Lecture 14 Policy, Legal, and Regulatory Issues in HIS (Chapters 18,19,20)

http://www.csun.edu/~dn58412/IS531/IS531_SP15.html

Lecture 14Policy, Legal, and Regulatory Issues in

HIS (Chapters 18,19,20)

Learning OutcomesLearning Outcomes

1. Status of current healthcare delivery system and related policies in US

2. Legal issues and their implementation3. Regulatory issues and agencies

IS 531 : Lecture 14 2

Status of U.S. Healthcare Status of U.S. Healthcare Delivery SystemDelivery System

• Higher expenditure• Standardization• Fragmented care• Unequal access to care• Less-than-optimal safety• Poor evaluation by patients• Payment for service rather than

maintaining wellness• Lack of rewards for primary care


Healthcare ReformHealthcare Reform

• Health IT was seen as a tool to aid the reform process with HER, PHR, HIE

• President Bush’s executive orders in 2004, 2006 to create National Health Information Technology Coordinator

• President Obama’s ARRA 2009 supports 2014 goal for the EHRs


National Health Information National Health Information Technology PolicyTechnology Policy

• Even with the creation many committees, taskforces, workgroups the United States has been very slow to follow.

• The American Recovery and Reinvestment Act (ARRA) of 2009 supported adoption of a nationwide health information infrastructure.

• Education of professionals and general public is needed.


Our RolesOur Roles

• Public– Need greater awareness on benefits and

risks• Nurses

– Professional responsibility– Professional duty


IssuesIssues

• Lack of motivation to share information across institutions

• Established constituencies are resistant to change


LegislationLegislation• Electronic Signatures in Global and National

Commerce Act (ESIGN) in 2000: legal status for electronic signature

• Medicare Improvements for Patients and Providers Act (MIPPA) in 2008: financial incentive fro e-prescribing

• Health Insurance Portability and Accountability Act (HIPAA) in 1996: legal protection for personal health information

• American Recovery and Reinvestment Act (ARRA) in 2009: provision for IT in HIS


HIPAAHIPAA

• The Health Insurance Portability and Accountability Act (1996) called for the establishment of an electronic patient records system and privacy rules.

• It also affects all aspects of health information management, including privacy and security of patient records, coding, and reimbursement.


ARRAARRA

• The American Recovery and Reinvestment Act (2009) included provision for information technology in general and health information technology.

• HITECH Act makes changes to HIPAA and provides more funding for EHRs.


EHR IncentivesEHR Incentives

• In 2011, Medicare and Medicaid will provide financial incentives to physicians and hospitals for meaningful use of health information technology.

• Negative incentives will begin in 2015.


Privacy and Security ProvisionsPrivacy and Security Provisions

• Breaches in privacy and security are reportable to DHHS.

• Patients can restrict some disclosure of personal health information.


Patient Protection and Patient Protection and Affordable Care Act (2010)Affordable Care Act (2010)

• Guarantees access to healthcare for all Americans

• Creates new incentives to change clinical practice and improve quality of care

• Gives practitioners more information to improve practice

• Give patients more information to make conscious decisions


Regulatory AgenciesRegulatory Agencies

• Regulatory agencies are public authorities or government agencies responsible for exercising authority over some area in a regulatory or supervisory capacity.

• Health insurance regulation is visible at every government level.

• Each state determines how it will fill this regulatory role mandated at the federal level.


Regulatory IssuesRegulatory Issues

• The ability to access sensitive health information in electronic patient records by many different sources generates growing concerns over privacy and confidentiality.


MedicareMedicare

• Medicare:– Part A: facility-related expenses (no

premium, annual deductible)– Part B: medically necessary physician

and outpatient expenses (80% with annual deductible)

– Part C: Advantage Plan with some additional benefits (monthly premium)

– Part D: certain prescription drugs and medical supplies


MedicaidMedicaid

• Medicaid eligibility is determined by income and regulated by state

• Medicaid covers approved expenses but not paid by Medicare


State Health DepartmentsState Health Departments

• Public health conditions in marketplaces and workforces

• Schools, mental health facilities, rehabilitation hospitals

• Diseases , contamination• Regulated by federal, state, county


Reimbursement IssuesReimbursement Issues

• Medicare, Medicaid, and other third-party payers dictate reimbursement criteria.

• Documentation is key to documenting the need for service and reimbursement.

• Automated systems enhance the quality of documentation, which can improve reimbursement, track claims status, report denials, and shorten the revenue cycle.



• Adhere to a uniform format• Common terms:

– Common procedural Terminology– Healthcare Common Procedure Coding

System• National provider Identifier• Unique Physician Identification Number

Electronic Data Interchange in Electronic Data Interchange in ReimbursementReimbursement


• Control for quality of healthcare services provided to patients by professional and facilities

• Hospital-based• Physician-based

Pay for PerformancePay for Performance

ICD-10-CM codesICD-10-CM codes

• ICD-10-CM codes (WHO’s International Classification of Diseases)

• System of codes for diagnoses and procedures

• Provide reimbursement for services delivered in outpatient areas


Healthcare Common Procedure Healthcare Common Procedure Coding System (HCPCS) Coding System (HCPCS)

• Level I (Current Procedural Terminology [CPT])—numeric system used for services and procedures furnished by physicians and other providers, maintained by the AMA

• Level II—products, supplies, durable medical equipment, prosthetics, and orthotics

• Medicare and Medicaid services maintain and distribute HCPCS Level II codes


IssuesIssues

• Expansion of the “Do Not Pay” List for preventable complication

• Financial incentives for implementing technology– Adoption for certified HER Systems and

Medicare reimbursement– Meaningful use of EHR


ReferencesReferences• Health IT Legislation and Regulationshttp://www.healthit.gov/policy-researchers-implementers/

health-it-legislation• Health Information Privacy (HIPAA, PSQIA)http://www.hhs.gov/ocr/privacy/• Medicarehttps://www.medicare.gov/• Medicaidhttp://medicaid.gov/• Medi-Cal (LA County)http://dhs.lacounty.gov/wps/portal/dhs/coverageoptions/

medical/


Documents

Lecture 14 Policy, Legal, and Regulatory Issues in HIS (Chapters 18,19,20)