1. HIPAA Privacy Training - DAS Keeping It To Ourselves! Protecting Client Confidentiality…

2. Introduction Vin Lombardo Henry Jovanelly Gene Shook (Keane) Purpose: Comply with the training requirements of HIPAA

3. Topics of Discussion What is HIPAA Privacy and Confidentiality Standards

4. What This All Really Means Use or disclose health information that identifies the individual for billing and collection (Payment) purposes only When you do that, disclose the minimum necessary and know who you disclose to

5. What is HIPAA? Health Insurance Portability and Accountability Act of 1996 (August 21) Public Law 104 –191 Guarantees insurability of employees that change jobs (Portability) Reduces fraud and abuse of federal entitlement programs (Accountability) Improves efficiency through standardization of electronic transactions and codes Protects individual’s private health information Establishes security standards for health care information systems National standards for unique health identifiers

6. It came out of the failed health-care reform effort of the Clinton administration. In the early 1990s there was a lot of concern about people who were restrained in moving from one employer to another because they were afraid of losing their health insurance due to pre-existing conditions. So although the overall health- reform efforts failed, one of the things that came out of those efforts was this bill, which was aimed at allowing the portability of health insurance by preventing insurers from imposing requirements about pre-existing conditions when you move from one employer to another. At the time, employers were concerned that this was going to lead to an increase in health insurance costs. So there was an effort made to reduce costs in the health-care system as a way of offsetting the increased costs caused by these portability requirements. People quickly identified the amount of administrative expense throughout the health- care system caused by inefficient communications. For example, there are more than 400 different transaction formats in use throughout the country related to services provided and payments made. So HIPAA contains within it a set of provisions under its administrative simplification section to standardize to 10 transactions. Congress recognized that this was going to result in enhanced flow of individually identifiable health information in electronic format. There was concern that this would increase the risk of private health information being improperly disclosed. So part of the administrative simplification rules deal with protective measures that health-care providers and payers have to take in order to protect the privacy and security of this individually identifiable health information.

7. Time Line April 2003 Oct 2003 April 2005 Privacy Transactions & Codes Security Unique Identifiers Enforcement Firm Estimated (awaiting publication of Final Rules) Implementation Dates:

8. Healthcare Payers (Plan)  An individual or group plan that provides, or pays the cost of medical care Healthcare Clearinghouses (DAS Collections)  An entity that processes/facilitates processing of health information received from another entity Healthcare Providers  Who transmit health information in electronic format Covered Entities

9. $30 Billion in savings over 10 years in administration costs ($18 Billion implementation cost) Title 1Insurability and Portability Title 3Tax Implications Title 4Group Health Title 5Revenue HIPAA Title 2 Administrative Simplification

10. 1. Electronic Health Transaction Standards and Code Sets 2. Privacy and Confidentiality Standards 3. Security and Electronic Signature Standards 4. Unique Identifiers Administrative Simplification Title II. Administrative Simplification

11. 1.Electronic Health Transactions Standards and Code Sets n All payers, providers and clearinghouses using electronic healthcare transactions, must use a national standard format. The act designates standards for 10 specific transaction sets. (835 Payment, 837 Claim) n Health organizations also must adopt a set of industry standard codes to be used with transactions. Various coding systems are already in use to identify: n diseases n injuries n other health problems (as well as their causes, symptoms, and actions taken) Administrative Simplification

12. 2. Privacy and Confidentiality This rule protects the privacy of information related to an individual's health, treatment, or healthcare payment. n Limits the use of individually identifiable health information, sent or stored in any format (electronic, paper, voice, etc) without patient authorization n Business partners who receive, store or have access to privately identifiable health information must ensure the privacy of the records n Patients may have access to their own medical records Administrative Simplification

13. 3. Security of Health Information & Electronic Signature Standards n A uniform level of security for all health information that is: n housed or transmitted electronically n pertains to an individual n Organizations who use Electronic Signatures will have to meet: n a standard ensuring message integrity n user authentication, and n non-repudiation Administrative Simplification

14. 4. Unique Identifiers for Providers, Employers, and Health Plans n The current system allows for multiple ID numbers assigned by different agencies and insurers. HIPAA sees this as confusing, conducive to error, and costly. n It is expected that standard identifiers will reduce problems. n HIPAA sets a standard identifier for: n Providers n Claims Payers n Employers n Identifier likely to be eliminated: n Unique Patient Identifier Administrative Simplification

15. n Minimum Necessary n Verification Prior to Disclosure n Administrative Requirements n Business Associate Agreements Privacy and Confidentiality Standards (Policies & Procedures) Limits the use of Protected Health Information (PHI)

16. n Protected Health Information (PHI) n Limit Access/Role Bases n Disclosure of Minimum Necessary n De-Identification n Right to Request Privacy Protection/Confidential Communication n Individual’s Access Minimum Necessary

