Discussion Week 5 : L.O 5 Explain the Provisions of HIPPA Le…

Learning Objective 5:

1. Summarize the HIPPA Act of 1996
2. Summarize the Provisions of HIPPA Act of 1996
3. Summarize the Penalties of HIPPA
4. Summarize the Titles of HIPPA

The HIPPA Act and the HI Tech Act are 2 laws that impact Resimbursement. Today’s discussion addresses the HIPPA Act Title II as highlighted below

HIPPA Fraud and Abuse:

Definitions:

• HIPAA Laws define fraud as an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment”. The attempt is considered fraud whether it is successful or not.
• HIPPA Laws define abuse as “Involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abused directly or indirectly results in unnecessary costs.
• The difference between fraud and abuse is intent.

What is the HIPPA Act of 1996?

• HIPPA Legislation of 1996 was implemented to improve portability of Health Insurance Coverage in various markets
• Mandates Administrative simplification regulations that govern privacy, security and electronic transaction standards for healthcare information
• Created a Healthcare and National Practitioner Data Bank
• Promotes the Use of Medical Savings Accounts
• Improves access to Long-term Care Services and Coverage
• Simplifies the administration of Health Insurance by creating unique identifiers to providers, health plans and Employers
• Established the Medicare Integrity Program which enters into contracts with entities to perform Cost Reporting Auditing, Medical Review, Anti-Fraud Activities and the Medicare Secondary Payer Program
• Expanded HHS Office of Inspector General’s Sanction by extending the application and scope of current Civil Monetary Penalizes and exclusion authorities for Federal Healthcare Programs

Penalty Structure for Violation falls into Categories called Tiers

1. Lack of knowledge
2. Reasonable Cause
3. Willful Neglect and Violation that is corrected within the time period
4. Wilful Neglect and Violation that is not corrected within the time period

HIPPA Laws are organized into 4 distinct categories:

• Title I : Healthcare Access Portability and Renewability
• Title II: Preventing Healthcare Fraud and Abuse, Administrative Simplification and Medical Liability Reform
• Title III: Tax Related Health Provisions
• Title IV: Revenue offsets

Following are Examples of Fraud as noted in Green, UHI 2026

• Accepting or soliciting bribes, kickbacks, and rebates
• Altering claims to increase reimbursement
• Billing for services or supplies not provided
• Misrepresenting codes to justify payment (e.g., upcoding)
• Entering a health insurance identification number other than the patients to ensure reimbursement
• Falsifying certificates of medical necessity, plans of treatment, and patient records to justify payment
• Billing noncovered services as covered services
• Billing or claim processing errors
• Reporting duplicative charges on a claim
• Charging excessively for services, equipment, and supplies
• Improper billing that results in payment by a government program when another payer is responsible
• Submitting claims for services not medically necessary
• Violating participating provider agreements with third-party payers

Possible Outcomes for Fraud Investigations:

• Administrative sanctions
• Civil monetary penalties
• Exclusion from the health program (e.g., Medicare)
• Referral to the Office of Inspector General:
• Exclusion from the Medicare program
• Sanctions and civil monetary penalties
• Criminal penalties (e.g., fines, incarceration, loss of license to practice, restitution, seizure of assets)
• Education
• Referral for Medical Review:
• Prepayment review of submitted claims

Discussion Questions:

Based on the Readings of Chapter 5 in your textbook and the Overview above. Please review the following 5 Case Scenarios and identify if they are cases of Fraud or Abuse.

Case Scenario #1

1. An insurance company breached its Medicare contract by failing to report errors identified in the quality assurance process. It concealed its true error rate by deleting claims selected for review by CMS and replacing them with claim files that would not significantly affect the error rate (and thus preserve its standing within payer performance rankings).

Case Scenario #2

2. A chiropractor performed ultrasonography to follow the progress of a patient treated for back pain. Medicare denied the payment because it determined that back pain does not support the medical necessity for ultrasonography.

Case Scenario #3

An ambulance company submitted false claims for reimbursement to Medicare.

Case Scenario #4

A consulting firm submitted false hospital cost reports, upon which reimbursement formulas are based, to the Medicare and Medicaid programs on behalf of its client hospitals. The consulting firm knowingly made claims that were false, exaggerated, or ineligible for payment, and it concealed errors from government auditors, thereby permitting the client hospitals to retain funds to which they were not entitled.

Case Scenario #5

A spinal video fluoroscopy was performed to demonstrate the extent to which joint motion of a patient was restricted. Medicare determined that physical examination procedures (e.g., asking the patient to bend) provided enough information to guide treatment of the patient and denied reimbursement.

Directions

Post your rsponses due by Thursday 11:59 PM

First respond to the Question with one word by indicating the word “Fraud” or “Abuse” to the Scenario

Case Scenario #1 ____________

Rationale ____________________

Case Scenario # 2 _______________

Rationale _______________________

Case Scenario # 3_______________

Rationale ______________________ and continue to # 5

Case Scenario #4 ____________

Rationale______________

Case Scenario #5 __________

Rationale__________________

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