Hipaa Laws: Understanding Their Scope And Your Medical Bills

The Health Insurance Portability and Accountability Act (HIPAA) was established in 1996 to protect sensitive health information from disclosure without a patient's consent. The act outlines rules for handling health information, including billing information, and applies to health plans, health care clearinghouses, and health care providers who transmit health information electronically.

HIPAA's Privacy Rule gives patients rights over their health information and sets rules and limits on who can access and receive it. This rule applies to all forms of protected health information, including billing information, whether in electronic, written, or oral form.

The Security Rule, a Federal law, specifically protects health information in electronic form and requires entities covered by HIPAA to ensure the confidentiality, integrity, and availability of all electronic protected health information.

While HIPAA generally restricts the disclosure of protected health information, it does allow for certain exceptions. For example, HIPAA permits covered entities and their business associates to disclose protected health information as necessary to obtain payment for health care services, including to consumer reporting agencies or credit bureaus. However, in such cases, the disclosure must be limited to the minimum amount of information necessary.

Understanding and complying with HIPAA rules are crucial for anyone handling medical records and healthcare data, as violations can result in significant monetary fines and legal implications.

The Privacy Rule permits covered entities to disclose protected health information to third parties for payment purposes

The HIPAA Privacy Rule permits covered entities to disclose protected health information to third parties for payment purposes. The Privacy Rule establishes a foundation of federal protection for personal health information, balancing the need to protect personal information with the need to avoid creating unnecessary barriers to quality healthcare.

Covered entities include health plans, health care clearinghouses, and health care providers that conduct standard electronic transactions. The Privacy Rule permits covered entities to disclose protected health information for their own payment activities, as well as the payment activities of another covered entity. For example, a hospital may disclose protected health information about an individual as part of a claim for payment to a health plan.

The Privacy Rule defines "payment" as the activities of health care providers to obtain reimbursement for their services, and the activities of a health plan to obtain premiums, fulfil coverage responsibilities, and provide benefits under the plan. Common payment activities include:

• Determining eligibility or coverage under a plan and adjudicating claims
• Billing and collection activities
• Reviewing health care services for medical necessity, coverage, and justification of charges
• Utilization review activities
• Disclosures to consumer reporting agencies

Covered entities are required to reasonably limit the amount of information disclosed for payment purposes to the minimum necessary. They must also abide by any reasonable requests for confidential communications and any agreed-upon restrictions on the use or disclosure of protected health information.

The Security Rule requires electronic protected health information to be kept confidential, integrity-controlled, and available only to authorised individuals

The HIPAA Security Rule establishes national standards to protect individuals' electronic personal health information (e-PHI). It requires appropriate administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of e-PHI. The Security Rule applies to health plans, healthcare clearinghouses, and healthcare providers who transmit health information electronically.

The Security Rule's confidentiality requirements ensure that e-PHI is not available to or disclosed to unauthorized persons. This supports the Privacy Rule's prohibitions against improper uses and disclosures of protected health information (PHI). The Security Rule also promotes the integrity and availability of e-PHI. "Integrity" means that e-PHI is not altered or destroyed in an unauthorized manner, while "availability" means that e-PHI is accessible and usable on demand by authorized individuals.

Covered entities and their business associates must implement the Security Rule. They must ensure the confidentiality, integrity, and availability of PHI and comply with the implementation of the rule. This includes healthcare providers, healthcare clearinghouses, and select entities handling PHI as defined under HIPAA.

To achieve these goals, covered entities and business associates must implement administrative, physical, and technical safeguards. Administrative safeguards refer to the administrative actions, policies, and procedures that govern the selection, development, implementation, and maintenance of security measures. Physical safeguards focus on securing PHI in medical offices, including facility access control and workstation and device security. Technical safeguards involve the use of technologies, policies, and procedures to ensure the safety of PHI.

The Security Rule is designed to be flexible and scalable, allowing covered entities and business associates to tailor their policies, procedures, and technology to their size, structure, and risks. This flexibility is crucial in the evolving healthcare industry, where new technologies and threats constantly emerge.

Compliance with the Security Rule is mandatory, and non-compliance can result in civil money penalties and, in certain cases, criminal prosecution. Proper documentation and employee training are essential for compliance. Covered entities and business associates must maintain records of their security measures, security incidents, and any required actions, activities, or assessments for at least six years.

