Whether you work at a hospital or own your own practice, it is vital that you establish a compliance program designed to help you avoid fraud, abuse, and privacy violations. Federal regulations around these activities include the Anti-kickback Statute, the Stark Law, and the Health Insurance Portability and Accountability Act (HIPAA).
The anti-kickback statute makes it illegal for providers (including physicians) to knowingly and willfully accept bribes or other forms of remuneration in return for generating Medicare, Medicaid or other federal health care program business.
A physician cannot offer anything of value to induce federal health care program business. The anti-kickback statute has been revised to allow exceptions or safe harbors.
Stark II is Phase II of the law that prohibits physician self-referrals.
The law applies to any physician who provides care to Medicare, Medicaid or other federal health program recipients and says that the physician cannot refer the patient for certain designated health services to any entity with which the physician has a financial interest. That is, unless one of Stark's exceptions apply.
Stark III is short for Stark II, Phase III of the physician self-referral prohibition. Stark III provides further clarifications and modifications to Stark II, Phase II, especially regarding physicians in group practice and the relationships between physicians and hospitals.
The Health Insurance Portability and Accountability Act (HIPAA) requires electronic transactions be transmitted using standard formats.
Obligations to notify patients of a breach of their protected health information (PHI) has been expanded and clarified under the new rule. Under the previous rule, a breach was not presumed reportable and was determined by whether or not there was a likelihood of “harm to the individual.”
Under the new rule, a breach is presumed reportable unless a covered entity can demonstrate low probability that the patient’s privacy or security of PHI was compromised based on a four-factor risk analysis. The new rule does not change the actual reporting and timeframe requirements.
Practices must amend their NPPs to reflect the changes to privacy and security rules, including those related to breach notification, disclosures to health plans, and marketing and sale of PHI. In addition, if a practice participates in fundraising, an amendment will also need to be made to the NPP to inform patients of their right to opt-out of those communications.
The new rules eliminate the requirements to include communications concerning appointment reminders, treatment alternatives, or health-related benefits or services in NPPs. However, the rules do not require this information be removed either.
Amended NPPs will need to be posted in the office. Copies should be provided to all new patients and do not need to be redistributed to existing patients. Copies should be made available to anyone by request. Practices that maintain a website should post the updated NPP on their website, which is a requirement of the existing HIPAA Privacy Rule.
The new rules expand the list of individuals and companies who are considered business associates to include:
All entities transmitting and receiving electronic health care transactions must use the 5010 version of the standards, which require upgrading or replacing software used to conduct electronic transactions, such as claims submissions, eligibility inquiries, and receipt of electronic claims acknowledgments and reports.
Some standards that physician practices should take note of are: