Two Quick Notes: On Parity and HIPAA for Business Associates


On November 8, the Administration announced a final rule on Parity of mental health and substance abuse benefits with physical health benefits. The Departments of Health and Human Services along with Labor and the Treasury issued this final rule that

…implements the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, and ensures that health plans features like co-pays, deductibles and visit limits are generally not more restrictive for mental health/substance abuse disorders benefits than they are for medical/surgical benefits.

While health insurers have claimed to be supportive of Parity, their implementation in the absence of a Final Rule has been spotty and challenged by providers. We will now get to see what changes, if any, emerge.

HIPAA for Business Associates

You are a behavioral health provider, right? You have Business Associates, right? You even have Business Associate Agreements with those Business Associates, right? But do your Business Associates really have any idea what HIPAA is all about and what responsibilities and liabilities they have under the law?

You can make sure they have at least been exposed to some information in order to protect yourself, your patients, and their protected health information (PHI) a bit better. Send them the link to this free webinar happening on Tuesday, November 19 and ask them to attend. ID Experts is a fine provider of education and consultation and tools focused on privacy and security. HIPAA Compliance for Business Associates: Ignorance is Not Bliss should be a very instructive event, especially for Business Associates who really do not know their responsibilities.


Please share any information you have obtained about the Parity Final Rule or about training for Business Associates. We would love to be sure this information is well-circulated.


Do You Own Your Patient Records?

I just re-read an email newsletter by Monica Oss of Open Minds asking the question: “Who Owns Patient Records?“. The answer to this question varies from state to state, with some locales not having clear statutory requirements. In Florida, the provider owns the record but must provide a copy of it if the patient requests it. In fact, the HIPAA privacy standards make it very clear that the provider is responsible for sharing records with a patient (making copies) if a patient so requests. One of the major exceptions to this requirement is psychotherapy notes, which the behavioral health provider is not responsible to share with the patient and must not share with anyone else (like an insurance company) without the patient’s specific permission.

This matter is complicated when a provider uses an Electronic Medical Record (EMR) that is hosted by a software company. Why should that matter, you ask. Well, in the case of the hosted product, the software resides on the company’s servers, not on the provider’s computer. The provider pays to use the software; they don’t own anything. Unless the provider prints everything out, they do not really have possession of a record; the software company does.

What happens when they decide to go to another software program? The first company may be willing to provide them with reports and printouts of their records, but getting that into a new program can be a challenge. And if the old company is willing to work with the new one to transfer the data, the process can be very time-consuming and costly…and some companies won’t even do it.

And if the EMR is free, the provider may be agreeing to share some of the data they enter so the software company can sell it to other companies…all within the confines of their role as a Business Associate, of course. You do have a BAA with the software company, right? And of course, you have a good contract that you have read and understood before you signed it, right?

Hmmm…..this ownership question is complicated.

Please share your comments below. Struggles in First Weeks

I don’t know about you, but I have been reading everywhere I turn about the shortcomings and failures of, the website created by HHS to serve as the health insurance exchanges for over half the states. The site was overwhelmed by the number of people who attempted to access it in the first days. The method of requiring the potential customer to create an account before they could even look at prices in their state, and the bottleneck that requirement caused meant that people could not get anywhere. Each time they tried anew, they were required to re-enter their information and still got nowhere. Many people were very frustrated.

President Obama has called for a ‘tech surge‘ including the assistance of heavy hitters from government and private sources. And now members of Congress are calling for investigations into who in the administration is to blame. The strong undercurrent in each of the articles I have read is that here we have yet another example of government ineptitude.

But is that what we have? After all, this entire project was contracted to a huge private corporation who had an open-ended contract to provide a mission-critical product for HHS. They failed, and now they are being paid even more money to fix their mess. Here’s one more example of private corporations fleecing the American taxpayer.

But wait, aren’t private corporations by definition more effective and efficient than the government? That is a story we have all been sold for the past forty years. Privatize! Private companies can always do it better…by definition!

According to Joshua Holland and Moyers & Company, that is anything but the case. Government has been so downsized since Reagan, Bush, Clinton and Bush, that it does not have the resources to even oversee these huge contracts; so when they go awry, there is no one there to get them back on track.

I don’t think large government is our problem; I think out of control private contractors and their cronies in the administration and in Congress are.



Medical Identity Theft: Fastest growing type of fraud

You know all that work you have been doing to make your organization HIPAA compliant? You have been tuning up your privacy and security practices in order to keep safe the protected health information (PHI) of your clients.

Good job…but not good enough!

