Providers are bracing for HIPAA privacy regulations
OIG also lists investigations for upcoming year
If President Clinton’s promise holds true, providers should now be reviewing the final privacy regulations, as mandated by the 1996 Health Insurance Portability and Accountability Act (HIPAA).
These regulations, expected to be released before the November election, should be some of the most challenging, since they require a modification in human behavior, says Jill Callahan Dennis, JD, RHIA, principal of Health Risk Advantage, a risk-management consulting firm in Parker, CO.
It’s also a job that is never really completed, she adds. "Just when you think you have it finished, you have a new batch of employees or volunteers and then you have to go through the [training] process again."
Suits for breach of confidentiality still are not as common as other types of suits, such as malpractice, according to Dennis. That may change, however, as the public becomes more aware of the privacy rules. "People are getting more sensitive to how their medical information is handled. We expect the number of suits related to this to increase quite a bit."
Providers should have already familiarized themselves with the proposed rule and have a sense of how the rule would change their internal practices, she says. Once the final rule is released, providers can look at it in an educated way and understand what needs to be done.
Dennis specifically recommends that providers put together an inventory of their current contracts. "Look at which of your vendors and which of your service providers have access to patient information so you are ready to amend those contracts once the final information security privacy regulations come out."
The final regulation will require changes to the contracts, she says. "A lot of facilities have so many contracts, they don’t even know who has the access."
Providers should also take note of what the Office of Inspector General (OIG) is going to target in its investigations this year. Each year, the OIG details the various projects planned for the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations (OI), and Office of Counsel to the Inspector General for the fiscal year. In October, it released its work plan for the period from October 2000 to September 2001.
The work plan lists the target of the OIG’s investigations in four general categories: Health Care Financing Administration (HCFA); public health service agencies; administrations for children, families and aging; and departmentwide discharges and readmissions, transfers, and diagnosis-related group (DRG) payments remain hot topics in the hospital section of this work plan. The outpatient prospective payment system (PPS) also makes an appearance.
Here are some of the projects under the HCFA category (20 for hospitals) that the OIG plans to review. (To see the entire report, visit the Web site at www.dhhs.gov/progorg/oig/wrkpln/2001):
• One-day hospital stays: The OIG will continue a series of reviews to evaluate the reasonableness of Medicare inpatient hospital payments for beneficiaries discharged after spending only one day in a hospital. The reviews will concentrate on the adequacy of existing controls to detect and deny unauthorized care.
• Hospital discharges and subsequent readmissions: This series of reviews by the OIG will continue to examine Medicare claims for beneficiaries who were discharged and subsequently readmitted relatively soon to the same acute-care PPS hospital. The OIG will review procedures in place for these related admissions at selected hospitals, fiscal intermediaries, and peer review organizations, and with HCFA’s help, determine if those claims were appropriately paid. The OIG also will review claim processing procedures to determine the effectiveness of existing system edits used to identify and review related admissions.
• Payments for related hospital and skilled nursing stays: The OIG will determine the extent of Medicare payments for short- and long-stay hospital and skilled nursing facility care that was provided sequentially to the same beneficiary. Inpatient services may be denied, based on peer review organization reviews, for patients admitted unnecessarily for one stay or multiple stays.
• Satellite hospitals: The OIG will determine the extent to which satellite units and "hospitals-within-hospitals" provide long-term hospital care and examine the effectiveness of HCFA’s payment safeguard protections.
• PPS transfers: The OIG will continue to support the Department of Justice’s assistance in seeking recovery of overpayments and penalties from Medicare PPS hospitals that incorrectly reported transfers. The OIG is working with HCFA to initiate a nationwide recovery of overpayments from hospitals that are not covered by the Justice Department’s project.
• PPS system transfers between chain members: The OIG will review Medicare Part A controls to prevent improper payment of claims for transfers between chain members. The OIG is expanding its work to identify all medical institutions within each chain organization. Additionally, selected chains may be separately reviewed at the request of the Justice Department or the OI.
