Unit 1 Lesson 2: Regulatory Compliance

A set of vocabulary-style flashcards covering regulatory compliance topics from HIPAA basics to PHI identifiers, consent types, EHR incentives, and related laws referenced in the video notes.

Implied consent

Consent inferred from a patient’s actions or behavior for low-risk or routine procedures, rather than explicit verbal or written confirmation.

Verbal consent

Consent given orally by the patient or their representative, without a written document.

Informed consent

Consent given after the patient is informed about risks, benefits, alternatives, and questions are answered; often documented in writing for high-risk or invasive procedures.

HIPAA

Health Insurance Portability and Accountability Act; a federal law protecting patient privacy, securing PHI (Patient Health Information), and standardizing electronic health information transactions.

PHI (Protected Health Information)

Identifiable health information created, received, stored, or transmitted by covered entities.

HIPAA Privacy Rule

WHAT you can/can’t do with patient info (all forms)

HIPAA - standardizes electronic transactions

uniform code sets and electronic formats

• ICD-10-CM for diagnoses

• CPT/HCPCS for procedures and services

• standard electronic forms (837 claim form)

Ensures compliance

mishandles PHI or fail follow HIPPA rules can face heavy fines and penalties

HIPPA Security Rule

HOW you must protect patient info in electronic form

Covered entities

organizations or people who must follow HIPAA rules because they handle protected health information (PHI) in connection with healthcare services or payment.

1. Healthcare Providers

2. Health Plans

3. Healthcare Clearinghouses

Healthcare Providers

Doctors, nurses, hospitals, clinics, therapists, pharmacies, etc., who transmit health information electronically (for billing, claims, eligibility checks).

Health Plans

Insurance companies, HMOs, Medicare, Medicaid, employer-sponsored health plans.

Healthcare Clearinghouses

Entities that process non-standard health information into a standard format (or vice versa), such as billing services or repricing companies.

Under HIPAA, there are 18 identifiers that are considered Protected Health Information (PHI)

1. Name

2. Address

3. All elements of dates (except year)

4. Telephone numbers

5. Fax numbers

6. Email addresses

7. Social Security numbers

8. Medical record numbers

9. Health plan beneficiary numbers

10. Account numbers

11. Certificate/license numbers

12. Vehicle identifiers (license plate numbers, serial numbers, etc.)

13. Device identifiers and serial numbers

14. Web URLs

15. IP addresses

16. Biometric identifiers (fingerprints, voice prints, retinal scans, etc.)

17. Full-face photographs and comparable images

18. Any other unique identifying number, code, or characteristic

PHI breaches

Incidents where Protected Health Information is accessed, used, or disclosed without authorization, potentially compromising patient confidentiality and privacy.

Written Consent

A formal agreement from a patient allowing the use or disclosure of their health information for specific purposes, ensuring compliance with HIPAA regulations.

Release of Patient Information

information (PHI) can be used and disclosed without a specific authorization to release the information

• Treatment

• payemnt

• operations

• law enforcement, public interest and benefit activities

• limited data set

Psychotherapy notes

Confidential notes taken by a therapist during or after a therapy session, focusing on the patient's thoughts and feelings. They are protected under HIPAA and have stricter requirements for disclosure compared to general medical records.

HITECH (health Information Technology for Economic and Clinical Health) ACT

A federal law aimed at promoting the adoption and meaningful use of health information technology while enhancing the privacy and security protections for electronic health information.

*if more than 500 patient records are affected, HITECH requires the media to be notified and offered identity theft protection services*

Fair Debt Collection Practices Act

protect consumers from abusive, unfair, or deceptive collection practices

False Claims Act

federal law that makes it illegal to knowingly submit, or cause someone else to submit, false or fraudulent claims for payment to the U.S. government.

● allows penalties to be placed on anyone who knowingly submits a fraudulent claim to the United States government for money.

Stark Law

A federal law that prohibits physician self-referral, specifically when referring patients to facilities in which they have a financial interest, to prevent conflicts of interest and protect patients from unnecessary procedures.