Consumer Authorization to Disclose Information by cqe16545


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Presentation provided by Greater Columbia Behavioral Health

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.

                  By the time…
…you‟ve 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?

              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.

    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.

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
•   Anger at the constant barrage of marketing

     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

                       PHI is…
Information relating to an identified individual‟s
    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

                 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

   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 entity‟s shredding company,
 printing company, and other contractors.

         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 ______________.
    HIPAA Requires that Patients Receive a
    Notice of Privacy Practices (NPP) that…
•   Advises the patient about the covered entity‟s privacy

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 patient‟s written
  acknowledgement of the receipt of the NPP or make a
  written record of why this was not done.

         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
   • Operations – normal business activities (reporting,
     data collection & eligibility checks, etc.)

  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

   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.

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.

         Besides for use in TPO,
       When should an entity disclose
   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
       entity‟s 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
A co-worker is on the phone discussing a
treatment-related issue. You inadvertently
overhear PHI about a patient.

          What should you do?

If you see or hear anything that is private, keep it
    to yourself.

                   Other ideas?

A co-worker calls you and asks for
information about a friend‟s mental health
         How do you respond?

Before looking at a consumer‟s health information, ask
    yourself one simple question:
           “Do I need to know this to do my job?”

Before sharing a consumer‟s health information, ask yourself:
   “Does this person need to know this to do their job?”

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?

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.

           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.

Special Authorizations

    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 patient‟s 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.

Psych notes are granted special protection under
A separate disclosure is required to release psych notes.
• 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

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

Other HIPAA Standards

                     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

•   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 provider‟s 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.

                      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.


In the context of HIPAA, privacy determines who
  should have access, what constitutes the patient‟s 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

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.

HIPAA mandates that security standards be
 applied in four main areas:

•   Administrative Procedures
•   Physical Safeguards
•   Protection for Data Storage
•   Protection for Data in Transit

        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

                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.

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?

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

         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

       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

                       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 you‟re 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 entity‟s
    domain. If transmitting PHI with a provider, you must use the a VPN.
•   Don‟t share your password
•   Dispose of sensitive materials in shredders or locked bins

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

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?

•   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.

           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.

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.

            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.                                                50
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.

                         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”

      The R.S.N. (Regional Support Network) HIPAA
                  Policies & Agreements
             are available on their website at
•   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


•   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


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