In spite of the efforts of healthcare organizations and providers of all stripes to secure the PHI of their patients, Medical Identity Theft and resulting fraud is dramatically on the rise. According to ID Experts’ Data Breach Examiner,

In the last year, medical identity theft has affected 1.84 million Americans, costing victims an estimated $12.3 billion in out-of-pocket expenses. . . . Medical identity fraud is estimated to cost the healthcare industry almost $40 billion annually, driving up the cost of healthcare for everyone.

Do you know someone who has allowed another person to use their Health Insurance card and ID? Maybe your friend who has insurance let her sister who did not use her card. Or possibly, your wallet was stolen and you noticed an EOB on your payer’s web site that was for services you never received.

Breaches are not the only way data finds its way into the hands of someone who does not own it. According to ID Experts, its all in the family.

 More than half the survey respondents said they would find another provider if they knew their healthcare organization could not safeguard their medical records. Yet 30 percent of those surveyed also reported that they knowingly allowed a family member to use their personal identification to obtain medical treatment, healthcare products, or pharmaceuticals, and more than 20 percent couldn’t even remember how many times they had shared their healthcare credentials. Even in cases where medical identity was stolen, 48 percent said they knew the thief (typically a family member) and didn’t want to report him or her.

Not only does this cost money, it also contaminates the medical record of the individual increasing the danger of misdiagnosis and improper prescriptions.

Perhaps you have never experienced this in your behavioral health organization. Perhaps you have and have many stories to tell. I know I was certainly asked to do some fraudulent insurance activities when I was in private practice.

Have you or your organization experienced someone falsely using another person’s medical identity? How did you handle it? Please share your comments below.


HIPAA Omnibus Final Rule Now in Effect

On September 23, 2013, the HIPAA Omnibus Rules became effective. You can read the detail of the process and get huge amounts of information from the HHS web site; you can read the entire Rule as published in the Federal Register. But if you are strapped for time and you want to be sure you and your organization have done everything you need to do to meet the requirements of the rule, you can take a look at an excellent summary published by the Godfrey Kahn Law Firm of Wisconsin that was published in March. There are many such summaries around and you definitely should take a look at one of them if you are the Privacy Officer for your organization. I know that many organizations have not done even the basics of updating their Notice of Privacy Practices or updating their Business Associate Agreement (BAA) . . . you do have those, right?

Keeping the protected health information (PHI) of your clients secure and private is a significant responsibility, especially the sensitive information of behavioral health clients. I hope you have taken these changes seriously.

Please share your comments below.

Telehealth: Is this a legitimate way to provide treatment?

My first article on telehealth services in mental health was in February 2009. Since that time, I have written about this subject on multiple occasions. It has seemed natural to many of us that some mental health services could be appropriately provided using services like Skype.

This area is very much open for debate, but in Oklahoma, a doctor has been sanctioned for mental health services he provided remotely. Investigative Reporter Andrew Knittle reported on NewsOK that Dr. Thomas Trow was disciplined because he prescribed controlled substances for a patient he had never met face-to-face (his nurse was with the patient and present during the remote session), the patient overdosed multiple times, and the patient ultimately died. Joseph Kvedar, M.D. re-reported this story and his comments in the cHealth Blog after he was invited to comment in WBUR’s Common Health blog. Dr. Kvedar wrote the following as part of his contribution:

The Medical Board of the state of Oklahoma recently sanctioned a physician for using Skype to conduct patient visits. A number of other factors add color to the board’s action, including that the physician was prescribing controlled substances as a result of these visits and that one of his patients died. This situation brings up several challenges of telehealth — that is, using technology to care for patients when doctor and patient are not face-to-face.

• Legal/regulatory: On the legal side, physicians are bound by medical regulations set by each state. It appears that the use of Skype is not permitted for patient care in Oklahoma.

• Privacy/security: Skype says its technology is encrypted, which means that you should not be able to eavesdrop on a Skype call. That would seem to protect patient privacy.

At Partners HealthCare, we ask patients to sign consent before participating in a ‘virtual video’ visit. Because this is a new way of providing care, we feel it’s best to inform our patients of the very small risk that their video-based call could be intercepted. I don’t know if the Oklahoma physician was using informed consent or not.

But the most interesting aspects of this case involve the question of quality of care. Can a Skype call substitute for an in-person visit? Under what circumstances?

While Dr. Kvedar brings up additional interesting points in his discussion, I think the three listed above are crucial.

