Introduction to Health Information Management
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UnitVII.pdf
HTH 2304, Introduction to Health Information Management 1
Course Learning Outcomes for Unit VII Upon completion of this unit, students should be able to:
5. Discuss an overview of billing issues in the context of health information management. 5.1 Explain how billing issues impact health information management professionals.
Course/Unit Learning Outcomes
Learning Activity
5.1
Unit Lesson Chapter 9 Article: “Keys to Coding” Unit VII Research Report
Reading Assignment Chapter 9: Legal Aspects of Health Information Management Additional Reading Assignment: In order to access the following resource, please click the link below. Eramo, L. A. (2017). Keys to coding. Medical Economics, 94(14), 22–24, 40–44. Retrieved from
https://libraryresources.columbiasouthern.edu/login?url=https://search-proquest- com.libraryresources.columbiasouthern.edu/healthcomplete/docview/1924503135/fulltext/AB94CC8C 67B04D08PQ/4?accountid=33337
Unit Lesson Foundations of Health Law and Ethics With Billing Issues When it comes to the healthcare industry, the law regulates all parts. There are specific state and federal laws that protect the rights of employees and patients when dealing with medical records, billing, coding, contracts, and other parts of healthcare administration. These laws include HIPAA (Health Insurance Portability and Accountability Act of 1996) and EMTALA (Emergency Medical Treatment and Active Labor Act) (Bowie & Green, 2016). Even with the law set up, there are still issues that occur on a daily basis because of individuals not following health laws, rules, regulations, and protocols. The law changes yearly because it cannot cover every possibility and answer every question. Health care is full of rules and regulations that serve as a guide. Due to new situations that occur on a daily basis, it is hard to have an answer for every circumstance. Within an organization, healthcare providers, staff, and administrators must understand and comply with a wide range of legal and ethical standards and ensure that providers and other employees adhere to these standards as well. The scope of health laws and ethics is vast and touches nearly every area of health care. Health Insurance Portability and Accountability Act (HIPAA) HIPAA provides federal regulatory standards for private health insurance (Bowie & Green, 2016). Under HIPAA, states share regulatory power with federal agencies that have some regulatory authority over private health insurance and group health plans. HIPAA was the first direct regulation on the business of health
UNIT VII STUDY GUIDE
Legal Aspects of Health Information Management
HTH 2304, Introduction to Health Information Management 2
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insurance by the federal government (Bowie & Green, 2016). HIPAA has tax incentives and abuse and anti- fraud initiatives with requirements for portability and access. Some of the benefits that occur with HIPAA include the deductibility of health insurance, tax incentives for the purchase of long-term care insurance, and medical savings programs (Bowie & Green, 2016). HIPAA balances the regulatory weight by having authority agencies in place for more protection (Bowie & Green, 2016). With the creation of HIPAA, states offer many federal standards and permits to make sure protection can be accessed (Bowie & Green, 2016). HIPAA also provides nondiscrimination by having these types of provisions in place to improve access to different insurance, especially for individuals with pre-existing conditions. Insurance companies cannot turn down individuals due to any pre-existing conditions that they may have (DHHS, 2017). A pre-existing condition is a condition that has occurred before the patient started participation with the insurance plan. The new act is supposed to regulate the use of pre-existing conditions, and make sure that health plans treat every individual equally. The goal is also to make sure that a person who is insured is not paying more money because of the health condition of the patient. HIPAA ensures that all dependents and employees who do not meet the deadlines of the initial enrollment period due to a circumstance are able to sign up at a later date. For instance, if an individual is working for a company, and he or she has insurance through the company and the company closes, then he or she can sign up for the insurance because of that unique circumstance that has occurred (Bowie & Green, 2016). This allows the individual to obtain health insurance even with the issues at hand. HIPAA’s goal is to reduce cost when completing all necessary paperwork. HIPAA regulations standardize the use of electronic transmission for administrative and financial transactions. The purpose of these provisions is to increase administrative efficiency and reduce overall healthcare costs. Previously, healthcare facilities handled most administrative and financial transactions via paper, which is more time-consuming and expensive. HIPAA and Privacy To address the growth in technology and the potential abuses and privacy exposure challenges, HIPAA includes expectations regarding the transmission, protection, and use of patient information. Providers are responsible for supporting protected health information (PHI) and electronic protected health information (ePHI) (Bowie & Green, 2016). To have an understanding of PHI, healthcare organizations and other companies, like insurance holders, that have access to personal information that can identify an individual, must have clear policies. These polices should have safeguards and other items in place to ensure proper storage. Protecting health information is key to health insurance. This ensures that information is kept safe and safeguards against medical fraud and other issues. Medical fraud is one of the biggest issues in the medical arena. This is why it is key to have safeguards and protected health information. Key elements that an organization must protect include the following items:
name;
address;
birth date;
telephone numbers;
fax numbers’
Social Security number;
medical record number;
account numbers, including certificates, credit cards, license numbers, and other documents where an account number is used as an identifier; and
photographs, voice recordings, and finger images (Bowie & Green, 2016). The handling, storing, and transmitting of any paper or electronic record, including personal computers, magnetic tapes and disks, removable storage devices, PDAs, smartphones, and the electronic transmission of data (such as e-mail, file transfers, wireless, modem, DSL, and cable or satellite network connections), is a process that employers and organizations consider when developing policies and processes for HIPAA compliance (Bowie & Green, 2016).
