Introduction to Healthcare and Public Health in the US

1. Introduction to Healthcareand Public Health in the US Regulating Healthcare Lecture e This material (Comp1_Unit6e) was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

2. Regulating HealthcareLearning Objectives • Describe the role of accreditation, regulatory bodies, and professional associations in healthcare in the US. (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) • Describe legal aspects of medicine involving the Affordable Care Act, professional standards in healthcare, medical malpractice, Tort reform, and Medicare and Medicaid Fraud and Abuse (Lecture c) • Describe key components of the Health Insurance Portability and Accountability Act (HIPAA) and current issues of privacy and patient safety in the US (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 healthcare organizations. (Lecture e) Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

3. The Health Record as Tool for Patient Safety • Quality of care is key to patient safety • Monitoring information in the health record • Use of health record to manage risk and improve healthcare Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

4. The Health Record as a Legal Record • Business Record • Legal Record Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

5. Governance of Health Record • Federal and State Laws, Regulations, and Rules • Joint Commission • Other voluntary accreditation • Medical staff bylaws Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

6. Quality Clinical Documentation for Legal Purposes • Hand-written documentation • Electronic documentation Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

7. Quality Clinical Documentation to Avoid Fraud and Abuse Accusations • Clinical documentation improvement programs • Coding and reimbursement • Issues of fraud and abuse Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

8. Compliance Program Tips from OIG The Seven Fundamental Elements of an Effective Compliance Program 1. Implementing written policies, procedures and standards of conduct. 2. Designating a compliance officer and compliance committee. 3. Conducting effective training and education. 4. Developing effective lines of communication. 5. Conducting internal monitoring and auditing. 6. Enforcing standards through well-publicized disciplinary guidelines. 7. Responding promptly to detected offenses and undertaking corrective action. Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

9. Corporate Integrity Agreements A comprehensive CIA typically lasts 5 years and 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; • establish a confidential disclosure program; • restrict employment of ineligible persons; • report overpayments, reportable events, and ongoing investigations/legal proceedings; and • provide an implementation report and annual reports to OIG on the status of the entity's compliance activities. Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

10. 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? Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

11. Regulating HealthcareSummary – Lecture e • The health record is the business and legal record for a healthcare organization • The health record is the communication tool for the healthcare 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 • Thorough and complete clinical documentation protects healthcare 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 Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

12. Regulating HealthcareSummary This unit discussed: • Healthcare accrediting and certification organizations; • The US legal system; • The laws governing healthcare practice; • privacy and security rules; • The clinical documentation in the health record supports quality healthcare, 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 Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e

13. Regulating HealthcareReferences – Lecture e References  American health Information Management Association. http://ahima.org/resources/infocenter/ehr.aspx. accessed on 11/11/2011. American Health Information Management Association. http://ahima.org/resources/cdi.aspx. accessed on 11/11/2011. American Health Information Management Association. http://ahima.org/resources/psc.aspx. accessed on 11/11/2011 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 Healthcare Compliance Program Tips accessed on 11/9/11: http://oig.hhs.gov/compliance/provider-compliance-training/index.asp  LaTour & Eichenwald, Health Information Management, concepts, Principles, and Practice, Third Edition, 2010 AHIMA Press: Chicago Russo, R. Clinical documentation improvement, 2010 AHIMA Press: Chicago Office of the Inspector General. http://oig.hhs.gov/. accessed on 11/11/2011. Office of the Inspector General. http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp. accessed on 11/11/2011. Office of Inspector General. A roadmap for new physicians: avoiding Medicare and Medicaid fraud and abuse. http://oig.hhs.gov/fraud/PhysicianEducation. Accessed 11/11/2011. Office of the Inspector General. http://oig.hhs.gov/newsroom/video/index.asp. accessed on 11/11/2011. Centers for Medicare and Medicaid. http://www.cms.gov/default.asp. Accessed on 11/11/2011. Corporate integrity agreements. http://oig.hhs.gov/compliance/corporate-integrity-agreements/index.asp. Accessed on 11/9/11 . Introduction to Healthcare and Public Health in the US Regulating Healthcare Lecture e