  1. What is the state law where you are working? If the patient is in another state, what is the law in that state? Which state’s laws govern the interaction?
  2. Is the method you are using for your session secure? Does the patient understand that it might not be so?
  3. Can you provide quality care remotely? Is this a new patient you have never met face-to-face or is this follow-up care with an already established patient?

Has your organization begun using remote sessions to provide behavioral health services? How do you do this? How do you handle the privacy/security issues? How do you assure that the quality of the patient’s care remains high?

Please share your comments below.


HHS Releases Model Notice of Privacy Practices

Yesterday I had the experience of going into an outpatient surgery center for a procedure. I was presented with a form to sign indicating that I had seen the Notice of Privacy Practices (NPP), but when I asked to see it they had to go searching. When I was presented with the document 15 minutes later, I was saddened to see that it was dated 2003. The notice indicated that it was posted on the wall of the office (it was not) and that it was distributed to each patient on admission (obviously, it was not). I was distressed to see how little energy even an organization the size of an outpatient surgery center has given to implementing HIPAA. I certainly fear for the security and privacy of my data.

A couple of weeks ago, I posted about the amount of time providers have spent implementing the new HIPAA Omnibus Rule that goes into effect on Monday, September 23, 2013. The Notice of Privacy Practices is the most time consuming part of this implementation.

On September 16, 2013, the Office of the National Coordinator (ONC) and HHS Office of Civil Rights released sample NPPs that you can customize and use in your own organization. Please note that these models are templates that are meant for you to edit. Please DO NOT just print them out as they are. You can also use them as models for an NPP that you create from scratch.

You should also know that HHS OCR maintains detailed background information about HIPAA NPPs, implementation of HIPAA, and anything else you can think of related to it. If you have never visited this web site, you should be sure to do so.

Please tell us where you are in implementing the HIPAA Omnibus Rule. Have you updated your NPP? Do you have BAAs with all your business partners who might have access to your PHI? What have you done to include the changes in your procedures and educate your staff? Please share your comments below.



New CMS-1500 Forms Required Soon

CMS has announced deadline dates for use of the new CMS-1500 form that will be ICD-10 compatible. CMS will begin accepting the new paper form (for those who have a special exemption to send paper Medicare claims) on January 6, 2014. Starting April 1, 2014, Medicare will accept only the new form. The information and links below are from an email notification we received on September 5, 2013.

CMS-1500 Claim Form Updates: Medicare to Accept Revised Form Starting January 2014

The CMS-1500 Claim Form has been recently revised with changes including those to more adequately support the use of the ICD-10 diagnosis code set. The revised CMS-1500 form (version 02/12) will replace version 08/05. The revised form will give providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes, which is important as the October 1, 2014, transition approaches. ICD-9 codes must be used for services provided before October 1, 2014, while ICD-10 codes should be used for services provided on or after October 1, 2014. The revised form also allows for additional diagnosis codes, expanding from 4 possible codes to 12. 

Only providers who qualify for exemptions from electronic submission may submit the CMS-1500 Claim Form to Medicare. For those providers who use service vendors, CMS encourages them to check with their service vendors to determine when they will switch to the new form.

Medicare will begin accepting the revised form on January 6, 2014. Starting April 1, 2014, Medicare will accept only the revised version of the form.

As you know, other insurers will follow CMS’ lead on use of the new form; you will need to find out from them when they will require the new form. SOS, like most other software vendors, will provide the new format for customers with current support agreements. But you will need to purchase the forms and use them…unless you have wisely moved to electronic claim filing!


HIPAA Omnibus Rule: How much time have you spent?

FierceHealthIT, one of the newsletters I monitor, just reported that the department of Health and Human Services Office for Civil Rights estimates that all healthcare organizations in total will spend 32.8 million hours implementing the new aspects of the HIPAA omnibus rule.

The bulk of that time–30.65 million hours–involves the dissemination and acknowledgement of privacy practices at provider offices, a notice published in the Federal Register reveals.

I recently went into a physicians office and needed to sign an acknowledgement that I had received their notice. Of course, I had not. I looked around to see if one was posted, as some offices do to make it a bit easier. When I did not spot one, I asked to see a copy. After a bit of rummaging in a desk drawer, I was graciously provided with a copy. It was a very nice, plain language policy that could easily have been framed and hung on the wall, or copied and included in the packet of materials I needed to sign. But it was not. I had to ask for it. In my humble opinion, that is not a dissemination of the privacy practices.

How does your organization handle this sharing of privacy practices? Do you provide a copy for every new patient when they arrive at your offices and complete your intake paperwork? Do your staff know exactly where it is located and just what it means in case they are asked? Have you forgotten all about this requirement that HIPAA places upon your organization?

