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Health Insurance Market Reforms under Obamacare: The Patient Protection and Affordable Act (PPACA), or Obamacare, sets out a number of provisions for health insurance market reforms. Having been set in motion in March 2010; the PPACA sets out health insurance market reforms that are being implemented in stages from dates commencing generally from January 1, 2014. PPACA's health insurance market reforms are aimed at health insurance standards and group health plans. These reforms set out dates for the implementation of these reforms. They also prescribe penalties for noncompliance with these reforms. What kinds of market reforms are needed? The health insurance market reforms suggested by PPACA are almost singularly for group health plans. A group health plan is defined as one in which the employer makes a contribution into expenses accruing from the employee's health insurance plans. When an employer chooses to bring an employee's health plan under her coverage; the employer has to mandatorily comply with the provisions of the health insurance market reforms. Areas of the health insurance market reforms: These are the essential areas in which the health insurance market reforms are to be applied: Removal of lifetime and annual limits on essential health benefits: One of the primary provisions of the health insurance market reforms under PPACA is that it prohibits both lifetime and annual limits on essential health benefits, which were allowed some dollar limits prior to enactment of Obamacare. Preventive health services: An area of preventive health services that has undergone an amendment under the health insurance market reforms is that of no-cost sharing. Accordingly, employer plans are to offer preventive health services without requiring the employee to share the burden for this part of the plan. The three-month waiting period: The health insurance market reforms don't require a waiting period of over 90 days. A waiting period is the period that has

Overview: Mental health care practitioners work in today's diverse, fast-changing, multidisciplinary health care environment. Nowhere but in mental health is there such diversity of clinicians who provide the same or similar services of counseling and therapy. A potential client has a wide choice of mental health providers from whom to choose. Yet each individual mental health profession has a unique education, training, and experience requirement for practice. While similarities exist, requirements differ from state to state and even from profession to profession with a single state. What are these requirements and how do they apply? The state's authority and power over mental health practitioners often presents challenges to these mental health professionals that are not easy to navigate. Differing sources of legal and ethical authority govern each respective health care practitioner in ways that are similar but not the same. Ethics and law are similar, but not the same. All mental health practitioners must adhere to standards of state law which govern their professional practices, including the very core of the doctor-patient relationship. Codes of ethics and state law may both apply to govern the conduct of this clinician. Even some state laws are referred to as ethical codes. Complaints as to alleged misconduct or ethical failings are received and investigated by a state agency and leave the mental health practitioner with an uncertain process to handle and to defend the state action against them. With this background, this seminar empowers the full understanding and application of ethics and laws for mental health practitioners. Learn to identify and understand an ethical framework for a sound mental health practice. An ethical framework is essential to having the right perspective to examine mental health dilemmas. Compare and contrast regulatory laws and codes of ethics to understand their differing applicability. Know the difference between laws and ethics,

Overview: Today's health care delivery occurs in a diverse, fast-changing, multidisciplinary health care environment. This often presents challenges to the health care professional that are not easy to navigate. Medical records and their confidentiality have long been the exclusive province of state law, but has now been recognized for some time in the federal HIPAA statutes and federal regulations. Differing and even conflicting sources of requirements at the state level still exist for the retention and disposition of medical records. These sources may vary based upon the specific health care practitioner - whether physicians, dentists, psychologists, or other health care providers, including mental health practitioners. As to the specific, individual health care practitioner, state laws mandate their confidentiality, retention, and even their specific content with regards to patient, clinical records. In addition to these clinical requirements, additional state laws set forth the content and retention of other types of records kept by the professional, such as supervisory agreements with other professionals subordinate to them as well as their own unique record content requirements. With the majority of medical records moving to an electronic format, special rules now exist with regard to the confidentiality, security, retention, and disposition of electronic medical records. This is particularly important as state laws continue to allow for and regulate the provision of telemedicine by various health care practitioners. For example, while psychotherapy and mental health services are ideal treatments to offer over the internet, that is, by simultaneous audio-visual transmission between the doctor and the patient, the risks of breaches of confidentiality also vastly increase. And when the successful doctor-patient relationship is over, how does the health care practitioner providing a mental health service dispose of these electronic records? In addit

