Please respnd to post:
With claims handling and processing regulatory provisions is always at the forefront. Even with the implementation of new groups joining, it is critical for claims specialists to adhere to strict compliance with HIPPA, state medical leave laws, workers’ compensation laws, HITECH, and the False Claims Act. Even access to patients’ personal health information (PIH) requires the protection of their personal medical information via electronic health records/electronic medical records (EHRs/EMRs). The purpose of healthcare laws is for medical professionals and healthcare workers to know these regulations are in place to:
Protection patients from fraud, errors, system abuse, and their rights to privacy.
Healthcare laws and boundaries stipulate what can/cannot be done to patients to prevent any harm.
Standard care has standardized procedures in place to ensure patients are treated fairly and prevent medical facilities/practices and the health insurance industry from making their own set of rules.
The most well-known healthcare law is Health Insurance Portability and Accountability Act (HIPPA) which prevents medical and healthcare professionals from discussing or releasing any medical information about a patient without their written and verbal consent. HIPPA gives patients the right to decide who is authorized access to their medical/health records including standards for electronic medical/health records. HIPPA will help reduce fraud and abuse of patients’ PIH.
The Health Information Technology for Economic and Clinical Act (HITECH) was created as electronic health records were emerging as new standards for healthcare providers to show proof that EHRs were being used to improve the delivery of health, improved engagement with patients, and reduce healthcare disparities. In conjunction with HIPPA, all healthcare professionals under privacy policy are required to secure and protect patients’ EHRs/EMRs.
The False Claims Act prohibits making false medical claims and records of services billed to any federally funded programs such as Medicaid, billing for services not provided, and multiple billing for a single service. (Why You Need to Understand Healthcare Laws).
During the strategic planning and strategic implementation of the phase be aware of how these laws are constant with the processing of any medical or health-related claims. This will hold every department accountable for managing and proper claims handling while preventing any security risks, preventing any breach, or erroneous errors. For this reason, it is important there are appropriate training procedures for new hires and annual refreshers for standard practices of appropriate claim handling.
Best practice methods for processing claims requires coverage verification, 3-point contact (employee, employer, and treating providers), and the creation/develop a strategic action plan within 2-3 business days. A claims specialist should have an idea about each claim, know the action plan for the life of the claim and act thoroughly within the required time for claim handling resolution. (Shafer, 2018). The plan is in an attempt to obtain the required or necessary paperwork, there is still adherence to ongoing strategic planning or a new course of action through the life of the claim. This is a similar practice used by senior health leaders when developing a strategic plan, implementation, and final resolutions. There are always time constraints and decision deadlines based on plan document and summary plan description which both are criteria for ERISA (Employee Retirement Income Security Act). Based on ERISA language, claims have the to request copies of plan documents or adverse decision letters. Plan administrators or employers not furnishing such documents within 30 days of request will have penalties up to $110 per day. (ERISA Code 502 C)
Shafer, Rebecca. 2018, August 15. Proper Claim Management Requires a Strategic Plan of Action. AMAXX Workers Compensation Resource Center.
Why You Need to Understand Healthcare Laws. National American University.