I think this is especially important in behavioral health organizations where people are seen for sensitive reasons. Please share your strategies for disseminating your privacy practices. I would love to know how you handle this. Just enter your comments below.

Contractor vs. Employee: How does your organization decide?

This week I received an email from the Florida Department of Revenue about classification of workers for tax purposes. With Labor Day upon us, I find myself wondering how your organizations make the decision about whether to treat their workers as W-2 employees or as 1099 independent contractors.

In behavioral health organizations there is often a mix of kinds of workers including licensed professionals, salaried and hourly workers. I am often confused when I hear a customer say that they have 14 counselors and two back office staff, and that they are all independent contractors. That does not fit with my understanding of what an employee and an independent contractor is.

I was surprised to learn that Florida (and many other states) have their own definitions of employee and contractor that are separate from the IRS definitions (additional IRS articles). There appear to be significant overlaps, but the email I received indicated that businesses should review their employment practices to make this determination. If someone believes they were your employee and files for Unemployment Compensation (Reemployment Assistance here in Florida) after you let them go, and you have not been paying those taxes because you have them classified as an independent contractor, you may find yourself with some explaining to do.

How does your behavioral health organization handle the employee vs independent contractor issue? Please share your comments below.

HIPAA Breach Fines Grow

Remember that CBS Evening News report back in 2010 that got everyone panicked about patient data that might be stored on the hard drives of copy machines and other multipurpose machines like combination printer/fax/copy machines?

Well, it turns out there is good reason that any health-related practice that uses such a machine (one that has a hard drive) should panic; in fact there are 1,215,780 such reasons. That is the amount Affinity Health Plan was fined by OCR this month for the potential breach of PHI that was reported in this incident.

I know, this could never happen to you. But are you sure of that? Does your organization own or lease a copy machine? Do you have one or multiple printers that are also copy and fax machines as well as a scanner? What is your organization’s policy for the hard drives in those machines? What about the hard drive in that computer you are using to read this? What is your policy for removing any PHI that might be on it?

If you do not know the answers to these questions, you may not have been properly trained in your organization’s HIPAA policies and procedures. Or you may not even have such policies and procedures. Or the practice you work for did all this before you were hired and you have never been informed. These excuses do not fly when it comes to OCR enforcement.

The Federal Trade Commission (FTC) has guidance on handling copier data. NIST, the National Institute of Standards and Technology, has recommendations on how to sanitize electronic media. And Medscape, among others, offers lots of training on HIPAA security. (You might need to register for Medscape before you can access their materials.)

When was your organization’s last HIPAA training? What did you learn? Please share how you address these issues.

Now Open for Enrollment: Health Insurance Marketplace

FierceHealthPayer reported that the U.S. Department of Health and Human Services (HHS) has announced the opening of the health insurance marketplace mandated by the Affordable Care Act (ACA). The Exchange enrollment process has begun for individuals and for small businesses who want to try out the new site.

The ACA requires states to set up exchanges or marketplaces where consumers and businesses can shop for reasonably priced health insurance plans that meet the minimum requirements of the law. So far, only sixteen (16) states have taken on that responsibility. The other thirty-four (34) states’ exchanges will be included in the site being developed by HHS.

Take a look when you get a chance. There will not be actual insurance plans up for offer until October 1, 2013, but in the meantime, you can visit the site and read some of the available information and enroll if you like. If you work for an employer who does not provide health insurance and live in one of those 34 states with no exchanges of their own, this is where you will go to shop for coverage. If you are an employer with fewer than fifty (50) employees who is not required by ACA to provide health insurance, there is a section here for you as well. The site is far from complete, but there is already lots of useful information.

Do you already have affordable health insurance? Will you be using the Exchanges to locate coverage for yourself or your business? I certainly will be comparing plans, their coverage and their cost, with our current insurance once the exchange is open!

‘Single Payer Healthcare Would Save Us $Billions’ Study Shows

Several years ago, I sat next to a colleague at a conference. She was CEO of a much-larger-than-SOS behavioral health software company. We were listening to a presentation on costs and duplication of services to chronically mentally ill Medicaid recipients, and the efforts of community mental health organizations to provide needed services with limited Medicaid dollars. We looked at one another and agreed that the only way all of us, including the most vulnerable populations, are ever going to get reasonably priced high-quality healthcare services is when we have a single payer system.

