Lab Compliance and Anti-Kickback Laws and HIPAA Flashcards
What are the seven primary elements and principals of laboratory compliance plan?
1) Written policies and procedures and standards of conduct that promote labs commitment to compliance. Chief compliance officer and compliance committee
2) Ways to report suspected compliance violations
3) System to respond to allegations of illegal or improper activities and take disciplinary action against employees involved
4) Internal monitoring, audits and evaluative methods to assess compliance efforts
5) investigation and correction of identified problems
What is medical necessity?
Lab should only submit claims to federally funded health care programs for services that lab has reason to believe are medically necessary
Requisition should contain ICD-10 codes
Lab should notify physicians annually regarding medical necessity policies
Lab should monitor test utilization over time to ensure only necessary tests are ordered
What are some required billing policies?
ensure that CPT codes used to bill medicare or medicaid accurately describe services performed
use ICD-10 information from ordering physician
don’t use past information or programs that automatically insert codes without physician information or make up diagnostic information
labs should only submit claims for tests that were both ordered and performed
only bill for appropriate automated multi-channel chemistry tests
tests on list should not be billed individually unless only one test was performed
standing orders are permitted but must be monitored for validity
What is the Stark Law?
Prohibits a physician from making referrals for the furnishing of testing to lab with which the physician or family member has a financial relationship
Group practice destination may allow exceptions
Applies to MEDICARE AND MEDICAID patients only
Allows labs to supply items to be used solely to collect or process specimens with equipment solely to communicate test results
What is the anti-kickback statute?
Penalizes anyone who knowingly solicits, receives, offers or pays renumeration in cash or support for referring patients for laboratory testing (incentives/inducements)
Applies to MEDICARE AND MEDICAID services
What is the Privacy Rule?
Standards for Privacy of Individually Identifiable Health Information (Privacy Rule)
Establishes set of national standards for the protection of health information
Issued by US Dept of Health and Human Services to implement requirements of HIPAA 1996
Privacy Rule Standards address the use and disclosure of individuals’ health information called PHI by organizations subject to the privacy rule - covered entities and standards for individuals privacy rights to understand and control how their health information is used
What are covered entities?
Organizations subject to the privacy rule
Which office within HHS enforces Privacy Rule?
Office for Civil Rights (OCR) implements and enforces Privacy Rule with respect to voluntary compliance activities and civil money penalties
List the 5 sections (Titles) of HIPAA
1) Focus on Health Care Access, Portability and Renewability
2) Preventing Health Care FraudP and Abuse; Administration simplification; medical liability reform = Privacy Rule, Transactions and Code Sets Rule, Security Rule, Unique Identifiers Rule (NPI), Enforcement Rule
3) Tax-related health provisions governing medical savings accounts
4) Application and Enforcement of group health insurance requirements
5) Revenue offset governing tax deduction for employers
What does Title I of HIPAA regulate?
Focuses on health care access, portability and renewability
regulates availability of group and individual health insurance policies
What are the 5 rules carried under title II to enforce Administrative Simplification?
Privacy rule, transactions and code sets rule, security rule, unique identifiers rule and enforcement rule
What is the Privacy Rule?
Regulates the use and disclosure of PHI (protected health information) by covered entities
upon request, covered entities must disclose PHI to an individual within 30 days
must also provide and disclose PHI as required by law enforcement for investigation of suspected child abuse
Provides individuals with general right to access, inspect, obtain copy of PHI in a designated record set
Under what circumstances can PHI be disclosed without written authorization?
PHI may be disclosed to law enforcement when requested by court orders
PHI can be revealed to facilitate treatment, payment or health care operations
What are elements of the 2013 omnibus rule update to the privacy rule?
revised definition of significant harm in analysis of breach provides more investigation to covered entities with intent of disclosing breaches previously not reported
protection of PHI is until 50 years after death
HIPAA privacy rule may be waived during natural disaster
What are the rights to access in the Privacy Rule?
Requires medical prviders to give individuals PHI access when requested by writing within 30 days
one 30 day extension is allowed if reason for delay is provided in writing to the requesting individual
