Legal and Financial Aspects of Patient Care

Patient Confidentiality and HIPAA

• Patients have the right to add individuals to their confidentiality list; this must be documented clearly in the chart for future reference.

• Professional information sharing is strictly limited to designated safe spaces, such as classrooms or behind closed doors, and never in public areas like cafeterias, hallways, or elevators.

• Liability for confidentiality breaches applies even if the person overhearing the conversation misidentifies the patient being discussed.

• Standard privacy barriers, such as curtains in the ER or OR, do not provide sufficient auditory privacy; doors must be fully closed during discharge instructions and sensitive discussions.

Medicare, Medicaid, and Financial Policies

• Medicare: Federal insurance designated for individuals aged $65$ and older.

• Medicaid: State-based insurance for anyone who qualifies based on specific criteria; some patients may have both.

• Facilities must strictly follow policies and procedures to ensure payment from $Medicare$ and $Medicaid$, as documentation errors can lead to non-payment.

• Private health insurance and long-term care insurance can sometimes counteract each other; patient account managers often review coverage and collect copays at the start of appointments.

• Reference the Point of Interest box on page $98$ for breakdowns of $Social Security$, supplemental insurance, $Medicare$, and $Medicaid$.

Emergency Care and Federal Regulations

• EMTALA (Emergency Medical Treatment and Labor Act): Ensures patients receive emergency treatment regardless of their insurance state (e.g., a Texas $Medicaid$ patient treated in an Indiana ER).

• Coverage under $EMTALA$ is limited to the emergency event; follow-up care may not be covered by out-of-state insurance.

• Affordable Care Act (ACA): Historically aided medication costs and preventative services like $mammograms$ and colon cancer screenings.

• Insurance dictates the medical pathway, often requiring a $Cologuard$ stool sample before authorizing a $colonoscopy$, despite the risk of false positives.

Questions & Discussion

• Question/Comment: A student noted that cameras in facilities and elevators increase the risk of being reported for confidentiality breaches.

• Incident Discussion: The instructor shared a case of a student reported for sharing information in an elevator. Despite the student discussing an $87$ year old man, a $22$ year old woman in the elevator believed the information pertained to her and reported a breach.

• Insurance Fraud Discussion: A case was mentioned involving a patient who committed insurance fraud by claiming both Illinois and Indiana $Medicaid$ using a rehab center address.

• Comment: "See, there's two things that I'm putting out, my food and the government money. He don't get back on you?"

• Comment: "I can pee pee do pee pee pee pee pee on? Everybody germs and gym."