Many of you know that I have spent the past eight years as primary caregiver for my elderly mother. A result of that process is significant experience with the Medicare system. My mother used traditional Medicare: doctors billed for services provided. Medicare and a Medigap policy paid for all covered services. Medicare Part D paid about 60% of medication costs. Our experience with the Medicare system was nothing but positive. Mom paid her extremely reasonable Medicare, Medigap and Part D premiums and she received all the care she needed from caring, outstanding providers.

This morning, I read my issue of FierceHealthPayer. They reported that a new study from Physicians for a National Health Program shows that we could save approximately $592 billion in healthcare expenditures next year if Medicare were extended to all. Gerald Friedman, Ph.D., a Professor in the Department of Economics at University of Massachusetts at Amherst details how these savings could be accomplished through a single payer system proposed in HR 676: The Expanded and Improved Medicare for All Act.

Dr. Friedman’s focus is on administrative costs. You know about those. They include your costs in meeting the requirements of myriad insurers in order to get paid for the services you render to your clients. Those costs include software, claim forms or clearinghouse fees, staff salaries and benefits, long distance charges for hours spent on hold with insurance carriers to verify coverage and object to claim rejections, to list only a few. These costs include insurer’s expenditures for their side of those same processes…and employers costs to shop for, administer, and pay for coverage.

Don’t think about other countries and their health care systems. Think about our 48 years with Medicare. Maybe Dr. Friedman and Rep. John Conyers, Jr. (D-Michigan), author of the bill, are onto something.


PHI Leaks: The Insider Threat

When most of us think of threat to the Protected Health Information (PHI) for which we are responsible, we think about breach by outside sources. After all, those of us who work in Behavioral Health and Substance Abuse are highly sensitized to the need to protect the privacy of our clients. Given that, we assure that our electronic systems are protected by adequate security….that the PHI is encrypted, that our firewall is effective, that no one is connecting remotely who should not have access. Right? We don’t as often think about what goes on inside our offices.

This morning, Seth sent the SOS staff an account reported by one of the HIPAA security blogs to which he subscribes. This event sounded very much like two that have happened to customers of SOS. Two staff members leave the practice taking patient information with them in order to feed a new practice/business. Most people immediately think about the theft of the patients by the departing provider. We think about the theft of the PHI and the breach report the practice may now be required to make.

Since the Office of Civil Rights (OCR) started real enforcement of HIPAA including fines, breaches have resulted in settlements averaging $1M each. Six out of nine of those breaches were the result of an insider’s actions, not those of an outsider. The fines mostly came about as the result of investigation by OCR of reports made by the health organization that experienced the breach.

Today I attended a webinar provided by IDExperts. They are one of my favorite sources of information about privacy and security of PHI. While their software may be beneficial to some of our larger customers, it is clear to me that our smaller practices and agencies are very much in need of information and education and could benefit from some of the resources available on their site.

If you think your PHI could ever be viewed by an inappropriate person based on employee mistakes, the loss of portable devices, or the theft of patient information by someone with whom you contract, you need to assure that you have protective policies and procedures in place, that your employees are adequately trained, and that you all follow the needed procedures. Hiring a consultant or buying software to write policies for you and then forgetting about them is a major mistake. You must develop a culture of compliance to assure the safety of PHI. The Ponemon Institute, in a study sponsored by IDExperts, found that only 52% of employers believe they have policies and procedures to prevent and detect unauthorized patient data access. Are you part of that 52% or of the 48% who do not have adequate policies and procedures to protect your PHI?

What does your organization do to protect PHI? What is your role in whatever your organization does? When was your last HIPAA Privacy/Security training? Do all staff attend including providers and executive staff? Do you have Business Associate Agreements with all the businesses who might have access to your PHI? If I were to come to you as a client, would I feel assured that my PHI is protected from preying eyes and secure from threat?

Please share your thoughts and comments below.


New Blog Strategy: Short, targeted posts….States prep for health information exchange in emergency

Since returning to the office regularly after my intermittent absences of the past year, I have had a difficult time renewing my weekly blogging schedule. In order to ease back in, I have decided to do very short blog posts that will provide information that has come across my desk recently. I am hopeful this will help me get back into a rhythm of regular posting and also get useful information to you. Once I have a regular pattern re-established, I will add in longer posts. Thanks for bearing with my changes and transitions.


As a resident of the state of Florida, I was very glad to see an article this week in FierceHealthIT reporting that several states, including ours, have begun working together to assure access to health information during a disaster. Hurricanes are a big concern for us here. Since my Mother was displaced from Louisiana to Florida by Katrina in 2005, we have seen precious little movement to assure that, eight years later, patients will continue to be treated properly when they do not have access to their own physicians and pharmacies.

