Protecting Healthcare Fraud And Abuse

Many healthcare professionals and organizations have not been following the regulations set forth by HIPAA. Whenever violations of HIPAA’s privacy or security laws occur the organizations responsible must be held accountable resulting in a fine or penalty. Penalties provide incentive for organizations to guarantee patient privacy and security. Recently, certain people have failed to follow through with the laws and restrictions and were forced to accept the penalty. This paper will provide three real examples of such HIPAA violations as well as solutions or ways each violation could have been prevented.

Healthcare technology has grown and evolved over time. With the conversion to electronic medical records and the creation of social media just to name a few, ensuring patient privacy is of the utmost importance for healthcare facilities in this day and age. In order for an organization to avoid hefty fines, it is imperative that a healthcare administrator maintains compliance with the standards and regulations associated with the Health Insurance Portability and Accountability Act (HIPAA). This paper will provide a summary

The protection and privacy of HIPAA (Health Insurance Portability and Accountability Act) which became law in ,1996. Subtitle F of Title II of HIPAA, entitled "Administrative Simplification, "requires the Secretary of Health and Human Services to adopt national standards for certain information- related activities of the health care industry. This law works to make the efficiency and effectiveness of the health care system by mandating the development of standards and requirements to enable

The Health Insurance Portability and Accountability Act also known as HIPAA was first signed into law on the federal level in 1996. Since it was signed into law it has had a huge effect on patient’s privacy, healthcare workers and even insurance company’s. “HIPAA is intended to improve efficiency throughout health care and requires that health care providers adhere to standardized national privacy and confidentiality protections.” (OMA p .236). It’s an invaluable tool that has created a standard of compliance across the healthcare field.

Even though hipaa violations are an important standard in preventing many individuals from causing several breaches of information from getting out, it is important to work on a strategies within several health care organizations that will work with the privacy rules regarding violation laws. “Jill Granger & Laura Cataldo (2013) reports When working in the healthcare setting, it is important to consult with the guidelines established by one's institution and to participate in any training programs to insure that the appropriate steps are being taken to maintain privacy. There are also a variety of additional resources available from the federal government and professional organizations to assist in the training process that may be especially

Most people have a basic understanding about HIPAA and what it entails, but for future healthcare leaders, it is a critical issue. The goals behind the HIPAA privacy rules are very beneficial for keeping individual’s health information private, but it does place a heavy burden on organizations to ensure the information remains protected. Healthcare leaders have always had to adapt to change, but it is becoming increasingly necessary to have leaders that can adapt quicker than ever. Not only do they need to keep up with the technological advances in healthcare, but they also need to become compliant with the new and ever-changing healthcare laws. Numerous modifications have been implemented under HIPAA in the

The Health Insurance Portability and Accountability Act (HIPAA) was signed into legislation in 1996, with the final version of its privacy rules going into effect in 2002. In addition to insurance and healthcare transaction regulations, HIPAA includes two key features. First, the portability of health care for workers who transition between jobs. Second, HIPAA regulates how patient’s health information must be secured with detailed privacy policies. It is important that HIPAA practices are employed by the clinic for several reasons. First and foremost, it is legally required by the Department of Health and Human Services (HHS). HIPAA non-compliance can lead to financial penalties and lost accreditation with The Joint Commission which will have

HIPAA, (Health Insurance and Portability Act of 1996) outlines rules and regulations and the rights of patients to access their healthcare information such as, notifications of privacy practices, copying and viewing medical records, and amendments. This paper explains why confidentiality is important today and discusses recourses patients can use if they believe their privacy has been violated. This paper will also discuss criminal and civil penalties’ that can occur for breaking HIPAA privacy rules.

The HIPAA Privacy Rule, which regulates the use and disclosure of certain information held by a covered entity, took effect on April 14, 2003. The Privacy Rule regulates the use and disclosure of PHI. A medical office specialist must know and understand the guidelines included under the Privacy Rule, such as the guidelines for release of a patient’s health information to their family, friends, or other persons identified by the patient which are outlined under the Health INsurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. As a medical office specialist you need to know the safeguards for reducing the risks to PHI.

The significance of patient privacy and the security of confidential information are increasingly vital given the approval of electronic health records. Healthcare providers have recognized striking prices due to security threats and subsequent breaches. According to U.S. Department of Health and Human Services (2002), under the Privacy Rule healthcare establishments must establish protections that establish procedures and rules that guarantee least levels of privacy in relation to patient information. When violations are recognized, it is required that a compliant be created by the individual or unit experiencing the violation. In the complaint, the name of the person who participated in the violation, in addition to the nature of the violation, must be comprehensive. The filing of the complaint initiates an investigation by the Secretary of the U.S. Department of Health and Human Services under HIPAA values (U.S. Department of Health and Human Services, 2013). The establishment of a procedure related to privacy violations has resulted in many cases relating to electronic data breaches. Next is a consideration of two such cases to demonstrate the role of privacy in regards to HIPAA and electronic health database breaches.

The HIPAA Privacy Rule creates business processes to protect the use and disclosure of protected health information (PHI). PHI includes any information about health status, type of care, or payment related to care that can be related to an individual. The term is broad, and generally includes all information contained in a patient’s medical record and payment history. It includes demographics, in paper, electronic, or oral form. PHI is not limited to the documents contained in the official medical record. The HIPAA Privacy Rule allows the use and disclosure of this PHI for treatment, payment, and health care operations without written authorization from the patient. Other uses and disclosures require permission or consent from the individual.

There are three types of safeguards to help secure health information. An administrative, physical, and technical security helps protect and maintain the HIPAA security rule. The HIPAA privacy law that regulates the use and disclosure of patients’ protected health information. The privacy Rule states that you should notify patients about their privacy rights and how their information can be used or disclosed. You should also have a set of privacy practices that are appropriate for its healthcare

The hospital accounting department will also be off limits except only for those personnel that are authorized. Extra vigilance must be place on all medical record rooms, since the hospital still has paper medical records. All medical staff will receive training so that they understand the importance of HIPAA. This policy will guarantee that we have controls in place in regards to accessing patient information and staff access is monitored.

Healthcare fraud and abuse has become a major issue in the medical industry, it is estimated that billions of dollars are lost annually due to healthcare fraud. Healthcare fraud can occur in many forms for instance, billing for services that weren't provided, or perhaps a duplicate submission of a claim for the same service. "Upcoding" is a term used when providers charge for a more complex or more expensive service than that which is actually provided. Also billing for a covered service when the service actually provided was not covered. Those are some examples of how providers commit healthcare fraud. Members also commit healthcare fraud when they use a member id that does not actually belong to them. Also when they add someone to a policy

According to one source, an estimated 4 billion health-related claims were made to all of the combined insurance companies in the United States in 2011 (National Health Care Anti-Fraud Association, 2016). It would certainly be a daunting, if not impossible task to monitor them for unnecessarily performed procedures and undoubtedly some physicians exploit this for their financial gain. Perhaps some physicians do see patients with Medicare or Medicaid as an easy way to make money. However, in the case of Medicaid, the standard payout is 56% less than that of private insurance and many specialists simply refuse to accept this insurance due to this (Dayaratna, 2016). This may be a two-edged sword for some of these patients. They may get an unnecessary