HIPAA TRAINING

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HIPAA TRAINING
Presentation provided by Greater Columbia
Behavioral Health
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• HIPAA

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• We must follow HIPAA regulations to protect
  consumers. The following slides will introduce
  HIPAA, including the reasons for it and how it
  impacts health care. At the end of the
  presentation you will be asked to complete
  several questions to assess your understanding of
  HIPAA and its impact on day-to-day health care.
  You must answer the questions in order to
  complete your HIPAA training.

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By the time

• youve completed this slideshow, you will be
  able to answer the following questions
• What is HIPAA and to whom does it apply?
• What is PHI and how is it protected?
• When are additional authorizations required?
• What are the penalties for violation?

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The Primary Intent

• and purpose of this law was to protect health
  insurance coverage for workers and their families
  when they changed or lost their jobs. It was
  recognized that this new protection would impose
  administrative burdens on health care providers,
  payers, and clearinghouses, and therefore, the
  law includes a section called Administrative
  Simplification. This section was designed to
  reduce the burden associated with the transfer of
  health information between organizations. The
  approach was to accelerate the move from
  paper-based administrative and financial
  transactions to electronic transactions through
  the establishment of nationwide standards.

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The Health Insurance Portability and
Accountability Act (HIPAA)

• When HIPAA was passed by Congress in 1996.
• In addition to its goal to reduce health care
  costs nationwide by requiring use of electronic
  data interchange (EDI) for routine health care
  transactions.
• Its goal was to protect the security and privacy
  of the health records used in these EDI
  transactions.

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• HIPAA contains Privacy Security rules
  responding to health care concerns such as
• Fears that once patients records are stored
  electronically on networks, a couple of clicks
  could transmit those records worldwide and
• Loss of personal control over personal
  information and
• Anger at the constant barrage of marketing

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HIPAA Security Privacy rules

• Established federal mandated requirements for the
  creation, transmission, and disclosure of
  individually identifiable health information that
  affect anyone who encounters patient information
• HIPAA uses the term PHI Protected Health
  Information

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PHI is

• Information relating to an identified
  individuals past, present, or future
• Physical or mental health or condition
• Provision of health care services
• Payment for provision of health care
• 45 CFR 164.501

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PHI includes

• Oral or recorded information, maintained or
  transmitted in any form or medium.
• The law refers to covered entities and the work
  that they perform as covered functions.
• Covered Entities are Health Plans, Clearing
  Houses, and Providers.

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HIPAA Business Associate (BA)

• HIPAA extends beyond the walls of the covered
  entity to Business Associates
• Someone that contracts with the covered entity
  will be subject to the same HIPAA regulations as
  the covered entity. Examples are an entitys
  shredding company, printing company, and other
  contractors.

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The Patient Consumer.

• Is entitled to notice about how their PHI will be
  used
• Is entitled to expect that caregivers will be
  careful with their PHI
• Is entitled to a copy of their record
• Is entitled to request correction of their record
• Is entitled to Receive Confidential Communication
• Is entitled to Complain about a disclosure of
  their PHI
• All requests or complaints regarding these
  rights, should be directed to the HIPAA
  Privacy/Security Officer at ______________.

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HIPAA Requires that Patients Receive a Notice of
Privacy Practices (NPP) that

• Advises the patient about the covered entitys
  privacy practices.
• Distribution of the NPP is usually done at the
  first face-to-face meeting except in a major
  emergency or due to an incapacitated patient.
• Covered entities must try to get a patients
  written acknowledgement of the receipt of the NPP
  or make a written record of why this was not done.

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Use and Disclosure of PHI

• A covered entity is permitted by HIPAA to Use
  (internal) and Disclosure (external) of PHI for
  the purposes of
• Treatment the provision of health care
• Payment the provision of benefits premium
  payment
• Operations normal business activities
  (reporting, data collection eligibility checks,
  etc.)

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The Minimum Necessary Rule

• The amount of PHI used or disclosed is restricted
  to the minimum amount of information necessary.
  Healthcare providers and health plans must make
  reasonable efforts not to use, disclose, or
  request more than is necessary to accomplish a
  task.
• Exceptions are
• Disclosure to a provider for treatment
• Release to an individual of their own PHI
• Disclosures required by law

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Minimum Necessary and TPO

• TPO is Treatment, Payment, and Operations.
• Patients must provide consent for use of PHI in
  treatment, payment, and healthcare operations.
• Providers and health plans must distinguish
  activities that fall outside TPO such as
  research, fundraising, and marketing.

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• The minimum necessary rule does not restrict
  the information used or disclosed in treatment.
• The minimum necessary rule does apply to
  payment and health care operations.

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Besides for use in TPO, When should an entity
disclose PHI?...

• A covered entity is required to disclose PHI to
• An individual (their own PHI) when requested
• The Secretary of the U.S. Department of Human and
  Health Services for investigation of complaints
  or to determine a covered entitys compliance.
• A covered entity is permitted to disclose PHI
  outside in special circumstances such as
• required by law
• court proceedings
• to avert a serious threat to health or safety
• emergencies
• abuse/neglect
• special government functions

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• A co-worker is on the phone discussing a
  treatment-related issue. You inadvertently
  overhear PHI about a patient.
• What should you do?

