HIPAA Collaborative of Wisconsin
PAYMENT,
COLLECTIONS, AND ACCEPTED
BENEFITS
FURTHER DEFINITION OF THE
PRIVACY RULE
Copyright 2003 - HIPAA Collaborative of Wisconsin
This Training Module is a Copyright 2003 by the HIPAA
Collaborative of Wisconsin (“HIPAA COW”). It may be
freely redistributed in its entirety provided that this
copyright notice is not removed. It may not be sold for
profit or used in commercial documents without the
written permission of the copyright holder.
This Training Module is provided “as is” without any
express or implied warranty. This Training Module is for
educational purposes only and does not constitute legal
advice. If you require legal advice, you should consult
with an attorney. HIPAA COW has not yet addressed
all state preemption issues related to this Training
Module. Therefore, this form may need to be modified
to comply with Wisconsin law.
Copyright 2003 - HIPAA Collaborative of Wisconsin
EXAMPLES OF
COMMON PAYMENT ACTIVITIES
• Plan eligibility or coverage determination
• Claims adjudication
• Risk adjustments
• Billing and collection
• Healthcare service review e.g. medical necessity
• Utilization Review
• Consumer Reporting Agency disclosures
Copyright 2003 - HIPAA Collaborative of Wisconsin
USE OR DISCLOSURE OF PROTECTED
HEALTH INFORMATION FOR PAYMENT
A Provider’s disclosure of
Protected Health Information (PHI)
is part of the claim for payment.
Copyright 2003 - HIPAA Collaborative of Wisconsin
DISCLOSURE OF PHI
TO ANOTHER COVERED ENTITY (CE)
FOR PAYMENT PURPOSES
• Providers disclose PHI to labs for billing
purposes.
• Hospital emergency rooms disclose PHI to
transporting ambulance company for billing
purposes.
Copyright 2003 - HIPAA Collaborative of Wisconsin
USE AND DISCLOSURE OF
PSYCHOTHERAPY NOTES
Authorizations are required for use and
disclosure of psychotherapy notes.
Copyright 2003 - HIPAA Collaborative of Wisconsin
MINIMUM NECESSARY REQUIREMENT
COVERED ENTITIES SHOULD DEVELOP & IMPLEMENT:
• Minimum necessary policies and procedures for
disclosures and requests for PHI.
• Role-based access policies and procedures
regarding workforce access to PHI for payment
purposes.
Copyright 2003 - HIPAA Collaborative of Wisconsin
CONSENT
The CE is not required to obtain individual
consent for use and disclosure of PHI to obtain
payment.
The consent cannot replace an authorization.
(See authorization requirements, CFR 164.508.)
Copyright 2003 - HIPAA Collaborative of Wisconsin
RIGHT TO REQUEST RESTRICTIONS
• Individual right to request restrictions on CE’s
use and disclosure of PHI for payment.
• The CE is not required to accept the
individual's request.
• However, if the CE agrees to the restriction, it
is bound to honor the individual’s request.
Copyright 2003 - HIPAA Collaborative of Wisconsin
NOTICE OF PRIVACY PRACTICES
The CE must use, access, or disclose PHI
as described in the CE’s Notice of Privacy
Practices.
Copyright 2003 - HIPAA Collaborative of Wisconsin
DEFINITION OF PAYMENT
45 CFR 164.506
“Payment encompasses the various activities of
health care providers to obtain payment or be
reimbursed for their services and of a health plan
to obtain premiums, to fulfill their coverage
responsibilities and provide benefits under the
plan, and to obtain or provide reimbursement for
the provision of care.”
Copyright 2003 - HIPAA Collaborative of Wisconsin
COLLECTION AGENCY COMMUNICATIONS
• The CE, or business associate operating
on CE’s behalf (e.g. collection agency), is
permitted to disclose PHI for payment
purposes.
• There is no limit on recipients of such
sources of information.
Copyright 2003 - HIPAA Collaborative of Wisconsin
CONSUMER CREDIT REPORTING
AGENCIES AND CONFLICTS WITH
FAIR CREDIT REPORTING ACT (FCRA)
The CE or CE’s business associate is permitted
to use or disclose PHI, as required under the
Fair Credit Reporting Act.
Copyright 2003 - HIPAA Collaborative of Wisconsin
CONSUMER CREDIT REPORTING
AGENCIES AND CONFLICTS WITH FAIR
CREDIT REPORTING ACT (FCRA)
• Disclosures to consumer reporting agencies are part of
HIPAA privacy rule’s definition of payment.
• Disclosures are limited to the specified individual PHI:
name and address; date of birth, social security number,
payment history and account number.
• Disclosure of the name and address of the health care
provider or plan making the report are allowed.
• The CE can choose to perform payment activity directly
or through a third party under the business associate
agreement.
Copyright 2003 - HIPAA Collaborative of Wisconsin
DEBT COLLECTION AGENCIES
• The CE is allowed to use debt collection agency
services.
• Debt collection is recognized as payment activity
within payment definition (45 CFR 164.501).
• Disclosures of PHI to collection agencies are
defined by Business Associate Agreements, the
Minimum Necessary Requirement and other
privacy rule provisions.
Copyright 2003 - HIPAA Collaborative of Wisconsin
COLLECTION AGENCY LOCATION
INFORMATION SERVICES
• Acquisition of information on an individual’s
location is considered a payment activity
(45 CFR 164.501).
• Business Associates of the CE are required to
comply with the Fair Debt Collection Practice
Act limitations on location information
services.
Copyright 2003 - HIPAA Collaborative of Wisconsin
LONG/SHORT TERM DISABILITY,
WORKERS COMPENSATON, SUBROGATION
These policies are not considered health
plans, as defined by the Privacy Rule.
Such policies, plans or programs provide or
pay for accepted benefits as listed in
Section 2791 (1) of the Public Health
Service Act, 42 U.S.C. 300gg-91 (1) See
45 CFR 160.103.
Copyright 2003 - HIPAA Collaborative of Wisconsin
EXEMPT FROM HIPAA PROVISIONS
• Accident, disability income, or a combination of
the two insurances.
• Liability insurance supplemental coverage.
• Workers compensation.
• Automobile medical payment insurance.
Copyright 2003 - HIPAA Collaborative of Wisconsin
EXEMPT FROM HIPAA PROVISIONS CONTINUED
• Credit-only insurance.
• Coverage for on-site medical clinics.
• Other similar insurance coverage, specified in
regulations, under which medical care
benefits are secondary or incidental to other
insurance benefits.
Primary Author:
Anthony Cooper, FHFMA, CFE
Training Workgroup Reviewers:
Karen Bauer
Joan Benson, MBA
William Jensen , MBA
Tammy Kritz, MBA
Jennifer Laughlin, RHIA
Christine Lidbury
Richard Reynolds, FHIMSS
Beth Zallar, MS, RHIA