AMARILLO, TX – This article discusses the HIPAA guidelines that DME suppliers should be aware of, including those pertaining to an Organized Health Care Arrangement.
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Definitions
a) Protected Health Information
“Protected health information” means “individually identifiable health information” that is transmitted or maintained in electronic media or any other form.
b) Covered Entity
A “covered entity” includes a “health care provider who transmits any health information in electronic form in connection with a transaction covered by this subchapter.”
“Health care providers (such as doctors or nurses) who work for a larger organization and do not conduct transactions on their own behalf are workforce members of the covered entity, not covered entities themselves.”
c) Business Associate
A “business associate” is a person or entity that, on behalf of a covered entity, but other than as a member of the workforce of the covered entity, creates, receives, maintains, or transmits protected health information.
d) Treatment
“Treatment” means the provision, coordination, or management of health care and related services by one or more health care providers.
e) Health care operations
“Health care operations” includes the following activities of a covered entity to the extent that the activities are related to covered functions: “(i) business planning and development and (ii) business management and general administrative activities, including the sale, transfer, merger, or consolidation of all or part of the covered entity with another covered entity.
f) Marketing
“Marketing” means to make a communication about a product or service that encourages recipients of the communication to purchase or use the product or service. Marketing does not include a communication made for treatment and health care operations except where the covered entity receives financial remuneration for making the communication.
g) Organized Health Care Arrangement
An Organized Health Care Arrangement is:
(1) A clinically integrated care setting in which individuals typically receive health care from more than one health care provider;
(2) An organized system of health care in which more than one covered entity participates and in which the participating covered entities:
(i) Hold themselves out to the public as participating in a joint arrangement; and
(ii) Participate in joint activities that include at least one of the following:
(A) Utilization review, in which health care decisions by participating covered entities are reviewed by other participating covered entities or by a third party on their behalf;
(B) Quality assessment and improvement activities, in which treatment provided by participating covered entities is assessed by other participating covered entities or by a third party on their behalf; or
(C) Payment activities, if the financial risk for delivering health care is shared, in part or in whole, by participating covered entities through the joint arrangement and if protected health information created or received by a covered entity is reviewed by other participating covered entities or by a third party on their behalf for the purpose of administering the sharing of financial risk.
Covered entities that participate in an OHCA are able to use joint notices of privacy practices and disclose information to each other for the purposes of the OHCA.
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Rules for use and disclosure
a) General rule.
A covered entity or business associate may not use or disclose protected health information (“PHI”), except as permitted by HIPAA regulations.
b) Use and disclosure of PHI by covered entity for health care operations and treatment.
• A covered entity is permitted to use or disclose PHI for health care operations and treatment.
• A covered entity may use or disclose PHI for its own health care operations.
• A covered entity that participates in an OHCA may disclose PHI about an individual to other participants in the OHCA for any health care operations activities of the OHCA.
c) Sale of PHI and marketing.
A covered entity can use and disclose PHI for the purpose of the sale of PHI and marketing pursuant to a valid patient authorization.
i) Marketing.
A covered entity must obtain a patient authorization for use or disclosure of PHI for marketing, except if the communication is in the form of (i) a face-to-face communication made by a covered entity to an individual or (ii) a promotional gift of nominal value provided by the covered entity. If the marketing involves financial remuneration to the covered entity from a third party, the authorization must state that such remuneration is involved.
ii) Sale of PHI.
A covered entity must obtain a patient authorization for the sale of PHI. Such authorization must state that the disclosure will result in remuneration to the covered entity.
The sale of PHI does not include a disclosure of PHI:
• for the sale, transfer, merger, or consolidation of all or part of the covered entity and for related due diligence;”
• for treatment and payment purposes;
• for any other purpose permitted by HIPAA regulations, where the only remuneration received by the covered entity or business associate is a reasonable, cost-based fee to cover the cost to prepare and transmit the PHI or a fee otherwise expressly permitted by other law.
d) Business Associates
A business associate may use or disclose PHI only as permitted (i) by its business associate contract or (ii) HIPAA regulations. Covered entities that participate in an OHCA are permitted to share PHI for the joint health care activities of the OHCA without entering into business associate contracts with each other.
Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato, a law firm with a national health care practice based in Texas. He represents pharmacies, infusion companies, HME companies, manufacturers, and other health care providers throughout the United States. Mr. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or [email protected].
AAHOMECARE’S EDUCATIONAL WEBINAR
Negotiating Managed Care Contracts
Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato & Laura Williard, American Association for Homecare
Tuesday, November 5, 2024
1:30-2:30 p.m. CENTRAL TIME
Approximately 50% of Medicare beneficiaries are signed up with Medicare Advantage Plans (“MAPs”), while approximately 70% of Medicaid beneficiaries are signed up with Medicaid Managed Care Plans (“MMCPs”). These percentages are increasing. MAPs and MMCPs work essentially the same way: (i) the government health care program contracts with a “Plan” that is owned by an insurance company; (ii) the Plan signs up patients; (iii) the Plan signs contracts with hospitals, physicians, DME suppliers and other providers; and (iv) the government program pays the Plan that, in turn, pays the providers. In order to serve MAP and MMCP patients, DME suppliers must sign managed care contracts. In so doing, the supplier needs to be careful. Not only must the contract provide sufficient reimbursement to the supplier, but the contract will have some “trap” provisions that may be harmful to the supplier. This program will discuss the most important provisions that are contained in managed care contracts, such as covered services, medical necessity, passive amendments, incorporation of collateral documents, set-off, remedy for delay in payment, and payment forfeiture for late claims. The program will discuss how the supplier can negotiate with Plans; and the discussion will point out the provisions that are often non-negotiable and the provisions that are open to negotiation.
Register for Negotiating Managed Care Contracts on Tuesday, November 5, 2024, 1:30-2:30 p.m. CT, with Jeffrey S. Baird, Esq. and Laura Williard.
Members: $99
Non-Members: $129