01-06e - introduction to healthcare and public health in the us - unit 06 - regulating healthcare -...

Introduction to Healthcareand Public Health in the US

Regulating Healthcare

Lecture eThis material (Comp1_Unit6e) was developed by Oregon Health and Science University, funded by the

Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

Regulating HealthcareLearning Objectives

• Describe the role of accreditation, regulatory bodies, and professional associations in healthcare in the US. (Lecture a)

• Describe the basic concepts of law in the United States: the legal system, sources of law, classification of laws, the court system, and the trial process. (Lecture b)

• Describe legal aspects of medicine involving the Affordable Care Act, professional standards in healthcare, medical malpractice, Tort reform, and Medicare and Medicaid Fraud and Abuse (Lecture c)

• Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and current issues of privacy and patient safety in the US (Lecture d)

• Discuss the need for quality clinical documentation for the use of the health record as a legal document, communication tool and a key to prove compliance for healthcare organizations. (Lecture e)

2Health IT Workforce Curriculum

Version 3.0/Spring 2012

Introduction to Healthcare and Public Health in the US Regulating Healthcare

Lecture e

The Health Record as Tool for Patient Safety

• Quality of care is key to patient safety• Monitoring information in the health record • Use of health record to manage risk and improve

healthcare




Lecture e

The Health Record as a Legal Record

• Business Record• Legal Record




Lecture e

Governance of Health Record

• Federal and State Laws, Regulations, and Rules• Joint Commission• Other voluntary accreditation• Medical staff bylaws




Lecture e

Quality Clinical Documentation for Legal Purposes

• Hand-written documentation• Electronic documentation




Lecture e

Quality Clinical Documentation to Avoid Fraud and Abuse Accusations

• Clinical documentation improvement programs • Coding and reimbursement• Issues of fraud and abuse




Lecture e

Compliance Program Tips from OIG

The Seven Fundamental Elements of an Effective Compliance Program

1. Implementing written policies, procedures and standards of conduct. 2. Designating a compliance officer and compliance committee. 3. Conducting effective training and education. 4. Developing effective lines of communication. 5. Conducting internal monitoring and auditing. 6. Enforcing standards through well-publicized disciplinary guidelines. 7. Responding promptly to detected offenses and undertaking

corrective action.




Lecture e

Corporate Integrity Agreements A comprehensive CIA typically lasts 5 years and includes requirements

to:• hire a compliance officer/appoint a compliance committee; • develop written standards and policies; • implement a comprehensive employee training program; • retain an independent review organization to conduct annual reviews; • establish a confidential disclosure program; • restrict employment of ineligible persons; • report overpayments, reportable events, and ongoing

investigations/legal proceedings; and • provide an implementation report and annual reports to OIG on the

status of the entity's compliance activities.



Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

Compliance Beyond Fraud and Abuse

• HIPAA Privacy and Security Rules– What is the plan for appropriate release of PHI?– How is the tracking of release occurring?– Who is responsible for breach notification?– What training is being done?– Is there a team reviewing policies and procedures?



Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

Regulating HealthcareSummary – Lecture e

• The health record is the business and legal record for a healthcare organization

• The health record is the communication tool for the healthcare team• Clinical documentation is used to assure high quality care of the patient, as

well as to provide information for decision-making, reimbursement and medical coding

• Thorough and complete clinical documentation protects healthcare organization from the risk of fraud, abuse, and malpractice claims

• Compliance programs are important to assure correct procedures to follow related to regulations, rules, laws, accreditation, and internal policies

• HIPAA privacy and security rules need to be included in compliance plans




Lecture e

Regulating HealthcareSummary

This unit discussed:• Healthcare accrediting and certification organizations;• The US legal system;• The laws governing healthcare practice;• privacy and security rules;• The clinical documentation in the health record supports quality healthcare,

administrative and business operations of the organization, and provides the basis for legal proof of care that assures compliance with laws, rules, and regulations as well as professional standards of care




Lecture e

Regulating HealthcareReferences – Lecture e

References • American health Information Management Association. http://ahima.org/resources/infocenter/ehr.aspx. accessed on

11/11/2011.• American Health Information Management Association. http://ahima.org/resources/cdi.aspx. accessed on 11/11/2011.• American Health Information Management Association. http://ahima.org/resources/psc.aspx. accessed on 11/11/2011• Bayes, N., Newby, J, Seggern, J, Valerius J. Medical Insurance An integrated claims process approach 5th edition, 2012.

McGraw Hill Companies: New York• Davis, N. Revenue Cycle Management Best Practices, 2011, AHIMA Press: Chicago• Healthcare Compliance Program Tips accessed on 11/9/11:

http://oig.hhs.gov/compliance/provider-compliance-training/index.asp• LaTour & Eichenwald, Health Information Management, concepts, Principles, and Practice, Third Edition, 2010 AHIMA

Press: Chicago• Russo, R. Clinical documentation improvement, 2010 AHIMA Press: Chicago• Office of the Inspector General. http://oig.hhs.gov/. accessed on 11/11/2011.• Office of the Inspector General. http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp. accessed on 11/11/2011.• Office of Inspector General. A roadmap for new physicians: avoiding Medicare and Medicaid fraud and abuse.

http://oig.hhs.gov/fraud/PhysicianEducation. Accessed 11/11/2011.• Office of the Inspector General. http://oig.hhs.gov/newsroom/video/index.asp. accessed on 11/11/2011.• Centers for Medicare and Medicaid. http://www.cms.gov/default.asp. Accessed on 11/11/2011. • Corporate integrity agreements. http://oig.hhs.gov/compliance/corporate-integrity-agreements/index.asp. Accessed on

11/9/11

.




Lecture e

http://ahima.org/resources/infocenter/ehr.aspx

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