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• If you see or hear anything that is private, keep
  it to yourself.
• Other ideas?

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• A co-worker calls you and asks for information
  about a friends mental health encounter.
• How do you respond?

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• Before looking at a consumers health
  information, ask yourself one simple question
• Do I need to know this to do my job?
• Before sharing a consumers health information,
  ask yourself
• Does this person need to know this to do their
  job?

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• You are advised that a visitor has arrived to see
  you. You are currently busy completing a
  work-related task. However, the visitor has come
  by several times before and knows where you are
  located.
• Should the visitor be allowed to enter on their
  own?

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• No
• Have all visitors, including family and ex
  employees escorted by an employee when entering
  or exiting the facility.
• You should also ensure that all PHI is obscured
  from view, prior to the arrival of the visitor.

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HIPAA Authorization

• Is written authorization from a patient to use or
  disclose PHI for specific purposes (such as
  employment related, research or marketing and
  also needed for psychotherapy notes)
• An authorization can be revoked at any time in
  writing.
• It must include the name of the patient, the
  purpose of the disclosure, an expiration date, a
  signature and date and an explanation of how to
  revoke the authorization.

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Special Authorizations
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Authorization to Disclose Psychotherapy Notes

• Psych notes are recorded during a counseling
  session. The notes are to be kept separate from
  the rest of the patients record.
• Psych notes exclude
• Prescription info and monitoring
• Session start stop times
• Modalities frequencies of treatment
• Results of clinical tests
• Summaries of diagnosis, functional status,
  treatment plan, symptoms, prognosis and progress
  to date.

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• Psych notes are granted special protection under
  HIPAA.
• A separate disclosure is required to release
  psych notes.
• Exceptions
• Use of notes by the originator for treatment
• Use by the covered entity for training
• Use in defense in a legal action
• Disclosure to HHS for HIPAA enforcement
• Use by a coroner or medical examiner

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• Unlike other health records, psychotherapy notes
  are not subject to disclosure to the patient.

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Other HIPAA Standards
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What is the NPI?

• The National Provider Identifier (NPI) is the
  unique health identifier for health care
  providers. The NPI is a 10-digit numeric
  identifier with a check digit.
• The National Provider System (NPS) will be the
  system used to assign unique numbers to health
  care providers.
• Health Care Providers must obtain an NPI and use
  it on standard transactions Health Plans and
  Health Care Clearinghouses must use the NPI to
  identify health care providers on standard
  transactions where the health care providers
  identifier is required.
• Health Care Providers, Health Plans (except small
  health plans), and Health Care Clearinghouses
  must comply with the implementation no later
  than May 23, 2007. Small Health Plans must comply
  with the NPI implementation specifications no
  later than May 23, 2008.

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Code Sets

• HIPAA requires every provider who does business
  electronically to use the same health care
  transactions, code sets, and identifiers.  Code
  sets are the codes used to identify specific
  diagnosis and clinical procedures on claims and
  encounter forms. The HCPCS, CPT-4 and ICD-9 codes
  are examples of code sets for procedures and
  diagnose.  

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Security
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• In the context of HIPAA, privacy determines who
  should have access, what constitutes the
  patients rights to confidentiality, and what
  constitutes inappropriate access to health
  records.
• Confidentiality establishes how the records (or
  the systems that hold those records) should be
  protected from inappropriate access.
• Security is the means by which you ensure privacy
  and confidentiality.

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• Threats to health information security and
  privacy include
•         Intentional misuse from internal
  personnel
•         Malicious or criminal misuse from
  internal personnel
•         Unauthorized physical intrusion of the
  data system by an external person
•         Unauthorized intrusion of the data
  system by an external person via information
  networks. 

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• HIPAA mandates that security standards be applied
  in four main areas
• Administrative Procedures
• Physical Safeguards
• Protection for Data Storage
• Protection for Data in Transit

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Administrative Procedures

• Covered entities need to
• Implement training programs
• Have a contingency plan
• Conduct a risk assessment
• Create policies and procedures including a
  password policy
• Have a formal mechanism for processing records
• Follow a termination process
• Establish roles and responsibilities for security

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Physical Safeguards

• Covered entities need to
• Secure physical access by locking doors,
  escorting visitors, wearing IDs
• Secure unattended workstations by using password
  protected screensavers and locking computers when
  unattended. You can manually lock your
  workstation by holding down the Windows key
  and the L key.
• Store notebook computers, PDAs, jump drives and
  any portable media in a secure place and password
  protect them
• Encrypt PHI on notebooks, PDAs, jump drives, and
  on any portable media.

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• You are walking by a trash can and notice a pile
  of consumer reports or other documents with PHI
  have been laid on top of the trash.
• Should you be concerned?

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• Consumer information should never be thrown away
  in an unlocked bin unless it has been shredded or
  destroyed.