The new collaboration described in this article will allow exchange of health records for persons displaced from their homes by widespread disaster. The states participating are Alabama, Georgia, Louisiana, Florida, South Carolina, North Carolina, Virginia, Michigan, Wisconsin and West Virginia. The plan is to have connection with at least one other state through a Health Information Exchange (HIE) to assure access to patient records. The Southeast Region HIT-HIE Collaboration (SERCH) Final Report published in July of 2012 explores the legal and technical details required of such a project.

A guidebook prepared by the Agency for Healthcare Research and Quality (AHRQ) provides information for providers on how to connect into a system that will allow sharing of information in case of emergencies like natural disasters. A Guide to Connecting Health Information Exchange in Primary Care was published by AHRQ in May of 2013.

These projects aimed at linking local records to regional systems to be shared in case of emergency may at some time help all of us. This is just a beginning step toward solidifying what electronic health records can do for us.

Please share your thoughts about this kind of healthcare information exchange in the comments below. Thanks for reading.

ICD-10 Implementation

This post on ICD-10 preparation and implementation is offered by Manon Faucher, SOS’ Lead Support Tech.


“Is SOS ready for the implementation of the ICD-10 codes?”

SOS has received many calls and e-mails from our customers asking us this question. Actually we should be asking you, ‘Has your practice implemented a process for the adoption of the new ICD-10 codes?’ Have you researched and planned for training of your providers and staff? Once you have trained your staff who will be responsible for revising all your accounts and assigning the new ICD-10 codes? Will you have someone overseeing and reviewing the process to assure the proper codes are used? As you can see, most of the intensive labor will not be on SOS but will be on your practice.

There are many online documents that will provide transition planning guides, resources and training information. You need to start researching your options now. Various sites such as those offered by the Centers for Medicare and Medicaid Services (CMS), American Psychological Association (APA), and the Centers for Disease Control (CDC) are great sources of information; and right now, information is your friend. The more you and the staff of your organization can learn about the ICD-10 codes related to the ICD-9 codes you currently use, the better prepared you will be.

It is important that you remember that there will NOT be a one-to-one code conversion utility or methodology to translate an ICD-9 code to an ICD-10 code. There are tools available to help you know which codes to use, but if you enter one ICD-9 code these tools will return multiple possible ICD-10 choices. Your clinicians must choose among the options…or provide enough information for your coding specialist to do so intelligently. SOS will NOT have a utility built into the system to convert the ICD-9 codes, but we will make it easy for you to link to your favorite crosswalk site to do look-up as you have the need.

To answer the question above, SOS has the ability to include both ICD-9 and ICD-10 codes in our next generation of software. On October 1st, 2014 the program will start including ICD-10 codes on your claims by default. If some insurance companies are not ready on October 2014 to receive the ICD-10 codes, you can set these insurance carriers to include ICD-9 instead. This can be done on a payer by payer basis.

As a note, ONLY the 5010 ANSI format will allow for the ICD-10 codes. If you are using any of SOS Electronic Claims Modules (this does NOT include the ‘Export CMS 1500 form for 3rd party products’), you do not need to worry. If you are using different Electronic Claim software you need to verify that by October 2014 they will have the ability to send in the 5010 ANSI format.

Has your organization begun preparations? What are you doing to get ready? Please share your experience in the Comments below.

Thoughts on the Quality of Death and Dying: A personal reflection

As many of you know, I have spent much of the past year taking care of my elderly mother. While she had lived with us since Katrina flooded her home in New Orleans in 2005, this past year has required the greatest amount of hands-on caregiving. Mom died on May 6, and I find myself thinking a great deal about her personal experience of the process of dying…and how we treat the elderly in this country. This is a huge area worthy of many a dissertation; this will certainly not be an exhaustive take on this topic and may be very subjective.

First, I should state pretty clearly my basic assumption: I believe we have not done ourselves any favors by extending human life for as long as we have without providing the elderly with a meaningful and satisfying place within our communities and our homes. Secondly, in this article, I am talking about the very elderly and those in significant decline. Even those who have stayed healthy and active well into their eighties are frequently shunted into custodial care and isolated from their families and their communities when they approach death. I think this is an unconscionable shortcoming of U.S. culture. Life without a meaningful role is not worth much; life in poverty and isolated from others for no reason but ‘being old’ is a crime. Below are a few thoughts about five areas I consider important.

