Lesson 6 Discussion
What is the definition of “indemnity” insurance? Why do you suppose it has largely been replaced by managed care? What are the three main types of managed care organizations? What are the pros and cons of each type?
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Component 1, Until 6: Lecture d: Introduction to Health Care and Public Health in the U.S.: Regulating Health Care Lecture e Introduction to Health Care and Public Health in the U.S. Regulating Health Care Lecture e This material (Comp 1 Unit 6) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/. Welcome to Introduction to Health Care and Public Health in the U.S.: Regulating Health Care. This is lecture e. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S. Health IT Workforce Curriculum Version 4.0 1 Regulating Health Care Learning Objectives - 1 Describe the role of accreditation, regulatory bodies, and professional associations in health care in the U.S. (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) 2 The Objectives for Regulating Health Care are to: Describe the role of accreditation, regulatory bodies, and professional associations in health care in the U.S. Describe the basic concepts of law in the U.S.: the legal system, sources of law, classification of laws, the court system, and the trial process. 2 Regulating Health Care Learning Objectives - 2 Describe legal aspects of medicine involving the Affordable Care Act, professional standards in health care, medical malpractice, Tort reform, and Medicare and Medicaid Fraud and Abuse (Lecture c) 3 Describe legal aspects of medicine involving the Affordable Care Act, professional standards in health care, medical malpractice, tort reform, and Medicare and Medicaid fraud and abuse. 3 Regulating Health Care Learning Objectives - 3 Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and describe efforts to promote patient safety in the U.S. (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 health care organizations. (Lecture e) 4 Describe key components of the Health Insurance Portability and Accountability Act, or HIPAA, and current issues concerning privacy and patient safety in the U.S. And, discuss the need for quality clinical documentation for use of the health record as a legal document, communication tool, and a key to prove compliance for health care organizations. 4 The Health Record Summarizes a patient’s health conditions and care activities Historically existed on paper but have become increasingly digitized Serves as a Communication and quality enhancement tool Legal record of the care provided 5 This lecture discusses the health record as a communication tool and legal document to demonstrate compliance with laws, rules, regulations, accreditation, and internal policies. Health records are documents that summarize a patient’s health conditions and care activities. Historically, health records were recorded on paper, but over the past few decades, health records have become increasingly digitized. The terms “electronic medical record” and “electronic health record” are largely synonymous, however, the use of the term “electronic health record” is frequently used to denote that the health record is multi-disciplinary in nature. The health record is, first and foremost, a tool for communication among members of the health care team. It is important that documentation in the health record be complete and accurate. When all components of the health record are used, such as clinical documentation, lab reports, x-rays, surgical reports, and consult reports, the patient has the best chance of receiving high-quality health care. Health IT Workforce Curriculum Version 4.0 5 The Health Record as Tool for Patient Safety Providing care based on a full understanding of a patient’s current and past conditions is a key element of safe care Information in the health record is monitored for accuracy and completeness The health record is used to manage risk and improve care 6 Safe patient care necessitates that all care providers have a complete and accurate picture of the patient’s current and past medical conditions. From admission to discharge, whether in an acute care facility, outpatient setting, long-term care, or any other health care system, the information that is documented in the health record is carefully monitored for accuracy and completeness. After the patient leaves a health care system, the health information management department, or HIMD, continues to assess the completeness of the electronic record. In an electronic health record that includes scanned paper documents, the quality of the scanning process and filing of the documents in the correct area of the record will affect future use of the scanned information. When an error or incident occurs, an incident report is generated and the risk management department reviews and addresses the incident. Health care organizations provide ongoing education to care providers regarding best practices in clinical documentation. Education is also provided regarding areas of identified clinical documentation deficiencies or inaccuracies so that they can be avoided. With improved documentation quality, patient safety and health care quality also improve. 