01-06E - Introduction To Healthcare and Public Health in The US - Unit 06 - Regulating Healthcare - Lecture E

Introduction to Healthcare
and Public Health in the US

Regulating Healthcare
Lecture e
This material (Comp1_Unit6e) was developed by Oregon Health and Science University, funded by the
Department of Health and Human Services, Office of the National Coordinator for Health Information
Technology under Award Number IU24OC000015.

Learning Objectives
Describe the role of accreditation, regulatory bodies, and professional
associations in healthcare in the US. (Lecture a)
Describe the basic concepts of law in the United States: the legal system,
sources of law, classification of laws, the court system, and the trial
process. (Lecture b)
Describe legal aspects of medicine involving the Affordable Care Act,
professional standards in healthcare, medical malpractice, Tort reform, and
Medicare and Medicaid Fraud and Abuse (Lecture c)
Describe key components of the Health Insurance Portability and
Accountability Act (HIPAA) and current issues of privacy and patient safety
in the US (Lecture d)
Discuss the need for quality clinical documentation for the use of the health
record as a legal document, communication tool and a key to prove
compliance for healthcare organizations. (Lecture e)

2
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
Lecture e
The Health Record as Tool for
Patient Safety
Quality of care is key to patient safety
Monitoring information in the health record
Use of health record to manage risk and
improve healthcare
3
Lecture e
The Health Record as a Legal Record
Business Record
Legal Record
4
Lecture e
Governance of Health Record
Federal and State Laws, Regulations, and Rules
Joint Commission
Other voluntary accreditation
Medical staff bylaws
5
Lecture e
Quality Clinical Documentation for
Legal Purposes
Hand-written documentation
Electronic documentation
6
Lecture e
Quality Clinical Documentation to
Avoid Fraud and Abuse Accusations
Clinical documentation improvement programs
Coding and reimbursement
Issues of fraud and abuse
7
Lecture e
Compliance Program Tips from
OIG

The Seven Fundamental Elements of an Effective Compliance Program
1. Implementing written policies, procedures and standards of conduct.
2. Designating a compliance officer and compliance committee.
3. Conducting effective training and education.
4. Developing effective lines of communication.
5. Conducting internal monitoring and auditing.
6. Enforcing standards through well-publicized disciplinary guidelines.
7. Responding promptly to detected offenses and undertaking
corrective action.

8
Lecture e
Corporate Integrity Agreements
A comprehensive CIA typically lasts 5 years and includes requirements
to:
hire a compliance officer/appoint a compliance committee;
develop written standards and policies;
implement a comprehensive employee training program;
retain an independent review organization to conduct annual reviews;
establish a confidential disclosure program;
restrict employment of ineligible persons;
report overpayments, reportable events, and ongoing
investigations/legal proceedings; and
provide an implementation report and annual reports to OIG on the
status of the entity's compliance activities.

9
Introduction to Healthcare and Public Health in the US Regulating
Healthcare Lecture e
Compliance Beyond Fraud and
Abuse
HIPAA Privacy and Security Rules
What is the plan for appropriate release of PHI?
How is the tracking of release occurring?
Who is responsible for breach notification?
What training is being done?
Is there a team reviewing policies and procedures?
10
Introduction to Healthcare and Public Health in the US Regulating
Healthcare Lecture e
Summary Lecture e

The health record is the business and legal record for a healthcare
organization
The health record is the communication tool for the healthcare team
Clinical documentation is used to assure high quality care of the patient, as
well as to provide information for decision-making, reimbursement and
medical coding
Thorough and complete clinical documentation protects healthcare
organization from the risk of fraud, abuse, and malpractice claims
Compliance programs are important to assure correct procedures to follow
related to regulations, rules, laws, accreditation, and internal policies
HIPAA privacy and security rules need to be included in compliance plans
11
Lecture e
Summary

This unit discussed:
Healthcare accrediting and certification organizations;
The US legal system;
The laws governing healthcare practice;
privacy and security rules;
The clinical documentation in the health record supports quality healthcare,
administrative and business operations of the organization, and provides the basis for
legal proof of care that assures compliance with laws, rules, and regulations as well
as professional standards of care

12
Lecture e
References Lecture e
References
American health Information Management Association. http://ahima.org/resources/infocenter/ehr.aspx. accessed
on 11/11/2011.
American Health Information Management Association. http://ahima.org/resources/cdi.aspx. accessed on
11/11/2011.
American Health Information Management Association. http://ahima.org/resources/psc.aspx. accessed on
11/11/2011
Bayes, N., Newby, J, Seggern, J, Valerius J. Medical Insurance An integrated claims process approach 5
th
edition,
2012. McGraw Hill Companies: New York
Davis, N. Revenue Cycle Management Best Practices, 2011, AHIMA Press: Chicago
Healthcare Compliance Program Tips accessed on 11/9/11: http://oig.hhs.gov/compliance/provider-compliance-
training/index.asp
LaTour & Eichenwald, Health Information Management, concepts, Principles, and Practice, Third Edition, 2010
AHIMA Press: Chicago
Russo, R. Clinical documentation improvement, 2010 AHIMA Press: Chicago
Office of the Inspector General. http://oig.hhs.gov/. accessed on 11/11/2011.
Office of the Inspector General. http://oig.hhs.gov/newsroom/video/2011/heat_modules.asp. accessed on
11/11/2011.
Office of Inspector General. A roadmap for new physicians: avoiding Medicare and Medicaid fraud and abuse.
http://oig.hhs.gov/fraud/PhysicianEducation. Accessed 11/11/2011.
Office of the Inspector General. http://oig.hhs.gov/newsroom/video/index.asp. accessed on 11/11/2011.
Centers for Medicare and Medicaid. http://www.cms.gov/default.asp. Accessed on 11/11/2011.
Corporate integrity agreements. http://oig.hhs.gov/compliance/corporate-integrity-agreements/index.asp. Accessed
on 11/9/11

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13
Lecture e

01-06E - Introduction To Healthcare and Public Health in The US - Unit 06 - Regulating Healthcare - Lecture E

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