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

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

Learning Outcomes Status of current healthcare delivery system and related policies in US Legal issues and their implementation Regulatory issues and agencies IS 531 : Lecture 14

Status of U.S. Healthcare Delivery 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 IS 531 : Lecture 14

Healthcare 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 IS 531 : Lecture 14

National Health Information Technology 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. IS 531 : Lecture 14

Our Roles • Public • Need greater awareness on benefits and risks • Nurses • Professional responsibility • Professional duty IS 531 : Lecture 14

Issues Lack of motivation to share information across institutions Established constituencies are resistant to change IS 531 : Lecture 14

Legislation 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 IS 531 : Lecture 14

HIPAA 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. IS 531 : Lecture 14

ARRA 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. IS 531 : Lecture 14

EHR 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. IS 531 : Lecture 14

Privacy and Security Provisions Breaches in privacy and security are reportable to DHHS. Patients can restrict some disclosure of personal health information. IS 531 : Lecture 14

Patient Protection and 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 IS 531 : Lecture 14

Regulatory 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. IS 531 : Lecture 14

Regulatory Issues The ability to access sensitive health information in electronic patient records by many different sources generates growing concerns over privacy and confidentiality. IS 531 : Lecture 14

Medicare • 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 IS 531 : Lecture 14

Medicaid Medicaid eligibility is determined by income and regulated by state Medicaid covers approved expenses but not paid by Medicare IS 531 : Lecture 14

State Health Departments Public health conditions in marketplaces and workforces Schools, mental health facilities, rehabilitation hospitals Diseases , contamination Regulated by federal, state, county IS 531 : Lecture 14

Reimbursement 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. IS 531 : Lecture 14

Electronic Data Interchange in Reimbursement • Adhere to a uniform format • Common terms: • Common procedural Terminology • Healthcare Common Procedure Coding System • National provider Identifier • Unique Physician Identification Number IS 531 : Lecture 14

Pay for Performance Control for quality of healthcare services provided to patients by professional and facilities Hospital-based Physician-based IS 531 : Lecture 14

ICD-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 IS 531 : Lecture 14

Healthcare Common Procedure 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 IS 531 : Lecture 14

Issues • 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 IS 531 : Lecture 14

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