6 The Health Record as a Legal Record Considered the business record for a health care organization Also a legal record Admissible in a court of law Substantiates quality of care provided 7 In any health care organization, the health record is considered the business record for the organization. As the business record of the organization, the health record holds key information for decision making, both administrative and clinical. The health record will be used for many purposes, such as analyzing the quality of care given a patient, processing claims for reimbursement, conducting research, and planning of resource needs. As such, it is also the legal record. Information documented in the health record can be used in a court of law as evidence to substantiate the quality of the treatment given to the patient. Therefore, health care organizations must consider the importance of clinical documentation as it relates to the legal health record. 7 Governance of Health Record Federal and State Laws, Regulations, and Rules The Joint Commission and other voluntary accreditation Medical staff bylaws 8 The components of the health record are governed by many different external agencies. These may include federal and state laws, regulations, and administrative rules. Voluntary accreditation, such as by The Joint Commission, introduces requirements for documentation in the health record. At the health care facility level, medical staff bylaws also provide direction for completion and maintenance of documentation in the health record. It is difficult to keep abreast of all the changes occurring in health record policies. Facilities must develop compliance plans to make sure that external and internal rules are followed. The director of a health information management department must stay up to date on legislative and accreditation changes that affect requirements for documentation in the health record. Key areas of focus include medical coding, reimbursement laws and regulations, and privacy of patients’ health information. Clinical departments within a health care organization must monitor new laws and regulations for their respective areas. In addition, each facility should also have an oversight committee, department, and/or director to ensure overall compliance with documentation requirements. 8 Quality Clinical Documentation for Legal Purposes Hand-written documentation Illegibility introduces malpractice risk Electronic documentation Mistakes can be made, but the legibility of health record content is improved More detailed notes “What isn’t documented isn’t done” 9 Hand-written documentation may be illegible, and mistakes can be made when interpreting the provider’s intentions about treatment. When mistakes occur because of illegible handwriting, the health care facility is at risk for malpractice claims in a court of law. Although mistakes can still be made in an electronic documentation system, illegibility of handwriting will not occur. Clinical documentation will not protect a health care organization from litigation unless the content is thorough enough to communicate with the members of the health care team about the treatment. Therefore, the health record must provide clear and honest reflections of the care needed or given to patients. There is an old adage, “What isn’t documented isn’t done.” If the health record does not indicate what is actually done for the patient, the health record as a legal document does not hold up in court. 9 Quality Clinical Documentation to Avoid Fraud and Abuse Accusations Clinical documentation improvement programs support high-quality documentation Train providers High-quality documentation supports accurate coding and reimbursement Accurate coding is needed to avert accusations of fraud and abuse 10 No legitimate individual provider or health care organization wants to be accused of fraud or abuse. Examples of fraud or abuse include billing for a higher level of service than was provided, or billing for a service that was not provided. Ethical standards must be upheld for reporting claims for reimbursement at all levels of health care. This is best done by developing clinical documentation improvement programs, in which providers are trained to provide high-quality documentation in the health record. Reimbursement of claims is based on documentation in the health record. A “coding specialist” reviews the health record and provides code numbers that are then linked to a payment system for the payer responsible for the claim. 10 OIG Compliance Program Tips - 1 The Seven Fundamental Elements of an Effective Compliance Program Implementing written policies, procedures and standards of conduct Designating a compliance officer and compliance committee Conducting effective training and education. Developing effective lines of communication 11 Compliance programs have been a focus of health care organizations since the late 1990s, when the U.S. Office of the Inspector General, or OIG, began a campaign against fraud and abuse in health care for the Medicare and Medicaid programs. The fight against fraud and abuse has escalated in the past few years. Those who report fraudulent practices, called “whistleblowers,” are protected. The issues of fraud and abuse are complicated. Compliance programs within health care organizations broadly focus on all external rules, regulations, laws, accreditation guidelines, internal medical staff bylaws, and department compliance responsibilities. The location of the compliance program depends on the organization. For example, it may operate under a separate department, within risk management, or in the quality department. The Office of the Inspector General provides training on compliance issues. There are seven fundamental elements of an effective compliance program. Four are shown here and there are three on the next slide. 11 OIG Compliance Program Tips -