17. n Protected Health Information (PHI): Protected Health Information (PHI) is information that identifies an individual and relates to the person’s physical or mental health or condition, the provision of health care to that person, or payment for the provision of health care to that person. DAS will limit the disclosure of Protected Health Information (PHI) to the minimum amount necessary to accomplish the intended purpose of the authorized use, disclosure, or request. Minimum Necessary

18. Some items that identify an individual are: Name, Address, Telephone or FAX #, Email Address, Names of Relatives, SS#, Birth Date, Account Number, Name of Employers, any other item that can ID a person in a small sample…

19. n Limit Access/Role Bases: DAS will identify and make reasonable efforts to limit the access: To those persons or classes of persons, as appropriate, in its workforce who need access to Protected Health Information (PHI) to carry out their duties Minimum Necessary

20. n Disclosure of Minimum Necessary: DAS will limit any request for Protected Health Information (PHI): To that which is reasonably necessary to accomplish the purpose for which the authorized request is made Minimum Necessary

21. It just means that if a person needs a date from a file, don’t give them the whole file. Give authorized individuals the minimum necessary to get the job done.

22. n De-Identification : DAS will de-identify Protected Health Information (PHI) (eliminate or cross out, identifiers of the individual or of relatives, employers, or household members of the individual), to limit the disclosure of Protected Health Information (PHI) to the minimum amount necessary to accomplish the intended purpose of the authorized disclosure This is not necessary for TPO (to carry out Treatment, Payment or health care Operations) Minimum Necessary

23. n Right to Request Privacy Protection/Confidential Communication: It is our policy that we respect the right of an individual to request restrictions on uses and disclosures of PHI and permit an individual to request confidential communication of PHI at alternative locations or by alternate means. DAS will document the restriction and termination of the restriction, should it occur. Minimum Necessary

24. The following will apply to requests for alternative confidential communications: n Request must be received in writing n Determine how payment will be handled, if necessary n Specification of an alternative address or other method of contact is required n Request or denial will be documented. DAS will not require an explanation from the individual The uses and disclosures of PHI are then subject to the agreed upon restriction and/or the confidential communications requirements. Minimum Necessary

25. n Individual’s Access:  DAS will give an individual the right to access and inspect or obtain a copy of his/her PHI for as long as DAS maintains the PHI. DAS will act on a request for access no later than 30 days after receipt of the request. Minimum Necessary

26. n ID Person and Authority n Verification Methods n Routine Communication n Non-Routine Disclosures n Recording of Uses and Disclosures n Exercise of Professional Judgment Verification Prior to Disclosure

27. n ID Person and Authority DAS will verify the identity of a person requesting Protected Health Information (PHI) and the authority of any such person to have access to the Protected Health Information (PHI) Verification Prior to Disclosure

28. DAS is a Clearinghouse and only uses and discloses healthcare information for Treatment, Payment and Health Care Operations (TPO). The Client Agencies for which it processes the data have already obtained the appropriate authorizations and consents. Verification Prior to Disclosure

29. All employees are required to sign a confidentiality agreement as a condition of employment whereby they agree not to request, use or disclose protected information unless necessary to perform their job Verification Prior to Disclosure

30. n Verification Methods: Verification is done when the identity of the requestor is not known or when documentation is required Routine communication, where entity relationships have been established, do not require special verification procedures Verification Prior to Disclosure

31. Verification Methods Examples: Phone: Caller ID; if they are holding a Statement, ask for identifying information off of the statement; if not, ask Social Security Number, date-of-birth, Letter: Verify name and address Signed Authorization, Claim Number, Company Tax ID Number, Letterhead, Callback, Copy of Appointing Document, Identification Badge, other official credentials; warrant, subpoena, order, or other legal process issued Verification Prior to Disclosure

32. n Non-Routine Disclosures: Non-routine disclosures, not covered in the Policies and Procedures, must be reviewed on an individual basis by a Team Leader. Unresolved issues are to be brought to the DAS HIPAA Privacy Officer for resolution Verification Prior to Disclosure

33. n Recording of Uses and Disclosures: A log for the recording of all non-routine disclosures will be maintained. A copy going back six years prior to request will be made available to clients at their request for $.50 per page to cover the cost of copying and mailing Verification Prior to Disclosure

34. n Recording of Uses and Disclosures: Non-routine disclosures will be recorded on the Avatar Admission Comments Screen, with-in 60 days. Items to be keyed in: Date of disclosure Name of entity or person who received the PHI (address if known) Brief description of PHI disclosed Brief statement of purpose of disclosure Verification Prior to Disclosure

35. Purpose of Use or Disclosure Routine Verify Identity See Team Leader/ Privacy Officer Record Patient’s Authorization Needed Minimum Necessary Safeguard TPO (Treatment, Payment, Operations) Routine NO*NO YES Law Enforcement/ Legal Proceedings, National Security, National Health Non- Routine YES NOYES Marketing, Fund-Raising, Medical Research Non- Routine YES *YES, where identity of requester is not known (like an unrecognized voice on the phone)