Overview: Today's health care delivery occurs in a diverse, fast-changing, multidisciplinary health care environment. This often presents challenges to the health care professional that are not easy to navigate. Medical records and their confidentiality have long been the exclusive province of state law, but has now been recognized for some time in the federal HIPAA statutes and federal regulations. Differing and even conflicting sources of requirements at the state level still exist for the retention and disposition of medical records. These sources may vary based upon the specific health care practitioner - whether physicians, dentists, psychologists, or other health care providers, including mental health practitioners. As to the specific, individual health care practitioner, state laws mandate their confidentiality, retention, and even their specific content with regards to patient, clinical records. In addition to these clinical requirements, additional state laws set forth the content and retention of other types of records kept by the professional, such as supervisory agreements with other professionals subordinate to them as well as their own unique record content requirements. With the majority of medical records moving to an electronic format, special rules now exist with regard to the confidentiality, security, retention, and disposition of electronic medical records. This is particularly important as state laws continue to allow for and regulate the provision of telemedicine by various health care practitioners. For example, while psychotherapy and mental health services are ideal treatments to offer over the internet, that is, by simultaneous audio-visual transmission between the doctor and the patient, the risks of breaches of confidentiality also vastly increase. And when the successful doctor-patient relationship is over, how does the health care practitioner providing a mental health service dispose of these electronic records? In addition to

Overview: The idea of providing health care treatments and insurance coverage according to "medical necessity" determinations seems eminently reasonable. Its obvious ethical thrust is to discourage unnecessary, wasteful or fraudulent practices. As practically implemented, however, "medical necessity" regulations and determinations have proven remarkably controversial and elusive. First of all, the language connected with medical necessity is inherently vague. Language to the effect that a treatment is medically necessary if it is "likely to achieve a significant practical improvement," is "realistic," or "reasonable" will predictably cause disputes between payors and providers of care. Second, the persistence of these disputes calls into question whether evidence based practices have evolved to a point where they are all that reliable and useful. Third, medical necessity determinations incur problems as to who should ultimately make them: payors, health providers or the courts. Obviously, whoever controls the definition of medical necessity controls the flow of health care dollars. While ethical theory can offer important insights about our moral obligations, it remains unable to reliably translate its theoretical principles and rules bearing on harms, benefits and justice into informing medical necessity determinations. Thus, resolving disputes over medical necessity have taken a procedural approach that looks to the interpretation of contractual language in insurance policies, often at the bench of an administrative law judge. This presentation will advance a reasonable set of strategies whereby a convincing case can be made for certain care interventions qualifying as "reasonable and necessary." Why should you Attend: Despite their central importance as a locus for determining reimbursement, "medical necessity" regulations and determinations have proven remarkably controversial and vexing for at least the last 20 years. Yet, whoever controls the definition

Overview: New changes modifying the HIPAA Privacy and Security Regulations are going into place to meet the privacy and security mandates within the HITECH Act in the American Recovery and Reinvestment Act of 2009. The changes include establishing new rights for individuals as well as changes to the limitations on uses and disclosures. New requirements for patient access to records and requirements to notify individuals in the event of a breach are only two of the many areas affected in the new law, including new requirements for restriction and accounting of disclosures and increased enforcement activity. Covered entities that use electronic health records (EHRs) will need to meet new access and disclosure rules and all kinds of business associates and their subcontractors will need to establish compliance programs. And if you are required to have a HIPAA Notice of Privacy Practices, you will need to update that to show all the new rights that patients will have, such as electronic copies, new rights to restrict disclosures, and much more. Business associates are now directly covered by the HIPAA privacy and security regulations and are liable for fines and penalties if they do not comply. If a business associate supplies services that interact with the new changes to the rules, the BA will need to be aware of the new requirements. We will explain what a Business Associate needs to do differently under the new regulations. Electronic records have new demands placed on them, in both providing access and in accounting for all disclosures of health information - the electronic age in health care brings new obligations to serve individuals as well as manage health information for healthcare professionals. We will discuss how disclosures must be tracked in an EHR and review the various ways patient records can be supplied electronically. The new regulations will be reviewed and their effects on usual practices will be discussed, as will what policies need to be chang

The federal Health Insurance Portability and Accountability Act (HIPAA) was legislated in 1996 with the primary aim of ensuring that employees who are in the process of changing or leaving their jobs do not lose their health insurance benefits. Additionally, HIPAA sought to bring down health care fraud and abuse by mandating pan-industry standards for the protection of health care information and automated billing and other related processes, and for ensuring the security of Protected Health Information (PHI). What is a HIPAA Security Audit? A HIPAA Security Audit is a program under the HIPAA Privacy, Security, and Breach Notification Audit Program of the Office of Civil Rights (OCR). A HIPAA Security Audit is carried out to make sure that the policies, processes and controls on the part of Covered Entities comply with the provisions of the HITECH Act of 2009. Adherence to the requirements laid out by HITECH is mandatory. Given the high degree of continued use of new technologies that go into and will continue to go into electronic records of patients and the criticality of the data contained in them; the US Department of Health and Human Services (HHS) recognizes that there could be chances of data breach of Protected Health Information. It is to prevent the occurrence of these breaches that a HIPAA Security Audit is mandated by the HITECH Act. Reporting of data breaches is mandatory The foremost highlight of the HITECH Act is the requirement that Entities covered by HIPAA report data breaches that affect 500 or more employees to the HHS. The OCR lays out an Audit Protocol, with whose policies, protocols and processes a facility has to comply if it is said to be compliant with the HIPAA Security Audit. Why is it necessary to carry out a HIPAA/HITECH Security Audit? Compliance with HIPAA Security Audit is necessary to demonstrate that a practice or business is well protected. The most important reason for which such entities need to be HIPAA/HITECH Security