The Privacy Rule gives individuals rights over their health information, including the right to access and amend their records

The Privacy Rule, a Federal law, gives individuals rights over their health information and sets rules and limits on who can look at and receive their health information. The Privacy Rule applies to all forms of individuals' protected health information, whether electronic, written, or oral.

Right to Access and Amend Health Records

Individuals have the right to access and receive a copy of their health records, including medical and billing records, upon request. This right extends to all protected health information (PHI) about the individual in a designated record set, which includes medical records, billing records, payment and claims records, health plan enrollment records, and case management records. Individuals can request that their PHI be sent directly to a third party of their choice.

Individuals also have the right to request corrections to their health information and to receive a report on when and why their health information was shared.

Right to Notice and Restrict Information Sharing

Individuals have the right to receive a notice explaining how their health information may be used and shared. They can also request that a covered entity restrict how it uses or discloses their health information.

Right to Opt Out of Marketing

Individuals have the right to opt out of having their health information used for marketing or advertising purposes or sold.

Right to File a Complaint

If individuals believe their rights are being denied or their health information is not being protected, they can file a complaint with their provider, health insurer, or the Department of Health and Human Services (HHS).

Covered entities include health plans, health care providers, health care clearinghouses, and business associates

The Health Insurance Portability and Accountability Act (HIPAA) outlines the privacy rules that covered entities must follow. Covered entities include health plans, health care providers, health care clearinghouses, and business associates.

Health plans refer to individual and group plans that provide or pay the cost of medical care. This includes health, dental, vision, and prescription drug insurance plans, health maintenance organizations (HMOs), Medicare, Medicaid, and long-term care insurance plans. Employer-sponsored, government-sponsored, and multi-employer health plans are also considered health plans. However, a group health plan with fewer than 50 participants that is administered solely by the employer is not considered a covered entity.

Health care providers, regardless of their size, are considered covered entities if they electronically transmit health information in connection with certain transactions. These transactions include claims, benefit eligibility inquiries, referral authorization requests, or other transactions for which the Department of Health and Human Services (HHS) has established standards under the HIPAA Transactions Rule. Health care providers include hospitals, doctors, clinics, psychologists, chiropractors, nursing homes, pharmacies, and dentists.

Health care clearinghouses are entities that process non-standard health information they receive from another entity into a standard format or vice versa. They typically receive identifiable health information when providing processing services to a health plan or health care provider as a business associate. Examples of health care clearinghouses include billing services, repricing companies, community health management information systems, and value-added networks and switches.

Business associates are individuals or organizations that are not members of a covered entity's workforce but have access to individually identifiable health information to perform functions for the covered entity. These functions include claims processing, data analysis, utilization review, and billing. Business associates must have contracts in place with covered entities to ensure the proper handling and protection of health information.

By understanding and complying with the HIPAA privacy rules, covered entities can protect sensitive health information and ensure that it is only used and disclosed in a manner that is consistent with the rights of individuals.

The Privacy Rule permits the use and disclosure of protected health information for 12 national priority purposes without individual authorisation

The Privacy Rule, a Federal law, gives individuals rights over their health information and sets rules and limits on who can look at and receive their health information. The Rule applies to all forms of individuals' protected health information, whether electronic, written, or oral.

The Privacy Rule permits the use and disclosure of protected health information for 12 national priority purposes without individual authorization. These 12 purposes are:

• Required by Law: Disclosures required by statute, regulation, or court orders.
• Public Health Activities: Preventing or controlling disease, injury, or disability, and reporting child abuse and neglect.
• Victims of Abuse, Neglect, or Domestic Violence: Disclosure of PHI belonging to victims may be necessary.
• Health Oversight Activities: Audits and investigations necessary for oversight of the health care system and government benefit programs.
• Judicial and Administrative Proceedings: Disclosure of PHI is permitted when responding to a subpoena or other lawful process, with certain assurances.
• Law Enforcement Purposes: Disclosure is permitted under specific circumstances, such as identifying a suspect or locating a missing person.
• Decedents: Identifying a deceased person or determining the cause of death.
• Cadaveric Organ, Eye, or Tissue Donation: Facilitating the donation and transplantation of cadaveric organs, eyes, and tissue.
• Research: Systematic investigations designed to develop or contribute to generalizable knowledge.
• Serious Threat to Health or Safety: Preventing or lessening a serious and imminent threat to a person or the public.
• Essential Government Functions: Execution of a military mission, intelligence activities, protective services, and determining eligibility for government benefit programs.
• Workers' Compensation: Disclosure of PHI is permitted as authorized by workers' compensation laws.

Frequently asked questions