The responsibility for fraudulent claims rests with anyone who “knows or should know” that the services were not provided as claimed, and the penalties can be severe. The Medicare audit can be a horrendous experience. Every medical practice needs a compliance plan to guard against fraud, whether intentional or inadvertent.
LAWS AND REGULATIONS
i HIPAA does the following:
It is of the utmost importance to stay informed with all current state and federal laws, rules, and regulations which impact licensure as well as the practice of medicine.
• Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs
In order to avoid this you should:
EMTALA
• Develop standards and procedures for billing and coding
In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.
• Designate a “compliance officer” with oversight and responsibility
• Reduces health care fraud and abuse
• Conduct effective training for your employees
• Mandates industry-wide standards for health care information on electronic billing and other processes; and • Requires the protection and confidential handling of protected health information.
• Develop a mechanism for employees to report suspected violations
• Create monitoring and auditing systems
• Investigate problems and take disciplinary action
HIPAA
• Initiate corrective action
HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996.
HEALTHY LOUISIANA
HIPAA has set various guidelines, which should be adhered to by anyone who handles any electronic medical data. These guidelines stipulate that all medical practices must ensure that all necessary measures are in place while saving, accessing and sharing any electronic medical data to keep patient data secure. Lack of compliance to the HIPAA security standards could lead to large fines and in extreme cases even loss of medical licenses.
Healthy Louisiana is Louisiana’s name for its Medicaid program, which provides health insurance coverage to more than 350,000 working Louisianans who could otherwise not afford health care, while bringing both jobs and economic development to the state. By receiving Medicaid coverage, Louisianans, many of them working adults in important industries like food service and construction, are finally able to get the regular, preventative, and primary care that best promotes health and wellness.
Several steps can be followed by medical practices to ensure compliance to HIPAA standards:
WHO CAN APPLY?
• Run a complete risk assessment of the medical practice. Some medical practices adopted electronic health recording systems before there were clear guidelines on what these systems should contain. This means that a medical practice could be using electronic systems which are not compliant with HIPAA standards. To ensure HIPAA compliance a risk assessment should be done on the current systems using HIPAA standards and guidelines to highlight areas in which compliance is not enforced. A risk assessment against HIPAA guidelines exposes areas in which changes are needed. • Prepare for disaster before it occurs. All the data handled by a medical practice should be safe both from loss and corruption. One of the main ways of ensuring that data is not lost in case of any mishaps is backing up of medical data regularly. Data should be backed up in an offsite location such that in case of incidents such as fires in the medical premises the data backup is not destroyed, as well. Antivirus programs should also be installed in all computers to ensure that data is not corrupted or destroyed by computer viruses. • Have an ongoing employee training program. Any system is only as strong as its weakest link and in most cases untrained employees are the weakest links in medical practices. A medical practice could have a very secure encryption system, but if the employees don’t use their passwords to securely access records and files the encryption system is rendered useless, and anyone can gain access to these records. Medical practices
Any adult who meets the eligibility criteria listed below are able to enroll in Medicaid under the expansion.
• Ages 19-64 years old.
• Has a household income less than 138% of the federal poverty level. Visit LDH.LA.gov for more information.
• Doesn’t already qualify for Medicaid or Medicare.
• Must meet citizenship requirement.
To enroll under expanded Medicaid, it is not necessary to have a dependent child in your household. There is no asset test.
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La State Med Soc NEW PHYSICIAN’S GUIDE 33
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