Hipaa And Insurance Billing: Walking The Compliance Tightrope

The unauthorized release of personal medical information is a violation of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was introduced in 1996 to ensure employees could maintain healthcare coverage between jobs and to prevent discrimination based on pre-existing conditions. It also strives to protect the confidentiality and security of healthcare information.

HIPAA violations can result in civil and criminal penalties. For example, if a covered entity or specified individual knowingly obtains or discloses individually identifiable health information, they may face a fine of up to $50,000, as well as imprisonment of up to one year.

In the case of a billing office sending patient records and billing information to the wrong insurance company, this would be considered a HIPAA violation.

Unauthorized release of personal medical information

The unauthorized release of personal medical information is a violation of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was introduced to ensure employees could maintain healthcare coverage between jobs and not be discriminated against for pre-existing conditions. It also aimed to prevent insurance carriers from passing on the cost of compliance to plan members and employers.

HIPAA violations can be administrative, civil, or criminal. The most common type of violation is the unauthorized disclosure of protected health information (PHI) beyond the permitted uses and disclosures.

PHI violations can range from providing more information than the minimum necessary to achieve the purpose of an allowable disclosure to the hacking of an unencrypted database that exposes the PHI of thousands of patients.

The unauthorized release of personal medical information is a violation of the HIPAA Privacy Rule, which establishes a set of national standards for the protection of certain health information. The Privacy Rule standards address the use and disclosure of individuals' health information, and standards for individuals' privacy rights to understand and control how their health information is used.

The unauthorized release of personal medical information is also a violation of the HIPAA Security Rule, which ensures the confidentiality, integrity, and availability of electronic protected health information.

The unauthorized release of personal medical information can result in termination of employment and criminal charges for the employee concerned. Financial penalties for healthcare organizations that have failed to prevent unauthorized releases are relatively uncommon, but they are possible.

The unauthorized release of personal medical information can also result in civil and criminal penalties. Civil penalties for HIPAA violations are determined based on a tiered civil penalty structure. Criminal penalties for HIPAA violations are handled by the Department of Justice.

HIPAA violation penalties

HIPAA violations can result in civil and criminal penalties, with fines ranging from $100 to $50,000 per violation, depending on the level of culpability. The Department of Health and Human Services' Office for Civil Rights (OCR) is responsible for enforcing HIPAA Privacy and Security Rules and can issue financial penalties, as well as corrective action plans and resolution agreements. The OCR follows a tiered penalty structure to assess the severity of the violation and issue a proportional penalty.

There are four tiers of increasing culpability for civil penalties:

• Lack of knowledge: The covered entity or business associate was unaware of and, through due diligence, could not have known the HIPAA rule was violated.
• Reasonable cause and not willful neglect: The covered entity knew or should have known through due diligence that its action (or omission) violated HIPAA, but the violation was not caused by willful neglect.
• Willful neglect, corrected within 30 days: The violation was caused by willful neglect, but the covered entity took corrective action within 30 days.
• Willful neglect, not corrected within 30 days: The violation of HIPAA rules constituted willful neglect, and the entity made no attempt to correct the violation within 30 days.

Criminal penalties for HIPAA violations are handled by the Department of Justice (DOJ) and can result in fines and imprisonment. There are three tiers of criminal penalties:

• Wrongful disclosure of PHI: Up to $50,000 fine, up to one year in prison, or both.
• Wrongful disclosure of PHI under false pretenses: Up to $100,000 fine, up to five years in prison, or both.
• Wrongful disclosure of PHI under false pretenses with malicious intent: Up to $250,000 fine, ten years in prison, or both.

It is important to note that ignorance of HIPAA rules is not an excuse for failing to comply. In cases of willful violation, the maximum fines may apply.

Protected Health Information (PHI)

PHI is typically held by a "covered entity" or its business associates. Covered entities include health plans, healthcare clearinghouses, and healthcare providers who electronically transmit PHI in connection with transactions for which the Health and Human Services (HHS) has adopted standards. Business associates are businesses with whom a covered entity shares PHI to help carry out its healthcare activities and functions.

PHI is protected by the HIPAA Privacy Rule, which provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. The Privacy Rule permits the disclosure of personal health information when it is needed for patient care and other important purposes.

PHI can be transmitted without consent in certain circumstances, such as for payment purposes, judicial proceedings, public health purposes (e.g., disease control, child abuse), and to avert a serious threat to a person's health or well-being.

