Union Plastic surgery center becomes hippa complaint
Scenario
This type of scenario will emphasize a situation that has led to the Union Plastic Surgery Center becomes a HIPPA complaint. The process undertook during a surgical operation of a woman clientele, aged 45 years old, working at a department store as she decides to undergo a liposuction in the center but the serious problem took place when the center failed to ask for authorization and permission consent in lieu to the HIPAA act of 1996 and failed to provide guidelines to consider upon the duration of the operation. The failure to insure the client in doing the process, the center then violates the guidelines of HIPPA and to always practice the profession in itself as well as in following the principles and provisions desired and included in the HIPPA guidelines. To simplify the situation, there is really a problem of implementing the HIPPA guidelines throughout the center respectively. Months after the operation, the client formally filed a complaint to the center, certain accounts for unsecured privacy information regarding health data and the failure to incorporate health insurance because the center may have had an expire license and did not follow strict implementation of health care service rules and protocols in which the latter must be observed properly and careful assumptions are to be realized. The center failed to have committed as required by applicable federal and state law to maintain the privacy of the health information and did not give you notice about their privacy practices, legal duties and client’s rights concerning her health information.
The center has not used and disclose her health information in connection with their healthcare operations as it includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification and licensing activities. The client’s authorization: In addition to their use of health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose.
Description of Facility
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishes a federal role for regulating the employer group and individual insurance markets (1997). Thus, HIPAA ensures access to insurance for some employer groups and individuals who previously were unable to purchase health insurance or unable to purchase adequate coverage. Moreover, variability among states in existing insurance legislation and the flexibility that states are given to implement the individual market reforms suggests that the answer to these questions will vary from place to place.
Develop Problem Statement
The problems in implementing HIPPA guidelines in the Plastic Surgery Center, in which a failure to adhere to the guidelines results into violation and certain form of malpractice of profession in providing stance for information about HIPAA and the provisions it contains, including: guaranteed issue, guaranteed renewal, portability, pre-existing condition exclusion limits and non-discrimination provisions. There could have possibilities of having the performance of state high-risk pools, one of the alternative mechanisms that states are allowed to adopt to meet the HIPAA provisions for the individual process reforms.
Problem Classification
The problem of HIPPA implantation in terms of its guidelines for the center. HIPAA prohibits all group health plans – insured or self-insured from denying coverage or charging higher prices based on health status. It requires that health insurance companies guarantee renewal of all group plans, to both large and small groups. It also requires insurance companies that offer health coverage in the small group market to make all products available to all applicants and that small groups must be accepted and all eligible members of a group must be accepted.
Categorize the problem
The specific provisions of HIPAA entail that health insurance issuers are required to guarantee renewability of coverage for all groups and guarantee issue all products for small groups. The group health plans must credit prior public or private insurance coverage toward preexisting condition periods, provided the coverage has not lapsed for days. The state must implement an acceptable alternative mechanism, to guarantee issue and apply no preexisting condition exclusions to individuals who had months of continuous coverage, the individual also must have exhausted all other sources of coverage – including COBRA coverage, Medicare or Medicaid. Individual health insurers must guarantee issue at least two different individual insurance products. These products may be either a) the two highest volume products b) a low and high policy option that represent individual policies offered by the insurer in the state that are subsidized, risk-adjusted, or covered by a risk-adjustment mechanism.
Data Collection
HIPPA’s group provisions were designed to eliminate insurer practices that discriminate against employer groups and their members on the basis of health status, industry, or other characteristics. Redlining, denying coverage to employees with poor health or to their entire group, and excluding coverage for pre-existing conditions are documented practices that can pose barriers that wish to offer health insurance as a benefit (1994).
HIPPA eliminates the first two practices in the small group market, and limits the exclusion on pre-existing conditions for all group plans. Proponents of these reforms believe that they will expand coverage; critics argue that they will lead to increases in premiums that might in turn lower access to coverage ( 1997 Moreover, many states had already taken steps to eliminate discriminatory carrier practices and have standards that meet or surpass HIPAA standards. One empirical study using state data suggests that guaranteed issue legislation may result in an increase in the number of firms offering insurance ( 1995). This study’s estimate implies about a 10 percentage point increase in the number of small firms offering insurance in states in which availability is guaranteed, holding constant other regulations and market characteristics (1995). HIPAA does not provide for affordable coverage; it only ensures the continued right to purchase a plan.