HTH 2304, Introduction to Health Information Management 3
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Challenges Facing Health Information Management The explosive growth of electronic communication through the Internet and the rapid development of applications for this technology created new means by which knowledge is created and transmitted worldwide. Making sure that the storage and delivery of information are strictly maintained is key to all of the patient information. This allows for no fraud errors or abuse, which is very important in the medical arena. These issues are just a few of the challenges facing the healthcare industry. New e-health applications provide new problems that will be solved through collaboration with community partners, state and federal regulators and legislators, medical and technology professional associations, and consumers. Even with the use of HIPPA, there are still billing issues that occur. Billing Issues Issues in billing can occur at many levels from the beginning of billing to the end. Let us take a look! An individual enters a doctor office with a cold. A healthcare professional would consider this as the chief complaint. While there, the physician runs many tests and diagnoses the individual with the flu. Since it is a mild case of the flu, he or she is able to go home and seek follow-up once completing all of his or her medications. The first billing issue can occur with the biller or coder. This person has to charge for the test that the healthcare professional conducted and for the charges from the healthcare facility and medical worker. These charges can range in cost and be a burden to the individual involved if he or she does not have insurance. The billing and coder can complete these changes and make sure they were coded correctly or they can undercode or overcode. As a biller and coder, it is important to double-check codes and make sure the charges have been coded correctly. Undercoding is coding for the services but not completely. If something is complex, they might have coded too simply. Overcoding is doing the opposite. It is coding for more than what has been completed. This can be one billing issue. Another huge billing issue involves files that end up in the wrong hands. This can be employees or visitors of the facility who gain access to files to obtain the individual’s identity in order to complete identity fraud. Another billing issue for us to review involves HIPAA violations where individuals are not following the protocol to file the insurance. This can be filing insurance for items that are not completed or it can be not charging the insurance at all. Billing issues take place all the time because individuals, at the time, do not follow rules and regulations. And finally, billing issues occur with the use of technology, which is why it is so important to have a health information management system set in place. Health information is key for legal and billing aspects of the healthcare arena. If legal protocol and billing regulation is not followed, there can be many issues for all parties involved. In the role as a biller and coder, it is important to complete the duties correctly. Conclusion All healthcare facilities, healthcare providers, and healthcare professionals must understand and comply with a wide range of legal and ethical standards of the field. The scope of health laws and ethics is vast and touches nearly every area of health care. As new e-health applications are created and evolve, healthcare professionals must also address and solve new problems through collaboration with community partners, state and federal regulators and legislators, medical and technology professional associations, and consumers.
References Bowie, M. J., & Green, M. A. (2016). Essentials of health information management: Principles and practices
(3rd ed.). Boston, MA: Cengage Learning. U.S. Department of Health and Human Services. (2017). Pre-existing conditions. Retrieved from
https://www.hhs.gov/healthcare/about-the-aca/pre-existing-conditions/index.html
Suggested Reading Please click the links below to access the PowerPoint presentations, which accompany the textbook reading assignments. Click here for the Chapter 9 PowerPoint presentation. Click here for the PDF version.
