Patient confidentiality issue looms large for CMs
HIPAA rules to have long-term effect on liability
The Health Insurance Portability and Accounta-bility Act’s (HIPAA) recently released final rules will significantly impact case managers responsible for telephoning or faxing clinical information to payers and their agents. Slated to go into effect October 2002, the new confidentiality rules are almost sure to have long-term consequences on the issues of e-health, legality, and liability.
Under the new rules, formulated to address Americans’ growing concerns regarding violation of the privacy of their medical information, case managers are specifically named as "providers" of health care and not just coordinators. Essentially, that means they will be accountable for patient privacy and confidentiality — something some case managers have not been responsible for until now.
With the new rules, institutions that transmit or maintain electronic health information will have to develop a security plan, provide training for employees, and secure physical access to records. Health information regarding patients must be protected during transmission and where it is maintained in electronic form. Other administrative procedures, physical safeguards, and technical security measures also will be needed.
The Case Management Society of America (CMSA) in Little Rock, AR, plans to develop a series of guidelines for case managers regarding protected information. The guidelines will be available to CMSA members early next year. The organization also has scheduled an authority on HIPAA to speak at its annual conference in June 2001.
Designed to streamline the processing of health care claims and other administrative health transactions while providing better service for providers, insurers, and patients, the new rules reportedly will promote the greater use of electronic transactions, while at the same time eliminating inefficient paper forms. The rules are expected to provide a net savings to the health care industry of $29.9 billion over 10 years.
As purveyors of so-called "atypical services," case managers under the new rules will be responsible for protecting the privacy of patients on their caseload as they disseminate information to providers and others. With the implementation date still almost two years away, many case management departments already are busy devising their own methods of complying with the new rules. At Shands Jacksonville (FL), a housewide multidisciplinary team has been appointed to study HIPAA issues and policies.
The facility already requires that like its other employees, case managers, social workers, and referral specialists sign a document annually holding them accountable for observing confidentiality and privacy. In addition, as a required competency for clinical personnel, maintaining confidentiality is currently incorporated into performance evaluations. "From a competency standpoint, case managers at our facility always have been considered caregivers," says Frank B. Bellamy, RN, MSN, CCRN, director of case management.
As a way of circumventing potential problems, the hospital recently has implemented a policy that prohibits its case managers from directly accepting calls requesting information from payers. Instead, all requests are directed to the appropriate case manager’s voice mail, with calls to be returned later that same business day.
Once it has been determined that the call is being made to a published number with an identified representative, case managers are then expected to place the call, details of which are then documented in an automated utilization review documentation system.
The system presents its own, unique set of challenges, Bellamy says. "Directing all requests to a voice-mail line does not always support customer friendliness. And from an administrative standpoint, unless the requests are carefully monitored and tracked, there’s always that risk they won’t be addressed on a timely basis." In spite of that, he’s confident that the benefits outweigh the risks. "[First], you have the added assurance that information is shared real time only with the payer or representative who has a need to know," he says. Bellamy adds that if the case manager returning the call reaches a voice mail, he or she will not leave the information unless the voice mail explicitly states that it is a confidential line with access limited to the individual for whom the call is intended. "We will not leave clinical information on an open or shared voice line."
Although the practice of faxing clinical information is heavily discouraged, on those rare occasions when it is unavoidable, at Shands, "we employ the [same] safeguards to ensure that the destination number is associated only with the payer or agent. We also ask for confirmation that the information was received intact," he says. Outside of the utilization review function, the department employs the same safeguards when making referrals to community agencies. "Both case managers and social workers are obligated to ascertain the identity of the person on the other end of the line whenever clinical information must be shared for continuity of care," Bellamy says.
At Baptist Health in Jacksonville, FL, case managers will not release clinical information to commercial payers unless a medical release signed by the patient at the time of admission has been obtained. "As nurses, we are bound to maintain confidentiality. Most patients would not mind us releasing clinical information to payers, but if the information was regarding sexually transmitted diseases or drug and alcohol use, it could be construed as inappropriate without that vital signature, so for that reason, we stand firm," says Harriet Ables, clinical coordinator, utilization review coordinator.
If for whatever reason a case manager is working in a setting that does not have a consent form of some type in place, Ables says it is critical that one be created. "Every case management course I have ever taken highly recommends a consent form for release of information to be signed by the patient."
In any situation where the implementation of new rules is involved, one of the biggest potential stumbling blocks is that unless a strong system of linkage is already in place, an institution’s various departments all too easily can end up at odds. "Rather than addressing the issues separately and running the risk of being in conflict, I would recommend where possible working with departments that already are addressing some of the issues involved," says Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI. "It’s a lot easier to have a centralized initiative and incorporate into an existing structure, than it is to create new ones."
For more information, contact:
Judy Homa-Lowry, RN, MS, CPHO, President, Homa-Lowry Healthcare Consulting, Canton, MI. Telephone: (734) 459-9333.
Harriet Ables, Clinical Coordinator, Utilization Review Coordinator, Baptist Health, Jacksonville, FL. Telephone: (904) 202-2000.
Frank B. Bellamy, RN, MSN, CCRN, Director of Case Management, Shands Jacksonville (FL). Telephone: (904) 549-4165.
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