Privacy
A financial counselor at Providence Alaska Medical Center accessed the medical records of two patients being treated at the hospital as a favor to a friend.
What is a privacy violation and potential breach?
Stacy was sentenced to two years in prison for a felony violation of HIPAA.
DME or IV Pharmacy sending Enteral medications to members without first confirming the member still needs them; or a physician ordering excessive diagnostic tests.
What is Waste?
Medical professionals providing treatment to a patient that is inconsistent with the diagnosis; or misusing codes and modifiers on a claim such as upcoding or unbundling codes.
What is abuse?
RAC
What is Recovery Audit Contractor?
“That is a very good question, let me ask Nina Salzman and get back to you.”
What should you say if a CMS auditor asks you a question or if a billing regulation is unclear?
An e-mail encryption tool used to send confidential information to a non-Providence e-mail address.
What is #secure#?
Cash or cash equivalents (i.e. gift cards or gift certificates)
Special favors or loans
Discounts or free services
Tips and gratuities
Paid travel for spouses
What are things that we are never allowed to accept as gifts?
A provider billing for services or supplies that were not provided; or a member knowingly sharing their ID card with a non-member in order to obtain services.
What is Fraud?
SIU
What is Special Investigative Unit?
The people responsible for detecting, correcting and preventing fraud, waste and abuse
Who is EVERYONE? You are part of the solution!
Before reaching your destination:
1.Make sure your laptop keyboard is locked; and
2.Cable lock the laptop in the trunk or under the seat of your vehicle.
What is the policy when/if you must leave your laptop in your vehicle?
Reminder: Never leave PHI in vehicle
DAILY DOUBLE
You ask a caregiver to use his/her user ID and password to login to a laptop and he/she will not be present during the meeting or for the entire meeting.
You ask a caregiver to use your user ID and password to login to a laptop for a meeting that you cannot be present for because your ID can get through the encryption.
What is a policy and code of conduct violation?
You have a patient that had a horrible experience. We had to reschedule the appointment 3 times, the clinician showed up at a non-scheduled time, then didn’t show up at the scheduled time. You realized when the team finally got to the home on the right date/time that you didn’t have current orders. You receive a call from the patient, who is on Medicare/Medicaid, you feel awful and decide to waive the patient liability (co-insurance/co-pay).
What is a potential Anti-Kickback Violation?
SMRC
What is Supplemental Medical Review Contractor?
The monetary damage tripled; the penalty between 5 – 10k per claim; jail and/or fine for the individual.
What is the result of a Civil False Claims Act violation?
Individually identifiable health information, such as:
-Name
-Address
-Phone number
-SSN
-Date of Birth
-Medical Record Number
What is protected health information (PHI)?
Gifts of nominal value (i.e. branded office items with vendor’s logo).
Occasional consumables, if shared within the department or unit (i.e. fruit basket, candy or cookies).
Infrequent meals of modest value (< $50) if associated with education or business presentation.
What are exceptions to the no gift policy?
Contact person for a possible widespread billing issue that could possibly lead to a refund to the payer
Who is Nina Salzman?
The unit that is primarily responsible for investigating, identifying, & reporting FWA regarding Medicare, Medicaid & Commercial payers
What is the SIU?
(Special Investigations Unit)
MFCU conducts a statewide program for the investigation and prosecution of healthcare providers that defraud the Medicaid program. The abbreviation MFCU stand for this.
What is the Medicaid Fraud Control Unit?
When working with PHI, only access or disclose the minimum amount of data needed to do your job.
Use shredder bins to dispose of confidential information.
Do not post confidential information on social media sites.
Keep papers and computer screens out of public view.
Double check fax numbers and use a cover sheet when faxing.
Use “#secure#” in subject line when sending confidential information to a non-Providence (or non-Swedish) email address.
What are confidentiality best practices?
1.Discuss the issue or concern with your supervisor;
2.Discuss the issue or concern with the department manager;
3.Contact HCC Compliance team; or
4.Call the Integrity Line (888-294-8455) or use Integrity Online, our Web-based reporting tool.
What is how to report a concern?
This is the process we teach all employees at new caregiver orientation.
PERM
What is Payment Error Rate Measurement?
Contact person if you receive a notification letter from the following:
SIU (Specialized Investigations Unit)
SMRC (Supplemental Medical Review Contractor)
RAC (Recovery Audit Contractor)
CERT (Comprehensive Error Rate Testing)
PERM (Payment Error Rate Measurement)
UPIC (Unified Program Integrity Contractor)
Who is Nina Salzman?
This document must be in place in order to release medical record documentation.
What is an authorization for release of medical information?
Subpoena
Court Order
Administrative Request
Reminder: all medical record requests should go through HIM.