [Link]
Additional References
Questions
u Instructor information
u Email : wendylbell1@[Link]