What Exactly Did The Omnibus Rule Allowing Regarding Patient Restriction Of Disclosure To Insurance Carriers

In Uncategorized on September 4, 2013 at 6:31 pm

Remember that pesky contractual provision in your provider participation agreements that obligates you to submit all claims for patient services to the insureds’ carrier(s) for processing?  Even if the patient didn’t want that claim to be filed?  Well, Congress has spoken, and the Omnibus Rule contains a provision that, as federal legislation, trumps those contracutal obligations. 

The Omnibus Rule now allows patients to pay a medical bill in full at the time of service and request that the provider NOT file a claim to the patient’s insurance company.  Again, this is a complete contradiction of previous rules, which demanded that patients and providers comply with their contractual obligations to file all claims to the carrier providing insurance coverage for the patient.  So, providers, take note:  if a patient pays his/her bill in fill at the time of service, and requests that your office not submit the claim to his/her insurance carrier, any submission constitutes a violation of HIPAA and the Omnibus Rule going forward!

This disclosure restriction relates only to services for which patient has paid in full.  So, if the patient pays by credit card, and that card is denied or if the patient pays by check and the check bounces, then the provider must to attempt again to obtain payment in full from the patient (absent sending to collections).  If the provider makes that attempt and is unable to obtain payment, then the he/she may finally submit the claim to the patient’s insurance company despite patient’s initial desire not to disclose the services.  Essentially, while the provider does need to try to comply with the patient’s desire for privacy, he/she does not need to forego compensation.

M.E.D.I.C., Inc.  would suggest that when the patient pays in full and asserts his/her right to restrict disclosure of the services, providers have those patients complete and sign a form to be maintained on file that identifies :

  1. whether this is a one-time claim restriction or permanent restriction on disclosure;
  2. that the restriction would need to be for the entire claim, not portions of the visit, for attempting to select only certain elements of a claim to restrict may be difficult due to “bundling” of procedures…  It is much more administratively efficient if the restriction is is an all-or-nothing proposition;
  3. the consequences of payment retraction (the denied credit card, the bounced check, etc…) – in other words, explain to the patient that in the event of these non-payments, the practice will make one attempt (only one attempt because of the short timely filing for some carriers) to collect payment.  Absent payment in full, the practice will then file the claim(s) to the patient’s insurance carrier – despite his/her previous desire to restrict disclosure;
  4. that a perhaps unforeseen consequence of this restriction is that the patient’s payment will not be applied to his/her deductible

As always, please contact M.E.D.I.C., Inc. should you have any questions related to this, or any other, medical billing/revenue cycle management matter.


HIPAA/HITECH Omnibus Final Rule – Last Few Weeks To Comply!

In Uncategorized on August 27, 2013 at 6:38 pm

On January 17, 2013, the U.S. Department of Health and Human Services (“HHS”) issued a final rule (“Omnibus Rule”) affecting multiple aspects of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the HITECH Act.  

The Omnibus Rule, commonly referred to by this name because of its sweeping scope, is comprised of four final rules that (in general and succinct terms):

  • modify aspects of HIPAA and its implementing regulations including the privacy standards located at 45 C.F.R. parts 160 and 164, subparts A and E (the “Privacy Rule”), the security standards located at 45 C.F.R. parts 160, 162 and 164, subpart C (the “Security Rule”), and enforcement standards located at 45 CFR part 160, subparts C, D, and E (the “Enforcement Rule”);
  • implement statutory amendments, including an increased and tiered civil money penalty structure, under the Health Information Technology for Economic and Clinical Health Act (“HITECH”);
  • modify the interim final rule for Breach Notification for Unsecured Protected Health Information located at 45 C.F.R. part 164, subpart D (the “Breach Notification Rule”), including replacing its harm threshold for breach notification requirements with a default presumption that an acquisition, access, use, or disclosure of PHI that violates the Privacy Rule is a breach, and supplant the Breach Notification Rule as of the Compliance Date (covered entities and business associates must continue to comply with the interim rule in the meantime); and
  • modify the HIPAA Privacy Rule by implementing section 105 of Title I of the Genetic Information Nondiscrimination Act of 2008 (“GINA”), clarify that genetic information is health information, and prohibit health plans, including group health plans, health insurance issuers (including HMOs), and issuers of Medicare supplemental policies, from using or disclosing genetic information for underwriting purposes.

