Jane Dotson
In the US, the Health Insurance Portability and Accountability Act, or HIPAA, was passed in 1996 to protect sensitive patient health information. This means that, in most cases, insurance companies cannot access your private medical information to determine coverage eligibility or cost. However, there are some exceptions to this rule, and insurance companies do have access to some parts of your medical records, especially those relating to payment processing and eligibility. This can create a significant risk of confidentiality breaches, with insurance companies blocking patients from more expensive treatments. So, can you block your medical information from your insurance company?
| Characteristics | Values |
|---|---|
| Can insurance companies access your medical records? | Yes, insurance companies can access some parts of your medical records, but only those necessary for their job. |
| Can you block insurance companies from accessing your medical records? | You cannot completely block insurance companies from accessing your medical records, but you can limit the scope of their access. For example, you can list specific providers and date ranges for the records they can access. |
| What information can insurance companies access? | Insurance companies can access information related to payment processing, eligibility, and treatment plans. They may also have access to aggregated data, such as the total amount spent by an insurer to cover employees. |
| What information can't insurance companies access? | Insurance companies cannot access your entire medical history without your consent. They also cannot use your health information for employment decisions, such as hiring, firing, promotion, or reassignment. |
| How can you protect your medical information? | You can protect your medical information by not signing a blank release and seeking legal advice before releasing your records. Additionally, you can request a copy of your MIB report to review the information insurance companies can access. |
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What You'll Learn
- Insurance companies can access some medical records
- HIPAA laws allow disclosure of PHI without authorization
- Insurance companies use codes to determine if further information is needed
- Doctors cannot send information to the MIB without written authorization
- Insurance companies cannot access private medical information to determine coverage eligibility
Insurance companies can access some medical records
In the US, the Health Insurance Portability and Accountability Act, or HIPAA, was passed in 1996 to protect sensitive patient health information. Under this law, it is illegal for certain individuals or organisations to share health information without the patient's written consent. This includes health care providers, health plans, and health care clearinghouses.
Despite these protections, insurance companies can access some medical records. When applying for health or life insurance, the insurance company may request information to determine eligibility for coverage. This does not, however, extend to an individual's entire medical history. Insurance companies typically belong to the Medical Information Bureau (MIB), which they use to access medical record information. The MIB database contains limited information, without detailed reports on medical exams, lab tests, x-rays, or other specific personal information. It keeps track of broad categories of medical conditions using codes, which insurance companies use to determine if further information is needed before insuring an applicant.
Once an individual has insurance, their healthcare and pharmacy providers begin regular communication with the insurer via billing. The insurance company needs to know what they are processing payments for, so providers share information relating to test results, treatment plans, and medical history. While the insurance company does not need to know every detail of a treatment plan, they are informed of procedures, tests, and other elements of care that they will be billed for and required to make a payment on.
It is important to note that individuals can request a copy of their MIB report to see the same information that insurance companies have access to. Additionally, doctors cannot send information about patients to the MIB without their written authorisation.
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HIPAA laws allow disclosure of PHI without authorization
While the HIPAA Privacy Rule protects all "individually identifiable health information", there are certain circumstances under which protected health information (PHI) can be disclosed without an individual's authorization or permission.
The HIPAA Privacy Rule allows for the disclosure of PHI for "treatment, payment, or healthcare operations". This means that a healthcare provider can disclose PHI to another provider for treatment activities, without needing patient consent or authorization. For example, if a medical test reveals a condition that requires follow-up treatment, the insurance company must be informed so that they can authorize payment for the treatment. This provision, however, creates a significant risk of confidentiality breaches.
PHI may also be disclosed without authorization for public interest purposes, and for benefit activity purposes. For instance, covered entities may disclose PHI to public health authorities to prevent or control disease, injury, or disability, or to report child abuse and neglect. In addition, PHI can be disclosed to employers when it concerns a work-related illness or injury, or workplace-related medical surveillance.
HIPAA also permits the disclosure of PHI to funeral directors, coroners, or medical examiners to identify a deceased person, determine the cause of death, and perform other functions authorized by law. Furthermore, PHI can be disclosed for research purposes without individual authorization, provided that approval is obtained from an Institutional Review Board or Privacy Board.
It is important to note that while HIPAA provides some protection for patient privacy, there are still concerns about the legal accessibility of medical information without explicit patient permission.
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Insurance companies use codes to determine if further information is needed
In the US, health insurance companies have access to some parts of your medical records, but only those necessary for their job. Most of the information they can view is related to payment processing and eligibility. For example, they need to know about your test results, treatment plans, and medical history to determine whether to authorize payment for a procedure.