• PPS transfers — administrative recovery: The OIG will work with HCFA and the Medical fiscal intermediaries to administratively recover overpayments resulting from incorrectly reported PPS transfers. The OIG’s work will focus on the incorrectly reported transfers declined for investigation.
• PPS transfers during hospital mergers: The OIG will determine the extent that PPS hospitals improperly billed for Medicare inpatient transfers when merging or consolidating multiple hospitals.
• Post-acute services for DRGs considered transfers: The OIG will assess early changes in utilization patterns for the 10 DRGs for which post-acute services are considered transfers rather than discharges for payment purposes. This review will examine whether providers exhibit different utilization patterns for those DRGs, such as sending beneficiaries home for several days before admission to inpatient rehabilitation, using a second post-acute provider to render care, issuing notices of noncoverage to beneficiaries, or coding inpatient stays to fall into other DRGs.
• Uncollected beneficiary deductibles and coinsurance: The OIG will continue a series of reviews addressing the reasonableness of Medicare payments to inpatient hospital providers that fail to collect deductible and coinsurance amounts from beneficiaries.
• DRG payment limits: The OIG will continue to assess the ability of Medicare contractors to limit payments to hospitals for patients who are discharged from a PPS hospital and admitted to one of several post-acute-care settings.
• Outlier payments for expanded services: The OIG will continue to examine the financial impact of outlier Medicare payments made in unusual cases for inpatient care.
• DRG payment window — hospitals: The OIG will determine whether hospitals have complied with the settlement agreements they entered into with the OIG to preclude duplicate billing for nonphysician outpatient services under the PPS. The review also will determine the extent that duplicate claims have been submitted by Part B providers for services (such as ambulance, laboratory, or X-ray services) provided to hospital inpatients.
• DRG payment window — Part B providers: The OIG will determine the extent of duplicate claims submitted by Part B providers for services, such as ambulance, laboratory or X-ray services, provided to hospital inpatients. This is a companion review of the OIG’s review of hospital providers.
• Hospital reporting of restraint-related deaths: The OIG will assess hospital compliance with Medicare requirements, issued July 1, 1999, to report all patient deaths that may have been caused by use of restraints or seclusion. The OIG will examine HCFA’s early experiences with hospital reporting and review Medicare claims and enrollment data to determine whether patient deaths are being reported.
• Outpatient PPS: The OIG will review implementation of the PPS for care provided to Medicare beneficiaries by hospital outpatient departments. The OIG will evaluate the effectiveness of internal controls intended to ensure that services are adequately documented, properly coded, and medically necessary. Controls over "pass-through" costs will also be reviewed.
• Outpatient pharmacy services at acute-care hospitals: The OIG review will determine whether pharmacy services rendered on an outpatient basis were billed and reimbursed in accordance with Medicare requirements. This review will focus on periods before implementation of the outpatient PPS.
• Outpatient medical supplies at acute-care hospitals: The OIG will determine whether medical supply services rendered on an outpatient basis were billed and reimbursed in accordance with Medicare requirements. This review will focus on periods before implementation of the outpatient PPS.
• Follow up on peer review organizations’ complaint process: The OIG will evaluate the effectiveness of the Medicare peer review organizations’ beneficiary complaint process. This follow-up to the OIG’s 1995 report (OEI-01-93-00250) will examine the progress that HCFA has made in implementing the OIG’s recommendations. It also will assess the current complaint process for accessibility, objectivity, responsiveness, timeliness, investigative capacity, enforcement follow-through, improvement orientation, and accountability.
• Advanced beneficiary notices: The OIG will examine the use of advance notices to beneficiaries and their financial implant on beneficiaries and providers. Physicians must provide advance notices before they provide services that they know or believe Medicare does not consider medically necessary or that Medicare will not reimburse.
• Critical care codes: The OIG will examine the use of two critical care codes that may be billed to Medicare only if the patient is critically ill and requires constant attention by the physician. The OIG also will examine claim data to determine whether some physicians may be billing inappropriately for critical care, as well as identify any other potential vulnerabilities. n
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