The Omnibus Rule went into effect on March 26, 2013, and, except with respect to certain grandfathered business associate agreements, HIPAA covered entities and business associates must comply with its requirements by September 23, 2013.   The Business Associate’s Agreement between you and youe billing company – if entered into prior to March 26, 2013 – is in fact one of those that has been grandfathered in, and allowed a one-year extension in which to comply. 

The AMA summarized more fully the portions of the Omnibus Rule that impact the medical provider community.  Please be sure to review this carefully to ensure compliance.  Additionally, I have attached a sample HIPAA/Omnibus Notice of Privacy Practices, which, once modified to include specific data points pertaining to your practice, may be used by your practice going forward.  This sample was taken largely (but modestly adapted) from the sample Omnibus Notice published by MGMA. sample HIPAA Omnibus Notice of Privacy Practices-adapted from MGMA

As always, please do not hesitate to contact M.E.D.I.C., Inc. with any questions that you may have about this.

SGR Update — Fix Remains High Priority for 113th Congress

In Uncategorized on August 27, 2013 at 6:28 pm

Congressional leaders remain committed to finding a permanent solution to the SGR problem that has plagued the Medicare program and provider payments for over a decade.  Although there has long been bi-partisan agreement that the SGR formula developed during the Clinton Administration was seriously flawed, a permanent fix has remained elusive. 

Although an SGR fix is not imminent, due to a convergence of factors, a permanent fix appears achievable in 2013.  All of the Congressional Committees (Senate Finance, House Ways and Means and House Energy and Commerce) that share jurisdiction over Medicare Physician Payment reforms have held hearings and solicited feedback from stakeholders on possible permanent solutions.  Democratic and Republican leaders in both the House and Senate remain committed to finding a permanent solution whereas in years past, the level of commitment to finding a permanent fix has not been as strong. 

Draft proposals have been circulated amongst the various physician and other healthcare organizations, and industry feedback and reaction have been sought. 

If Congress should fail to come up with a permanent fix before the end of 2013, current estimates are that a cut of approximately 24% in provider payments will be necessary to comply with the SGR law. 

Some of the common themes that are emerging as part of the SGR discussions center around the following concepts:

Repeal SGR and replace with statutory increases (possibly 1 – 2 % per year but still to be determined) for a period of time (possibly 3 – 5 years but still to be determined). This would eliminate the 24 % cut slated for January 1, 2014.

  1. Incorporate Specialty Specific Quality Measures as part of the payment formula (aka Update Incentive Program).
  2. Provider payments would be a combination of a “base rate” plus a variable rate tied to quality/performance (Specialty Specific Quality Measures).
  3. Score on Quality would be based upon a comparison against peers (risk adjusted) AND compared to the individual provider’s prior year scores AND provider participation in specialty specific clinical improvement initiatives.
  4. Each provider would “self-identify” with a peer cohort (i.e. providers of the same specialty); and provide information on each of the following:

*             Identifies the peer group the provider wants to be compared to; and
*             Provides information on each quality measure applicable to such peer group to which the provider shall be assessed.

The Secretary of HHS will be responsible for developing the methodology for assessing the performance of providers with respect to the measures and with developing the methods for collecting information needed for such assessments.  The Secretary is directed to establish these processes in a way that minimizes the “… amount of administrative burden needed to ensure reliable results.”

In reviewing the proposals, several administrative/operational questions have arisen.  These include: 

  • Auditing/data retention requirements
  • Claims reporting requirements
  • Administrative complexity of process
  • How/when will payments be made
  • What will be necessary to support provider participation in this type of payment model
  • Predictability of payment


Clearly, much still needs to be done to address and hopefully to resolve this ever-pressing matter.

reprinted with permission, Healthcare Business & Management Association (HBMA)