Places to live

In Florida where I live, and in many other places with a large senior population, older adults have isolated themselves in communities for active, over-55 residents. These communities have the reputation of feeling like a resort…at least, until debilitating illness strikes or infirmity makes continued independent living difficult. Then these retirement communities have the same problems as any other neighborhood in which a person might choose to live. Doctors’ offices are a drive away and transportation and drivers are limited. Houses are built with no thought to canes and walkers and wheelchairs; doorways are too narrow, stairs are too frequent, bathtubs are impossible to step into or get out of, counters and appliances are too high. And in many communities there is often an additional problem; the elderly residents are far away from their children or other closely connected people who are able and willing to assist them. In 2011, almost half (47%) of women over 75 lived alone. In 2009, 14.3% of adults 85 or older lived in an institutional setting rather than in their own home. A small percentage live in some other kind of community-based residence ranging from communal farms to Continuing Care Retirement Communities (CCRC’s). Even so, there are not yet enough good choices.

Activities/jobs/functions that maintain involvement and contribute to the community well-being

One of the biggest problems we encountered when Mom moved into our home was that she had been displaced and no longer had a community of her own. Most of her dear friends and family were still loving somewhere in Louisiana. She was in shock because of the loss of her home and her community and was unwilling and unable to undertake the work needed to develop friendships here. At 85, the effort to build a new community was outside her capabilities. I would venture a guess the same might be true for many people at that age.

Respectful care

Doctors in Florida believe they are the best at taking care of the elderly. They have lots of experience at it and often do a very good job. Our overwhelming experience was of very good care; my experience was that the amount of and complexity of care was overwhelming. Without me or someone equally knowledgeable as an advocate, it is my hunch that Mom would have floundered when faced with the choices with which she was presented.

The right to receive and to refuse treatment

Even given the high quality of the care she received, the tendency of physicians and the system is to provide a great deal of care…many medicines, recommendations for procedures and surgeries, frequent visits. Part of my job was to support her in her decisions about her care, especially when she decided “no” to something. Even given her leaning toward little care, the number of medications prescribed for her was high. The pressure to accept treatment is significant. Early on in her stay with us, one doctor told me that declining an endarterectomy (a high risk procedure with little upside for an 86 year old) was irresponsible; we were certainly inviting stroke. We did not return to that physician.

To their credit, physicians are charged with curing/helping/fixing their patients…even if their patient is over 85; but is this what we really want? And how is a compliant patient who is used to doing what her doctor recommends supposed to turn down what is offered and even expected? How much do we actually have a right to refuse treatment?

The right to die at home with excellent care

And then we get to the biggest, final question…how does one arrange to be taken care of and to die at home while also having excellent care? Fortunately, there is an answer to that question…hospice care.  When cure is no longer the focus, when an elderly person has begun a significant decline and is failing to thrive, hospice care may be the kindest, most satisfying way to be comfortable, to be cared about, and to be cared for respectfully. One of the largest benefits to the person dying is the support provided to the primary caregiver, making it possible for them to continue providing care and to remain loving during the process. It certainly was one of the most helpful things Mom and I experienced in the last three months of her life. Warm, cheerful, supportive caregiving assistants taught me how to lovingly allow her to die.

Many of you have privately shared some of your own caregiving experiences. I hope you and others will weigh in here. I am sure you have thoughts we can all benefit from. Just enter your comments below.

PQRS Intro


NOTE: Trish Merchant, our SOS Business Development Manager, stepped up to my request for guest bloggers. Hope you find her information useful.


Recently, we’ve had a few customer support calls asking about PQRS. I thought it would be a good subject to share on the SOS blog.

PQRS or Physician Quality Reporting System is a voluntary reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality measures for services in the covered Physician Fee Schedule (PFS) by eligible professionals. While the program is considered voluntary, starting in 2015, eligible professionals who do not satisfactorily submit data on quality measures will see a payment adjustment in their Medicare claims.

According to the CMS website, the PQRS program provides an incentive payment to practices with eligible professionals who provide and report on certain services. Eligible professionals are identified on the claim by their NPI or Tax ID number. SOS customer organizations with eligible professionals can choose to report data via their Medicare Part B claims. Other ways to report include using a registry; reporting directly to CMS via qualified EHR system; or using a qualified PQR data submission vendor.

Participating in this program where eligible professionals satisfactorily submit quality measures data, via one of the above mentioned reporting vehicles, will qualify a provider to earn a PQR incentive payment. The percentage of the payment is based on Medicare Part B Physician Fee Schedule and is an estimate of allowed charges for a covered professional service that was rendered during the same reporting period. Percentages and documents for this incentive vary from year to year so it is important to verify the correct documents are reviewed.