Decision Making
If there is an authorization, the client may revoke it in writing at any time and the revocation will not affect any use or disclosures permitted by the authorization while it was in effect. The center cannot use or disclose her health information for any reason except those described from the notice. The center must disclose the health information to as it is described in the Patient Rights section. The use of health information for marketing communications without a written authorization is not allowed as required by Law that the center may disclose any health information when required to do so by law in accordance with the HIPPA guidelines, to the appropriate authorities if the center believe that the client is a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes as well as to avert a serious threat to your health or safety or the health or safety of others. The client may have the right to receive a list of instances in which the business associates disclosed health information for purposes other than treatment, payment, healthcare operations and certain other activities. The client have the right to request that the center place additional restrictions on their use or disclosure of the health information and are not required to agree to these additional restrictions, but if they do, they will abide by the agreement.
If the concerned believed that there was violation of privacy rights or you disagree with a decision made about access to the health information or in response to a request made to amend or restrict the use or disclosure of the health information by alternative means or at alternative locations, the client may file a formal complain to the U.S. Department of Health and Human Services. In the absence of guidelines from professional organizations then, it is necessary for each institution to examine their policies to determine whether they should consider requiring change in their requirement for patients and maximize cooperation with such policies.
Alternative solutions
Solution One
The center and the HIPPA guidelines must adhere to a balanced coordination of their respective functions and must agree on such terms and conditions and avoid challenges to incorporate relevant information for the client’s security within the clinical clinical practice and every imaging data is stored digitally on easily accessible intranet systems and workstations. However patient confidentiality issues and HIPPA guidelines guide their appropriate use and dissemination
Solution Two
There should have an in-dept understanding of the HIPPA guidelines in terms of authorization that implies, before the center begin to retrieve and save any images or clinical data, they have to ensure that they have privileges and authorization to do the operation and will require the patients consent and approval of the center’s institutional review board
Solution Three
Aside, it is critical to have a protected health information which refers to any information which may identify the background of the client and there is a need to integrate such provacy rules within the process as the HIPPA regulation require that such information be “de-identified” or removed in any communication if not needed for direct care related issues.
Solution Four (The best solution)
Most importantly, the role of a permission and consent is vital for the center to follow carefully in terms of handling properly the client’s case and provide awareness of the services strengths and limitations promulgating its by-laws to the context of the guideline. There needs to adapt a generic disclosure and consent upon admission top a clinic or hospital will cover the general use of information in the course of treatment, discussion among consultations and multidisciplinary clinics. As the HIPPA mandates that reasonable caution be exercised in collecting storing and transmitting this information in an electronic form. Thus, this solution is essential to avoid references to any information that might easily identify a patient – particularly if the audience includes members not directly involved in the care of the patient. Moreover, it is rarely necessary to scan documents to highlight the clinical record. This is usually reserved for morbidity and mortality discussions and have to scan the client’s EKGs, EEGs, PFTs respectively before undergoing any form of surgery. The situation protocol would include what steps have been taken within the selected states to identify these and other problems that limit access to HIPAA coverage.
For example, the protocol would include specific questions to be covered in the site visit interviews. Has the state put in place routine compliance review mechanisms to identify how HIPAA is being implemented or do states wait for complaints? Has the state implemented a voluntary compliance regime that encourages firms to self-correct without sanctions? Once a problem limiting access to HIPAA is identified, what steps are taken to eliminate the barrier? The legislation requires that the center provide certification to the clients and dependents as they leave a group plan. It will be important to identify the specific roles played by the state, employers, and insurers and to identify problems in the notification process.
The Decision Matrix
Criteria 1
Criteria 2
Criteria 3
Criteria 4
Total
Weight
Weight
Weight
Weight
Option 1
25
25
25
25
100
Option 2
25
25
25
25
100
Option 3
25
25
25
25
100
Option 4
25
25
25
25
100
Furthermore, to gain enough perspectives, those involved from the following entities would have these four decision options to make 1) state officials involved in HIPAA implementation; 2) a sample of large and small surgery centers 3) health insurers and 4) a sample of HIPAA eligibles . The desired strategy is to triangulate in order to obtain more than one voice for the client’s interest, and interviews should be coded to ensure that every responses are included in synthesizing outcomes to solutions. For instance, using high-risk pools as an alternative HIPAA mechanism, the interview would include questions about risk pool funding, the premium schedule, and the methodology for determining premiums. In states that have adopted guaranteed issue, the interview would focus on the number and characteristics of guaranteed issue plans, risk adjustment or risk-spreading mechanisms, marketing practices, and enforcement. In advance of the interviews, the evaluator should collect available documentary evidence. A data checklist should be developed and distributed requesting that documents be provided or made available to the site visit team for review.