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Protection for Data Storage

• Covered entities need to
• Have a Data Back-up Plan
• Have a Disaster Recovery Plan
• Store Paper, Tapes, Disks securely
• Dispose of Paper PHI securely

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Protection for Data in Transit

• Covered entities need to
• Use Encryption for PHI
• Use Audit Trails
• Report adverse events
• Use precautions when sending PHI on faxes

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What can I do?... The Basics

• Keep your work area free of PHI when not present
• Lock your computer when you walk away
• Log off at the end of the day
• Double check the number youre calling before
  faxing PHI and pick up your faxes A.S.A.P. Use
  a cover page with a confidentiality statement.
• Emails containing PHI may only be emailed to
  others on the entitys domain. If transmitting
  PHI with a provider, you must use the a VPN.
• Dont share your password
• Dispose of sensitive materials in shredders or
  locked bins

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What can I do? The BasicsContinued

• If you have a Building or door code, dont share
  it.
• Wear your id
• Escort your visitors
• Talk quietly on the phone when it involves PHI or
  close your door if needed
• Dont access more PHI than you need to do your
  job
• Dont leave your notebook computer on the seat of
  your car
• Dont allow anyone at home to access your work
• Report any security incidents immediately

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When do I Report a Breach of PHI?...

• Employees must report a breach to their
  supervisor when PHI shared does not pertain to
• Treatment
• Payment
• Operations
• Consumer authorization
• Uses and disclosures permissible under federal
  and state law

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• You are at the fax machine or printer to pick up
  a document. There is consumer PHI already in the
  receiving bin.
• What should you do?

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• Notify the Office manager or supervisor that
  there is PHI on the fax machine. They will
  deliver the document to the recipient and if you
  see private information, keep it to yourself.
• For PHI in the receiving bin of the printer,
  notify the HIPAA Privacy/Security Officer.
  Documents will be delivered to the recipient with
  a reminder not to leave PHI unattended on the
  printer.

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Incidental Disclosures

• Examples of incidental disclosures
• A patient seen in a waiting area
• A conversation between a provider and a patient
  in a semi-private room heard by the other
  occupant
• Incidental Disclosures are not violations if the
  covered entity has safeguards in place and they
  are observed by the staff.

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Sanctions

• Covered entities are required to develop and
  impose sanctions appropriate to the nature of the
  HIPAA violations. The type of sanction applied
  should vary depending on factors such as the
  severity of the violation, whether the violation
  was intentional or unintentional, and whether the
  violation indicated a pattern or practice of
  improper use or disclosure of PHI. Sanctions can
  range from a warning to termination.

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Penalties for Violations

• Civil Penalties
• Violations can result in civil monetary penalties
  of 100 per violation, up to 25,000 per year.
• Criminal Penalties
• In June 2005, the U.S. Department of Justice
  (DOJ) clarified who can be held criminally liable
  under HIPAA. Covered entities and specified
  individuals, whom "knowingly" obtain or disclose
  individually identifiable health information in
  violation of HIPAA regulations face a fine of up
  to 50,000, as well as imprisonment up to 1 year.
  Offenses committed under false pretenses allow
  penalties to be increased to a 100,000 fine,
  with up to 5 years in prison. Offenses committed
  with the intent to sell, transfer, or use
  individually identifiable health information for
  commercial advantage, personal gain or malicious
  harm permit fines of 250,000, and imprisonment
  for up to 10 years.

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Enforcement

• The DHHS Office of Civil Rights (OCR) enforces
  the privacy standards, while the Centers for
  Medicare Medicaid (CMS) enforces both the
  transaction and code set standards and the
  security standards (65 FR 18895). Enforcement of
  the civil monetary provisions has not yet been
  tasked to an agency.

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Of note

• According to reports, the US government has not
  imposed a single fine for violations of the
  HIPAA.
• There have been several complaints received by
  the Bush Administration on HIPAA violations.
  However, only two criminal cases have been
  prosecuted to date.
• June 6, 2006 HIPAA Compliance Journal

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The R.S.N. (Regional Support Network) HIPAA
Policies Agreementsare available on their
website at www.gcbh.org

• Designated Record Set
• Administrative Requirements for Implementation of
  HIPAA
• Administrative Requirements Documentation
• Business Associate Addendum
• Confidentiality and Security Agreement
• Computer and Information Security
• Computer and Information Security Agreement
• Workstation Use and Portable Computer
• Remote Access
• Password Protection
• Consumer Protected Health information Rights
• Confidentially, use and Disclosure of Protected
  Health Information

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(Continued)

• E-mail and Internet Security
• FAX
• HIPAA Complaint
• Information Systems Security Checklist Onsite
  Inspection
• Sources of PHI Inventory and Location
• Privacy officer Job Responsibilities
• Sanction
• HIPAA Training
• Staff Training Plan for Privacy and Security
• Virus Protection
• HIPAA Administrative Simplification Definitions
• Privacy and Security Plan
• Removal of PHI from Office
• GCBH Privacy Notice