Introduction to Health Care and Public Health in the U.S.

1. Introduction to Health Careand 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/.

2. Regulating Health CareLearning 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)

3. Regulating Health CareLearning 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)

4. Regulating Health CareLearning 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)

5. 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

6. 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

7. 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

8. Governance of Health Record • Federal and State Laws, Regulations, and Rules • The Joint Commission and other voluntary accreditation • Medical staff bylaws

9. 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”

10. 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

11. 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

12. OIG Compliance Program Tips - 2 • The Seven Fundamental Elements of an Effective Compliance Program • Conducting internal monitoring and auditing • Enforcing standards through well-publicized disciplinary guidelines • Responding promptly to detected offenses and undertaking corrective action • OIG compliance education videos: http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp

13. Corporate Integrity Agreements - 1 • A comprehensive CIA includes requirements to: • Hire a compliance officer/appoint a compliance committee • Develop written standards and policies • Implement a comprehensive employee training program • Retain an independent review organization to conduct annual reviews

14. Corporate Integrity Agreements - 2 • A comprehensive CIA includes requirements to: • Establish a confidential disclosure program • Restrict employment of ineligible persons • Report overpayments, reportable events, and ongoing investigations/legal proceedings • Provide an implementation report and annual reports to OIG on the status of the entity's compliance activities

15. Compliance Beyond Fraud and Abuse • HIPAA Privacy and Security Rules • What is the plan for appropriate release of PHI? • How is the tracking of release occurring? • Who is responsible for breach notification? • What training is being done? • Is there a team reviewing policies and procedures?

16. Regulating Health CareSummary – 1 – Lecture e • The health record is the business and legal record for a health care organization • The health record is the communication tool for the health care team • Clinical documentation is used to assure high quality care of the patient, as well as to provide information for decision-making, reimbursement and medical coding

17. Regulating Health CareSummary – 2 – Lecture e • Thorough and complete clinical documentation protects health care organization from the risk of fraud, abuse, and malpractice claims • Compliance programs are important to assure correct procedures to follow related to regulations, rules, laws, accreditation, and internal policies • HIPAA privacy and security rules need to be included in compliance plans

18. Regulating Health CareSummary - 1 • Health Care accrediting and certification organizations • The U.S. legal system • Laws governing health care privacy and security rules

19. Regulating Health CareSummary - 2 • The clinical documentation in the health record supports quality health care, administrative and business operations of the organization, and provides the basis for legal proof of care that assures compliance with laws, rules, and regulations as well as professional standards of care

20. Regulating Health CareReferences – 1 – Lecture e References American Health Information Management Association. http://www.ahima.org/topics/ehr. Accessed January 30, 2017. American Health Information Management Association. http://www.ahima.org/topics/cdi. Accessed January 30, 2017. American Health Information Management Association. http://www.ahima.org/topics/psc. Accessed January 30, 2017. Bayes, N., Newby, J, Seggern, J, Valerius J. Medical Insurance An integrated claims process approach 5th edition, 2012. McGraw Hill Companies: New York Davis, N. Revenue Cycle Management Best Practices, 2011, AHIMA Press: Chicago Health Care Compliance Program Tips http://oig.hhs.gov/compliance/provider-compliance-training/index.asp. Accessed January 30, 2017.  LaTour & Eichenwald, Health Information Management, concepts, Principles, and Practice, Third Edition, 2010 AHIMA Press: Chicago

21. Regulating Health CareReferences – 2 – Lecture e References Office of the Inspector General. http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp. Accessed January 30, 2017. Office of Inspector General. A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse. http://oig.hhs.gov/fraud/PhysicianEducation. Accessed January 30, 2017. Centers for Medicare and Medicaid. http://www.cms.gov/default.asp. Accessed January 30, 2017. Corporate integrity agreements. http://oig.hhs.gov/compliance/corporate-integrity-agreements/index.asp. Accessed January 30, 2017.

22. Introduction to Health Careand Public Health in the U.S.Regulating Health CareLecture e This material 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.