Criteria for selecting the best solution
Criteria 1: Integration
Criteria 2: Relevance
Criteria 3: Substance
Criteria 4: Applicability
The implications for the solution
The implication for each solution is to focus on the privacy and security measures to be adapted by the center as the client may be in high risk industries within the key outcomes to monitor include the availability of group coverage, the cost of group coverage and mobility and compare what would have happened over time without reforms to the changes that we observe in states in which the HIPPA provisions lead to the changes of ways and reforms prior to the HIPAA legislation and for the control measure that the center should have.
Implementation
HIPAA provides for substantial state flexibility in implementing the intent of the individual market reforms to ensure that those who leave a group health insurance plan are able to maintain coverage and are not denied individual insurance if that is the only coverage option available. To meet the requirements of an acceptable alternative mechanism – a state program must provide all eligible individuals with a choice of coverage, including one providing comprehensive benefits, and not impose pre-existing condition exclusions to meet the requirements, in most cases expanding on an existing risk pool (1998), other alternative programs include mandatory group conversion policies, or guaranteed issue of designated individual policies.
The HIPAA group provisions ensure access to coverage for groups and individuals in those groups, but also place some limits on insurers ability to segment risks. Insurers cannot charge higher prices to high risk individuals in a group; they cannot exclude entire groups from the risk pool. Risk segmentation results in lower premiums for the healthy than the sick; greater pooling of risks may result in adverse selection and increasing premiums that will cause the healthy to drop coverage. However, HIPAA does not place any restrictions on the manner in which insurers can set premiums, and so insurers retain substantial ability to segment the market (1996). Thus, the HIPAA provisions are unlikely to result in substantial premium increases for those individuals currently purchasing insurance (1992). HIPAA imposes new requirements that may increase the administrative costs of insurance. HIPAA requires employers to provide certification of creditable coverage to employees and their dependents as they leave a group plan; in subsequent contracts, employers are likely to place this responsibility on insurers (1996). Insurers view this as costly and unnecessary, favoring certification on demand. They note that state portability rules have been successfully implemented without global certification requirements (1998). The necessity of certifying periods of coverage for spouses and dependents may pose special problems and require costly new record keeping systems. Employers and insurers currently do not have records to track this coverage (Humo, 1997).
Evaluation
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Department of Health and Human Services to report on the effectiveness of the provisions of HIPAA in providing access to health insurance and ensuring coverage security for the currently insured. This document describes components of a design for undertaking such an evaluation. The design builds on the literature review and database review described in earlier parts of this report, and on the policy database developed by the Institute for Health Policy Solutions The approach to evaluation design is to identify the key outcomes address on changes brought about by the HIPAA legislation. In doing this, there must have designs to measure the effects of reform packages that have been adopted to conform to HIPAA that have been produced that are subsequent to the HIPAA legislation. According to a recent report, state insurance regulators have encountered implementation barriers resulting in part from the lack of federal guidance before policymakers and stakeholders can take action to address the perceived weaknesses in the HIPAA structure, there must accurately assess how HCFA and the states are enforcing HIPAA provisions, what seems to be working, what the potential barriers to implementation are and what covered populations or services have been most affected by the implementation process. (1998)
Feedback
HIPAA was targeted to address the most important insurance abuses and not to ensure affordable coverage ( 1997). But, there are many implementation issues and problems facing employers, insurers, and regulators that also need to be addressed in the evaluation. One observer notes that HIPAA may appear modest in scope to public policy makers, but it is anything but simple for the private sector (1997). Monitoring employer and insurer efforts to document creditable coverage, insurer benefit design practices and the characteristics of products available to HIPAA eligible and state practices to insure compliance with HIPAA requirements, are all important issues that will need to be addressed as a part of a qualitative assessment of HIPAA.
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