HIPAA Compliance

Title II: Preventing Medical Healthcare Fraud and Abuse, Administrative Simplification, and Medical Liability Reform

Title II addresses many more concerns relevant to the medical billing and coding field, namely, security and privacy requirements for handling a patient’s medical records and methods to simplify the billing and processing of claims. In addition, it establishes guidelines for electronic recordkeeping and electronic transactions between parties in the healthcare system.

Title II also stipulates how healthcare providers and insurance companies should avoid fraudulent activity. The law puts the Officer of the Inspector General (OIG) of the Department of Health and Human Services (DHHS) in charge of investigating and if necessary prosecuting those who commit fraud. Your responsibilities as a medical billing specialist will be discussed in the next section of this lesson.

The Privacy Rule

Title II expands security and privacy measures within the healthcare system with the creation of the Privacy Rule and the Security Rule. The Privacy Rule addresses how insurance companies and providers can handle patient information by regulating how they disclose the information to each other and to other entities that may require medical data. Under the Privacy Rule, medical billing and coding specialists must be careful not to share a patient’s Protected Health Information (PHI) with parties that aren’t covered entities (providers, insurance companies, etc.) as stipulated by Title II. A patient’s PHI includes the following data:

• The patient’s medical record, including present and past medical conditions or illnesses and treatments received for them
• The location and type of healthcare provider wherein the patient received care
• Any and all fees paid by the patient or a patient’s insurance company to cover healthcare expenses rendered by a provider

The Security Rule

The Security Rule, on the other hand, establishes the rules for protecting a person’s information and also explains how those rules can be enforced if necessary. The security rule explains how covered entities must collaborate to protect patient medical information. Part of this collaboration involves the creation of computerized physician order entry (CPOE) systems and electronic healthcare records (EHRs) that medical billing and coding specialists use everyday to file and process claims. The Security Rule also requires that any technologies developed by covered entities to facilitate their administrative work must be secure and up to standards established by HIPAA.

Title II also creates unique identifiers for providers, employers, and patients in an attempt to optimize communication between entities in the healthcare system and universalize the billing process. This is done in accordance with the Electronic Data Interchange (EDI) Rule set forth in Title II. The unique identifiers created for the EDI are either individual numbers or code sets assigned to covered entities for the use of electronic transactions and should have equal value and meaning for any medical billing specialist. Some of the unique identifiers include the following sets:

• The National Standard Employer Identifier Number (EIN) for tracking employers
• The National Provider Identifier Number (NPI) for tracking providers such as private clinics, hospitals, and nursing facilities
• The National Health Plan Identifier Number (HPID) for tracking participating health insurance companies

For medical billing and coding purposes, the standards set forth under Title II are important because they optimize the claims process. The format and transaction of electronic claims in particular is simpler and more secure now than ever before thanks to Title II of HIPAA.

Medical Billing Guidelines

Medical billing and coding specialists deal with sensitive information on a daily basis. As a medical billing and coding specialist, you will handle provider, patient, and insurance information that must be kept secure at all times. You will also be responsible for facilitating the secure electronic and physical transference of sensitive medical information between these parties. Failing to perform your duties within the guidelines may result in a federal investigation.

An overview of guidelines and compliance requirements set by the Health Insurance Portability and Accountability Act (HIPAA), the Office of the Inspector General (OIG), and the Healthcare Reform Act of 2010 follows. The guidelines set forth by these entities comprise some of the most important privacy, security, and filing-related rules you will need to know as a medical billing specialist.

HIPAA Compliance

HIPAA was passed by Congress and signed into law by President Clinton in 1996. Chief among the goals set forth by HIPAA was increased security and accountability when it comes to patient medical information. Specifically, HIPAA established guidelines that healthcare providers and health insurance companies must follow in order to keep a patient’s information secure.

These HIPAA guidelines apply to the gathering, cataloging, and transferring of any and all patient information. For the purposes of medical billing and coding, HIPAA serves to curb fraudulent activity before, during, and after the claims process as well as establishing standards for transferring patient information electronically.

HIPAA is divided into five Titles.

Title I: Healthcare Access, Portability, and Renewability

Title I of HIPAA addresses health insurance policies within the confines of a person’s employment. Under Title I, HIPAA sets guidelines for what an employer can and cannot do with an employee’s healthcare plan as provided by the employer. Specifically, Title I protects health insurance coverage for employees and their dependents by making healthcare plans available to those who have either lost their job or those who are in the process of switching employers.

Title I protects employees by modifying and improving the Consolidated Omnibus Reconciliation Act of 1985 (COBRA). Title I of HIPAA extended healthcare benefits already offered by COBRA, including extending the duration of benefits of disabled persons eligible for COBRA from 18 to 36 months. Title I also allowed dependents of a person covered under COBRA to continue to receive the same healthcare coverage as they did when that person was employed with health benefits.

Title I also addresses how health insurance companies treat patients with pre-existing conditions. Before HIPAA, a person with a pre-existing condition might have trouble finding a healthcare plan that covers their medical expenses because commercial insurance companies would consider them too risky to cover. Under Title I, insurance companies are limited in how many restrictions they can put into place in their healthcare plans for people with pre-existing conditions.

For medical billing and coding professionals, Title I is important because it ensures that more people are eligible for health insurance. Because of the laws set forth in Title I, you will process claims that involve patients covered by COBRA or those with pre-existing conditions that still receive coverage thanks to this act.