LEGAL ISSUESA medical bill submitted in
your name can subject you to
penalties and fines for lack of
compliance.Disclosures of confidential
health information must
comply with the privacy rule
of HIPAA.Credentialing
Hospital credentialing is specific to each institution. A committee of physi-
cian colleagues and administrators grants an approved list of activities, espe-
cially procedures based on education, training, and experience. Hospitals may
accept ABEM certification as a sufficient indicator of competence, but they
do not have to. When new techniques and technologies are introduced, physi-
cians must often demonstrate knowledge and skills. State boards, insurors, reg-
ulatory agencies, and others organizations may use credentialing, or denial
and revocation of credentials by one another, as a basis for adverse action on
payment, participation, and even licensing.
COMPLIANCE AND CONFIDENTIALITYAlthough the word compliance in common usage has much wider meaning,
in health law it refers to conformity with rules, especially federal medical
billing rules and patient confidentiality laws.
Billing
Billing for services requires both the CPT®(Current Procedural Terminol-
ogy) and International Classification of Diseases (ICD) codes. One overly
simple way to look at the two is that the CPT is what you did and the ICD is
why you did it.
CURRENTPROCEDURALTERMINOLOGY
■ Basis of Evaluation and Management (E&M) codes
■ Owned and published by the American Medical Association
■ Enforced by Medicare
■ Five levels of E&M codes plus the critical care code
■ Insurers insist on the codes in all billing submissions.
Billing for services not performed is fraud, if intentional. Fraud is a form of
theft and subjects the physician to fines and other penalties. The more com-
mon problem for physicians is error. It often results from use of billing agen-
cies or the hospital’s system. Even honest error can subject the physician, not
the billing company, to investigation by insurers, principally Medicare or
Medicaid. Investigators come to the hospital and review a number of charts. If
inaccurate or unsupported coding is found, the percentage of that finding can
be applied to all bills in a given period. Errors are discovered through auto-
mated review, focused medical review, and random audits.
An ED patient in police custody is being discharged and the officer wants a
copy of the medical record. Can you give it to him?
Only if the patient/arrestee consents.Confidentiality and HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
was intended to:
■ Standardize health information transfers
■ Require identification numbers for providers, health plans, and employers
■ Protect confidential protected health information