It is important to protect PHI to prevent unauthorized access and potential negative consequences for patients. Healthcare providers can take precautions such as data masking, encryption, and deidentification to ensure PHI remains confidential.

HIPAA compliance

The Health Insurance Portability and Accountability Act (HIPAA) sets the standard for sensitive patient data protection. The HIPAA Privacy Rule establishes national standards to protect individually identifiable health information, giving individuals rights over their health information. The HIPAA Security Rule establishes a national set of security standards for protecting specific health information that is held or transferred in electronic form.

Covered entities (anyone providing treatment, payment, and operations in healthcare) and business associates (anyone who has access to patient information and provides support in treatment, payment, or operations) must meet HIPAA Compliance. Other entities, such as subcontractors and any other related business associates, must also be in compliance.

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) is responsible for enforcing the HIPAA Privacy and Security Rules. The OCR enforces the Privacy and Security Rules in several ways, including investigating complaints filed with it, conducting compliance reviews to determine if covered entities are in compliance, and performing education and outreach to foster compliance with the rules' requirements.

The HIPAA Privacy Rule gives patients more control over their health information. This includes the ability to obtain copies of their records and make corrections if necessary. It also sets boundaries on how companies can use and disclose health records and requires that safeguards be in place to protect PHI from unauthorized access.

The HIPAA Security Rule outlines the regulations for protecting electronic protected health information (ePHI). The Security Rule defines three areas where safeguards must be in place to protect ePHI: administrative, physical, and technical safeguards. These safeguards are intended to ensure the confidentiality, integrity, and availability of ePHI; identify and protect against threats to ePHI; protect against unauthorized use or disclosure of ePHI; and ensure compliance with the rules by all employees and contractors.

To achieve HIPAA Compliance, organizations must implement all of the required administrative, physical, and technical safeguards to protect PHI and ePHI. This includes establishing physical and technical safeguards, such as limited facility access and control, policies about the use and access to workstations and electronic media, and access control allowing only authorized personnel to access ePHI.

Billing the Wrong Insurance

In the context of billing the wrong insurance, a HIPAA violation may occur if there is an unauthorized release of personal medical information. This could include sending patient records and billing information to the wrong insurance company. In such cases, individuals may file a complaint with the OCR, which will review the information and take appropriate action.

It is important to note that HIPAA does not provide for a private right of action, meaning individuals cannot sue for a HIPAA violation. However, state laws may allow for legal action in response to a HIPAA violation.

HIPAA violation examples

HIPAA, or the Health Insurance Portability and Accountability Act, is a piece of legislation that was introduced in 1996 to ensure employees could maintain healthcare coverage between jobs and not be discriminated against for pre-existing conditions. The legislation also simplifies healthcare administration, eliminates wastage, and prevents healthcare fraud.

A HIPAA violation refers to the failure to comply with HIPAA rules, which can include the unauthorized access, use, or disclosure of Protected Health Information (PHI).

• Unauthorized release of personal medical information: For example, sending medical records to the wrong insurance company.
• Lack of employee training on HIPAA rules: All members of an entity's workforce need to be trained on the policies and procedures related to PHI and the sanctions for non-compliance.
• Improper disposal of PHI: This includes failing to destroy sensitive information properly.
• Failure to conduct a risk analysis: Covered entities are required to undertake risk assessments to assess the risk of virus infection and hackers and create safeguards against these risks.
• Failure to implement safeguards to protect PHI: Covered entities must put in place physical, technical, and administrative safeguards to protect PHI. This includes securing printers, fax machines, and computers, controlling access to PHI, and protecting electronic information.
• Failure to notify individuals of a breach: Covered entities are required to notify individuals of a breach of their PHI and take steps to mitigate any potential harm.
• Unauthorized disclosure of PHI: This includes disclosing more than the minimum necessary information for a permitted use.
• Sharing PHI online or via social media without permission: This includes posting on social media or public forums, such as in a hospital waiting room.
• Mishandling and mis-mailing PHI: This could include sending PHI to the wrong recipient via email or fax.

It is important to note that not all accidental disclosures of PHI are considered HIPAA violations. Incidental disclosures that are accidental and occur as a by-product of a permissible disclosure are permitted by the Privacy Rule if reasonable safeguards are applied and the minimum necessary standard is met.

Frequently asked questions