A typical health insurance covers hospitalization expenses incurred during the treatment procedure.However health insurers have acknowledged

A typical health insurance covers hospitalization expenses incurred during the treatment procedure.However health insurers have acknowledged

Overview: In 2013, The US Department of Health and Human Services made major changes to rules implementing The Health Insurance and Portability Act of 1996 (HIPAA) and Health Information Technology for Economic and Clinical Health Act of 2003 (HITECH). Among the many areas impacted by these rules (billing, marketing, research, IT security, etc.) is fund raising. The amendments significantly modify the methods and practice that hospitals, their institutionally related foundations, and other healthcare charities may or must employ when using ANY patient or client information for fund raising. The webinar will cover how to effectively implement the fund raising regulations in a manner that increases both opportunities for philanthropic support and compliant implementation of the new mandates. The rules include specific operational requirements, some of which prohibit protocols that were required under the original HIPAA regulations. The "magic words" mandated by HIPPA-related regulations changed in multiple areas. The webinar will cover all of these areas to ensure your organization is both legally compliant and operationally effective. The types of information that may be used for fund raising changed significantly. This presents numerous substantial fund raising opportunities, as well as challenges on the use and storage of such information. Among other areas to be presented are The required method for individuals to opt-out of receiving fund raising communication The methods of informing patients and clients of their right to opt-out from receiving fund raising communication The broadly expanded types of fund raising communication subject to opt-out rights How providers, hospital, and related fund raising foundation apply an opt-out election by an individual The type of patient and client information that health charities may use for fund raising The contents of provider's Notice of Privacy Practice How clinicians can assist both their patients/clients and the

Overview: Remember spaghetti code? The HIPAA breach area is now almost as convoluted and overlapping and confusing as spaghetti code. Sometimes you think you are both coming and going at the same time when you think through an event to determine if your organization has had a breach. For example: Is a security incident always a beach? Is an ePHI breach a security incident as well? Is a cybersecurity event always a breach? What if it does not steal any clinical information, diagnoses or procedures information, or any payment information? A security incident? Or both? Are all the necessary kinds of notice in the Breach rule? What is Cybersecurity Insurance? Is it really the finger in the dike or itself full of Swiss cheese? Can the loss of patient or member data be a HIPAA breach and identity theft plus a fraud issue? Why should you Attend: HIPAA breaches now number in the multiple thousands, if not multiple millions. Your organization needs to be prepared for the initial sense of panic, a complete investigation, and the federal, state and reputational costs of a mega breach. A breach now costs in money approximately $225/record. And this does not include any fine of any type. The loss and theft of 1000 records may cost you organization from a quarter to $1 M, or more, and 6 months to a year to resolve. You need to know the basics of what PHI and ePHI really are; what puts the event into the breach safe harbor, what breach exceptions keeps the event out of OCR's hands, what the 4 factors are and how they are used. You need to know that your organization's breach plan and your policies and procedures include the need to notify when necessary the police, the FBI and other state and federal organizations beyond the Office for Civil Rights. Your organization needs to know how to protect itself after the fact by considering Cybersecurity Insurance. Areas Covered in the Session: Definition and reporting of a Security Incident Definition of a breach Breach Guidance Br

Overview: You need to attend in order to control your own destiny. Get involved up front instead of being a "sitting duck". More Audits are coming and government & private payers are increasing their budgets for increased audit activity around the health care provider industry. The Department of Justice is zeroing in on providers who are aberrant. Private insurance special investigations units are also gearing up and local prosecutors who are hungering for these types of prosecutions are all part of building machinery to eliminate fraud and abuse in the nation's health care system. The concern about the audit/investigative machine that has been developed should create horrendous concern for the health care provider community, because these entities will have to come up with results. Don't become one for their "results". Areas Covered in the Session: Overview of audit risks 14 Strategies to tackling auditors: i.e. Appoint Audit Manager Appoint Audit Committee Proactively seek out info from audit visitors Respond quickly to audit visitor requests Identify On Site control person Provide strong support for onsite control person Onsite control person must be close to the visitors Audit committee to meet daily with visitors Respond quickly to early findings Request feedback from visitors Request Exit conference Carefully review preliminary findings Respond to final report Correct problem findings Who Will Benefit: Health Care Professionals Health Service Providers Compliance Officers CEO's Corporate Attorneys Speaker Profile Joseph R. Batte is president of Kristall Associates, a compliance, and risk assessment specialist for the health care provider community as well as the litigation support community. He is a former special agent with the US Office of Inspector General and participated in the development of that Departments compliance guidance's. He is a nationally known speaker on compliance and has authored the book "Doctors are from Jupiter, Compliance is from