When you apply for health or life insurance, the insurance company may request some information to determine your eligibility for coverage. However, this does not extend to your entire medical history. Typically, insurance companies belong to the Medical Information Bureau (MIB) and will refer to this database for medical record information about you. The information about you in the MIB database is not extensive and doesn't contain detailed reports about any medical exam, lab tests, x-rays, or other specific personal information. Instead, it keeps track via codes that refer to broad categories of any medical condition. Insurance companies use these codes to determine if they need further information about an applicant before insuring them.
Health plans, medical billing companies, and healthcare providers use three different coding systems to ensure there is a consistent and reliable way for health insurance companies to process claims from healthcare providers and pay for health services. These codes are sometimes used instead of plain English, although most health plans use both codes and written descriptions of the services included on Explanation of Benefits (EOBs). It is useful to learn about these codes, especially if you have one or more chronic health problems, as you will likely be reviewing more EOBs and medical bills.
The three coding systems are:
- HCPCS codes: The Centers for Medicare and Medicaid Services maintains a website where updated HCPCS code information is available to the public.
- CPT codes: These are used to identify the services you received.
- ICD codes: These codes, developed by the World Health Organization (WHO), identify your health condition or diagnosis. ICD codes are often used in combination with CPT codes to ensure that your health condition and the services you received match. For example, if your diagnosis is bronchitis and your healthcare provider ordered an ankle X-ray, it is likely that the X-ray will not be paid for because it is not related to bronchitis. However, a chest X-ray would be reimbursed.
In addition to these medical billing codes, commercial insurers also use NAICS codes to determine if your business is in a high-risk industry classification and to set your premium. Every company will have a primary NAICS code, which indicates the company's primary line of business operations.
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Doctors cannot send information to the MIB without written authorization
In the US, health insurance companies have access to some parts of patients' medical records, but only those necessary for payment processing and eligibility. When applying for health or life insurance, insurance companies may request some information to determine eligibility for coverage. However, this does not extend to the patient's entire medical history. Most of the information insurance companies can view is related to payment processing and eligibility.
Insurance companies typically belong to the Medical Information Bureau (MIB), which contains medical record information about individuals. Doctors cannot send information about patients to the MIB without their written authorization. The information in the MIB database is not extensive and does not contain detailed reports about any medical exam, lab tests, x-rays, or other specific personal information. Instead, it uses codes to refer to broad categories of medical conditions.
While health care providers generally seek patients' permission to disclose their information for insurance claims, the HIPAA Privacy Rule allows disclosure of PHI without authorization for "treatment, payment, or healthcare operations". This creates a significant risk of confidentiality breaches. Additionally, HIPAA allows for disclosures for the purposes of payment without authorization and, more broadly, for disclosures with authorization, which patients are usually required to grant to their insurers as a condition of coverage.
The obligation to protect patient privacy has a long history, dating back to the Hippocratic Oath. This confidentiality obligation is also enshrined in the codes of ethics and policy pronouncements of various medical organizations, as well as extensive federal and state laws.
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Insurance companies cannot access private medical information to determine coverage eligibility
While insurance companies can access some of your medical information, they cannot view your full medical history. When applying for health or life insurance, insurance companies may request certain information to determine your eligibility for coverage. However, this does not include your entire medical history.
Insurance companies typically belong to the Medical Information Bureau (MIB), which contains limited information about medical conditions indicated by codes. These codes refer to broad categories of medical conditions, and insurance companies use them to determine if they need further information about an applicant. The MIB database does not contain detailed reports of medical exams, lab tests, x-rays, or other specific personal information.
Your doctor cannot send information about you to the MIB without your written authorization. Additionally, you have the right to request a copy of your MIB report to see the same information that insurance companies view. The MIB keeps information for underwriting purposes and to protect insurance companies from inaccurate insurance applications.
HIPAA laws and the privacy rule protect your medical information and require your permission for insurance companies to access it. However, HIPAA allows for disclosures of information for "treatment, payment, or healthcare operations" without authorization. This creates a risk of confidentiality breaches, and there are continued refinements and implementations of policies to address these challenges.
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Frequently asked questions
Yes, insurance companies can access some of your medical records. This is typically information relating to payment processing and eligibility. They cannot access your entire medical history but will need to know information related to the history of symptoms, treatments, and testing for a procedure you need or elect to have done.
You cannot completely block your insurance company from accessing your medical information. However, you can limit the scope of what they can access by listing specific providers and date ranges of records. You can also have an attorney review the release before signing it.
No, your employer cannot see your individual health care records. They may, however, access aggregated data, such as the total amount of money their insurer spent to cover employees.
Yes, insurance companies can deny coverage or block patients from accessing certain treatments based on their medical information. They may require patients to try cheaper treatments first before approving more expensive ones.
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