To learn more about this program and how to get started, please visit the CMS website. For questions on how to set up SOS Office Manager for these services, SOS customers with current support agreements can contact the SOS Support Desk.


Caregiving Revisited

Several times in the past few of years, I have mentioned that I am the primary caregiver for my almost 93 year old mother. Last week, she took a fall that has left her in terrible pain and needing a great deal more assistance.

In addition to getting help from others, I am trying to implement some of the suggestions that I have read about. While resources are available, many of us do not find them in time to be of real assistance to us.

One decision I have made is that it is time to set priorities and to follow through on them. I will be going to the medical equipment store today to look at hospital beds. On Thursday,  we will get an order from the doctor for home health care assistance. Hopefully, on Friday I will be able to get input about sitters and the like.

In the meantime, I will need to put this blog on hiatus. If I can get some of my co-workers to do a post, there will be something here. If I get inspired and have some found time, I will do a post. Otherwise, I will leave you until things quiet down on the home front.

Thanks for reading. Hope to talk to you again soon.

HIPAA Final Rule Finally Released

I know you thought that all your HIPAA policies and procedures were in place and that you were finished with learning about how this law affects you. I am sorry to say that you were wrong.

The HIPAA Omnibus Rule has finally been released. According to FierceHealthIT, HHS released the Omnibus Rule to simplify compliance actions that must be taken by affected entities.

The four rules that combine to create the omnibus final rule include:

  • Modifications to the HIPAA Privacy, Security, and Enforcement Rules mandated by the Health Information Technology for Economic and Clinical Health Act, and certain other modifications to improve the rules, which were issued as a proposed rule on July 14, 2010.
  • Changes to the HIPAA Enforcement Rule to incorporate the increased and tiered civil money penalty structure provided by the HITECH Act, originally published as an interim final rule on Oct. 30, 2009.
  • A final rule on Breach Notification for Unsecured Protected Health Information under the HITECH Act, which replaces the breach notification rule’s “harm” threshold with a more objective standard and supplants an interim final rule published on Aug. 24, 2009.
  • A final rule modifying the HIPAA Privacy Rule as required by the Genetic Information Nondiscrimination Act (GINA) to prohibit most health plans from using or disclosing genetic information for underwriting purposes, which was published as a proposed rule on Oct. 7, 2009.
Read more: HHS unveils final HIPAA omnibus rule - FierceHealthIT

Ascertaining the impact of this Omnibus rule could be a while in the making, but HIPAA commentators have begun their assessments. I will be attending a webinar hosted by IDExperts on February 6 in an attempt to start to understand just what has been changed and to try to get an idea about how that affects us and our customers.

On January 30, FierceHealthIT indicated that providers must attend to at least four areas:

Monetary penalties aside, four areas of the rule that will have a significant impact on providers are:

  • A change that makes business associates and their subcontractors liable for breaches of personal health information
  • An enhanced right for patients to obtain electronic copies of their records
  • An enhanced right for individuals to request restrictions regarding disclosure of their PHI
  • A change to the breach notification rule in which any disclosure of PHI is presumed to be a breach
Read more: Handling HIPAA: 4 new provisions providers must know - FierceHealthIT

That fourth area, the breach notification rule, is one that could affect anyone who handles PHI. Any disclosure of PHI is presumed to be a breach.

When the Interim Final Rule was released in 2009, the notion of assessing whether any significant “harm” had occurred to those whose data had been lost or viewed inappropriately was introduced. David Harlow, author of HealthBlawg discussed the current change in FierceHealthIT. The bottom line for Mr. Harlow is this:

… the default assumption is that any irregular release of PHI is a breach, with no subjective standard of harm getting in the way. The covered entity or business associate unfortunate enough to have suffered this breach may either (a) immediately acknowledge that it is, in fact, a breach, and rev up the notification machinery (notice to data subjects, the federales–possibly for posting on the Wall of Shame–and the press, as appropriate, based on the size of the breach) or (b) decide that a risk assessment is necessary, and begin its assessment of at least the four factors highlighted in the regulation.

Read more: Uncertainties surround new HIPAA breach notification rule – FierceHealthIT

What impact will this have on you and your organization? If you allow PHI to be released contrary to your policies and to the law, how will you proceed? Do you know? Who is your Privacy Officer? Do they know?

Time to wake up the HIPAA education machinery again! …or for the first time if you do not have such machinery in place.