Guide to Medical Billing CHAPTER Third Edition Legal and Ethical Issues of Billing 2

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler AMA Ethical Standards (1 of 2) Providing competent service with compassion and respect for patients Dealing honestly with people Being a law-abiding citizen Working to change laws that are not in the best interest of patients Respecting rights of others

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler AMA Ethical Standards (2 of 2) Continuing to study and upgrade skills Providing emergency medical treatment to anyone who is in need Working to improve the community

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Ethical Guidelines for the Medical Biller (1 of 2) Avoid making critical remarks about the provider, another provider, or any treatment given or not given Notify provider if discovered that a patient is being treated by more than one provider for the same ailment

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Ethical Guidelines for the Medical Biller (2 of 2) Respect the dignity of others Refuse to participate in illegal or unethical acts or to conceal the illegal or unethical acts of others

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Reasons for Medical Record Privacy (1 of 2) People are becoming more litigation minded Health plans reimburse for more sensitive services that were excluded in the past

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Reasons for Medical Record Privacy (2 of 2) More employers are self-administering or self-funding their health plan New HIPAA regulations require that all health care professionals respect patients’ right to privacy and confidentiality

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler HIPAA (1 of 2) Health Insurance Portability and Accountability Act Set a national standard for electronic transfer of health data

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler HIPPA (2 of 2) Encompasses: –Portability  ability to transfer insurance companies and still be covered for preexisting conditions –Accountability  dealing with patient’s right to privacy

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Privacy Section of HIPAA Limits release of patient Protected Health Information (PHI) Patient’s personal information must be more securely guarded and carefully handled when conducting the business of health care

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Fines for HIPAA Noncompliance Fines up to $25,000 for multiple violations of the same standard in a calendar year Fines up to $250,000 or imprisonment up to 10 years for knowledge of misuse of individually identifiable health information

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Ensuring Privacy (1 of 6) Always obtain an authorization for release of medical information before releasing any information. Gather only information that is necessary and relevant for billing or processing the claim. Use only legal and ethical means to collect information required.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Ensuring Privacy (2 of 6) When requested, and subject to any applicable legal or ethical prohibition or privilege, advice the insured or patient of the nature and general uses of the information. Make every reasonable effort to ensure the information on which an action is based is accurate, relevant, timely, and complete.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Ensuring Privacy (3 of 6) On request, give the patient or insured the opportunity to correct or clarify the information given by or about him/her. Disclose information to a third party only when written authorization exists.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Ensuring Privacy (4 of 6) Take all practical precautions to ensure medical files are physically secure and access to the use of these files is limited to authorized personnel. Advise all personnel involved in keeping medical records of the need to protect privacy. Never disclose a diagnosis to a patient or his/her family.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Ensuring Privacy (5 of 6) Unless otherwise instructed, never release any information to an ex- spouse. Do not leave files, patients’ records, or appointment books open on desk or in an area where they may be seen by others.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Ensuring Privacy (6 of 6) When addressing a patient in the waiting room, use as little information as possible to gain the attention of the patient Be aware of a minor’s status

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Maintaining Confidentiality When Faxing (1 of 3) Use a fax cover sheet. Never fax information regarding diagnosis, treatments, sexually transmitted diseases, HIV, drug or alcohol abuse, or finances.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Maintaining Confidentiality When Faxing (2 of 3) When faxing allowed information, consider asking the receiving party for a code number. Black out all pertinent information on the patient and replace it with the code number. When possible avoid faxing information and use regular or certified mail.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Guidelines for Maintaining Confidentiality When Faxing (3 of 3) When faxing, call ahead to verify that recipient is available to receive the fax. Follow all office policies and HIPAA requirements when faxing.

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Fraud and Abuse (1 of 2) Fraud: –Intentional misrepresentation of a fact with intent to deprive a person of property of legal rights Medicare fraud: –Intentional misrepresentation of information that could result in payment for an unauthorized Medicare benefit

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Fraud and Abuse (2 of 2) Medicare abuse: –Includes any item or procedure that is inconsistent with accepted Medicaid norms or practices

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Fraud Offenses Defined by HIPAA Health care fraud Theft or embezzlement in connection with health care False statements relating to health care matters Obstruction of criminal investigations of health care offenses

Guide to Medical Billing, Third Edition Sharon Brown Lori TylerEmbezzlement Act of an employee illegally taking funds from his/her employer Can be committed by anyone in a firm, including the receptionist, biller, or provider

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Respondeat Superior Legal term Means that an employer is liable for harms caused by an employee while that employee is acting within the scope of his/her employment

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Errors and Omissions Typically part of a professional liability insurance policy Insurance covers damages caused by mistakes (errors) or damages caused by something an employee failed to do (omissions)

Guide to Medical Billing, Third Edition Sharon Brown Lori TylerBonding Process where employer can be insured for loss of money or other property sustained through dishonest acts of a “bonded” employee Can cover many types of acts

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Claim Audits Analysis of claims payments made to provider to determine whether claims were allowable and if provider was paid appropriate amount for services rendered

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler Internal Audits Considered to be prospective reviews Performed before a claim is submitted for payment

Guide to Medical Billing, Third Edition Sharon Brown Lori Tyler External Audits Considered to be retrospective reviews Performed after a claim has been submitted for payment and the claim has been processed by insurance carrier