38. n Exercise of Professional Judgment : The verification requirements are met if DAS relies on the exercise of professional judgment or acts on a good faith belief in making a disclosure Verification Prior to Disclosure

39. n Privacy Officer n Training n Safeguards n Complaints to DAS n Refraining from Intimidating or Retaliatory Acts n Sanctions n Policies and Procedures Administrative Requirements

40. n Privacy Officer DAS will create, document and maintain a position of privacy official that is responsible for the development, implementation and maintenance of the policies and procedures of DAS Responsible for receiving complaints regarding privacy of Protected Health Information (PHI) Administrative Requirements

41. n Training DAS will train all members of its workforce on the policies and procedures with respect to Protected Health Information (PHI) as necessary and appropriate for the members of the workforce to carry out their functions within DAS Administrative Requirements

42. n Safeguards DAS will have in place appropriate administrative, technical, and physical safeguards to protect the privacy of Protected Health Information (PHI). Administrative Requirements

43. n Safeguards Administrative: Scalable confidentiality and security procedures, designated security officer, sanctions for violations, signed statement by all employees regarding confidentiality of data Administrative Requirements

44. n Safeguards Technical: Unique ID and Password, system stores password encrypted, weak passwords not allowed, automatic time logoff, system enforced password changes, firewall, virus checking Administrative Requirements

45. n Safeguards Physical: Secure computer room, secure access to displays and printers, secure destruction of printouts, other outputs and obsolete equipment, disaster recovery plan in place and tested Administrative Requirements

46. n Complaints to DAS DAS will document all complaints received, and their disposition, if any, in written or electronic form. These documents must be retained for a period no less than six years Administrative Requirements

47. n Refraining from Intimidating or Retaliatory Acts DAS will not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against anyone making a Privacy complaint Administrative Requirements

48. n Sanctions Consistent application of sanctions for failure to comply with privacy policies for all individuals in the organization’s workforce (can result in dismissal, other disciplinary actions, criminal prosecution and/or civil suit) Administrative Requirements

49. n Policies and Procedures DAS will implement Policies and Procedures with respect to Protected Health Information (PHI) that are designed to comply with the standards, implementation specifications or other requirements of the Health Insurance Portability and Accountability Act of 1996 Administrative Requirements

50. n Definitions n Vendor Contracts n Agreements Business Associate Agreements

51. n What is a Business Associate? An organization or person who performs activities on behalf of or in coordination with DAS that involves the use or disclosure of individually identifiable health information Business Associate Agreements

52. n Contracts/Agreements DAS will ensure continued privacy protections of health information by entering into a Business Associate Contract Business Associate agrees that it shall be prohibited from using or disclosing the information provided or made available by DAS for any purpose other than as expressly permitted or required by the Contract Business Associate Agreements

53. Business Associate Contract Covers: n Use and Disclosure n Safeguards n Subcontractors n Right to Access/Amend n Accounting of Disclosures n Return of Information or Destruction n Mitigation n Sanctions n Property Rights n Termination Business Associate Agreements

54. n Contracts/Agreements Business Associate Contract wording will be included in every vendor contract ’ s terms and conditions for the state of Connecticut through DAS ’ Procurement Unit MOU will be executed between DAS and our partnering state agencies Business Associate Agreements

55. n Fines up to $25,000 for multiple violations of the same standard in a calendar year n Fines up to $250,000 and/or imprisonment up to 10 years for knowing misuse of individually identifiable health information “Hot Water” Penalties

56. Real Life New York Times  Answer: Sorry, can’t by law Police Officer (properly identified)  Answer: Yes, minimum necessary Billing and Collection  Answer: Yes (TPO)

57. Real Life - Confidentiality: - No Gossiping Neighbor’s name noticed on case  Don’t go home and tell your family Celebrity’s name noticed on case  Don’t gossip to friends/coworkers

58. What This Means DAS will limit the disclosure of Protected Health Information (PHI) to the minimum amount necessary to accomplish the intended purpose of the authorized use, disclosure, or request DAS will verify the identity of a person requesting Protected Health Information (PHI) and the authority of any such person to have access to the Protected Health Information (PHI)

59. What This Really Means Use or disclose health information that identifies the individual for billing and collection (Payment) purposes only When you do that, disclose the minimum necessary and know who you disclose to

60. It is all about information – There is an explosion of Health Information out there – There is an information explosion: Just to give you a perspective on information today: The Internet is doubling in content every 100 days. The Sunday edition of the New York Times alone now contains more information than all the written information available in the 15 th Century. There are more than 300,000 books published every year. When Columbus discovered America, the largest library in the world was the Queen’s College Library in Cambridge. It contained only 199 books. Most of us have more than that in our homes today.

61. Next Steps Be more aware of client privacy and confidentiality Exercise professional judgment/make reasonable efforts

62. The End