Pharmaceutical drug prices are rising and contribute significantly to total health expenditure worldwide. Since 2014, prescription drug prices have increased by 33%. In 2020, global spending on prescription drugs is expected to be US$ 1.3 trillion. Increasing drug prices and consumer spending on prescription drugs are increasing the demand for the pharmacy benefit management system. The system is operated by third-party administrators who act as a link between drug manufacturers, insurance providers, and pharmacists. The system assists in reducing drug prices by negotiating with drug manufacturers and retail pharmacies. Those who are enrolled in various health schemes and those without insurance can get the benefit of the pharmacy benefit management system. The system provides medicines at a lower price than those available at retail pharmacies. To reduce rising health expenses, Japan planned to start reviewing drug prices every year instead of every two years. The move reflects growing resistance to rising drug prices worldwide. In Europe, different approaches have been implemented to regulate drug prices. In Germany, manufacturers can freely set the prices of newly developed drugs during their first year on the market. Benefit assessments are done during this year and then used in price negotiations between manufacturers and the country's representatives of statutory health insurers. Read more @ https://coherentmarketinsights-cmi.blogspot.com/2020/12/pharmacy-benefit-management-is-integral.html

What is HIPAA ? Compliance with the Health Insurance Portability and Accountability Act (HIPAA) is a core requirement of the stakeholders involved in health information. HIPAA has prescribed standards with which to protect critical data relating to patients. Electronic Health Records (EHRs) are important documents that contain sensitive patient data, and are thus considered Protected Health Information (PHI). Since this data is accessible to a number of players involved in the field of healthcare; it extremely important to set regulatory guidelines aimed at ensuring that patient information remains protected. HIPAA compliance is essentially about staying in compliance with these guidelines. Measures needed to show compliance with HIPAA HIPAA requires a healthcare organization dealing with PHI to implement all of the following measures and comply with them: Physical measures Network measures, and Process security measures The role of HIPAA Privacy Rule and HIPAA Security Rule HIPAA has set out two important rules that pertain to compliance. These are the HIPAA Privacy Rule and the HIPAA Security Rule. While the Privacy Rule relates to how the medical information of a patient is saved, accessed and shared; the Security Rule is about how to implement national security safeguards for protecting electronic PHI, or ePHI. Who all need to be HIPAA compliant? Since the aim of HIPAA compliance is to ensure complete safety of patient data, it has requirements for every stakeholder in the EHR process. These stakeholders comprise: Covered Entities (CE): Anyone involved in the treatment, payment and operations in healthcare Business Associates (BA): Any person who has access to patient information and is involved in supporting treatment, payment or operations. These include third-party administrators and private sector vendors Those with whom BA's work, or those that are called subcontractors Hosting providers. These typically include healthcare software pro

A helpful resource for entrepreneurs, freelancers, and any other self employed health insurance consumers.

HIPAA Enforcement trends : Health Insurance Portability and Accountability Act (HIPAA) is a legislation of the American Congress. HIPAA enforcement consists of taking steps to confirm that rules set out in HIPAA are being complied with by the requisite entities. Primarily passed with the intention of ensuring that employees do not lose their health insurance benefits when they change or leave their current jobs; this 1996 law also has the protection and security of Protected Health Information (PHI) as one of its chief aims. The Office of Civil Rights (OCR), which enforces actions relating to HIPAA, imposes harsh penalties on healthcare organizations and Business Associates and Covered Entities that are proven to be in noncompliance of HIPAA requirements. What are HIPAA enforcement actions? The actions that the OCR takes to ensure implementation of HIPAA provisions constitute the essence of HIPAA enforcement actions. There are a good number of areas which the OCR can cite as constituting cases of HIPAA violations or noncompliance. A look at recent HIPAA enforcement actions point to a trend. These trends serve as an indicator of what to expect from HIPAA enforcement actions, which will help entities get some idea of what they should implement and what they should not and thus prevent being cited by the OCR. Security risk assessments are the foremost element of HIPAA enforcement actions: A look at recent trends suggests that HIPAA enforcement actions mainly target security risk assessments. This leads to harsh penalties, as happened in the case of New York-Presbyterian Hospital (NYP). The hefty $ 4.8 million penalty slapped in 2014 on this hospital was for data breach caused by insufficient security risk assessment. While this is the biggest sum fined; the OCR issued at least three other hospitals for putting in place inadequate security risk assessments in 2014. Risk management comes a close second: If inadequate security risk assessments come first in te

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