Proudly Serving Massachusetts

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Massachusetts Health Care Software Since 1981

Track the productivity and profitability around patient care.

My healthcare knowledge is in the creation and maintenance of software for Radiology and Pathology.  This is inclusive of billing, revenue cycles, primary/secondary insurance filings, ICD9/ICD10 diagnose codes, charge codes, facility code modifiers, EDI, electronic claims submission and more.  I created all software from scratch even terminal emulation at that time.

Massachusetts Customers

Some information I know about Massachusetts is I believe the state was admitted or ratified to the United States around or about 'February 6, 1788'.  Massachusetts is located around latitude '42.407211' and longitude of '-71.382439' and has a population of roughly '7,029,917 million'.  If I remember correctly the capital is 'Boston' and the largest city is 'Boston'. 

If you have ever been in the hospital it's hard to realize what goes on behind the scenes.  It's easy to see how busy everyone is and there seems to be a lot going on but health care is a very complicated realm when it comes to diagnosing, treating, recording and being responsive to government and legal requirements.  Having an understanding of privacy, security and administrative challenges along with billing is critical to those running hospitals, medical or pharmaceutical practices.

COVID's Impact on Medical Billing and Coding

I continue to keep abreast of industries I have worked in and see where the COVID-19 pandemic prompted several changes to medical billing and coding processes.

For example, in 2020, electronic claims management adoption increased by 2.3 percentage points across the medical and dental industries.  In the medical industry, those transactions included eligibility and benefit verification, prior authorization, claim submission, claim status inquiry, claim payment, and remittance advice.

In March 2020, the WHO created the first ICD-10 code for COVID-19.  Since then, there have been at least a dozen new ICD procedure codes related to the virus and many more changes to CPT and HCPCS codes to document COVID-19 and related conditions.

As for 2021 and beyond medical billers and coders have had to determine new codes and reimbursement policies with the emersion of a pandemic and the virus COVID-19.  Wait!  didn't you just say something about the WHO and COVID-19 in 2020.  Yep, I sure did that was all done before the emergence of the outbreak.  As new virus's are detected and policies we will continue to make changes in procedures while everyone still asks "Where did the Flu go?".

CMS also made a significant change to the Medicare Physician Fee Schedule during the pandemic that impacted medical billers and coders.  The new guidelines stated that physicians could select an evaluation and management (E/M) code based on the total time spent on the date of the patient encounter instead of relying on a patient's history or physical exam to determine appropriate E/M coding.

Medical billing and coding are integral healthcare revenue cycle processes.  Ensuring that the medical billing and coding cycle run smoothly ensures that providers get paid for services delivered, and provider organizations remain open to deliver care to patients.

What are Healthcare Privacy Rules?

Critical to hardware health care software development is the understanding of HIPAA and how it relates to privacy rules and regulations.  The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub.L.  104-191, 110 Stat.  1936, enacted August 21, 1996) was enacted by the United States Congress and signed by President Bill Clinton in 1996.  It was originally sponsored by Sen.  Edward Kennedy (D-Mass.) and Sen.  Nancy Kassebaum (R-Kan.).  Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs.  Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.

If at any point you decide to reach to me just know the area codes I am familiar with for Massachusetts are '339, 351, 413, 508, 617, 774, 781, 857, 978'.  For Health Care assistance you will find my rates very reasonable for Massachusetts.  Now just keep in mind my time zone is 'Eastern Standard Time (EST)' and I know the time zones in Massachusetts are 'Eastern Standard Time (EST)' in case you wish to call me.  Anyway let me continue.

The effective compliance date of the Privacy Rule was April 14, 2003 with a one-year extension for certain "small plans".  The HIPAA Privacy Rule regulates the use and disclosure of Protected Health Information (PHI) held by "covered entities" (generally, health care clearinghouses, employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions.) By regulation, the Department of Health and Human Services extended the HIPAA privacy rule to independent contractors of covered entities who fit within the definition of "business associates".  PHI is any information held by a covered entity which concerns health status, provision of health care, or payment for health care that can be linked to an individual.  This is interpreted rather broadly and includes any part of an individual's medical record or payment history.  Covered entities must disclose PHI to the individual within 30 days upon request.  They also must disclose PHI when required to do so by law, such as reporting suspected child abuse to state child welfare agencies.

A covered entity may disclose PHI to facilitate treatment, payment, or health care operations, or if the covered entity has obtained authorization from the individual.  However, when a covered entity discloses any PHI, it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose.

The Privacy Rule gives individuals the right to request that a covered entity correct any inaccurate PHI.  It also requires covered entities to take reasonable steps to ensure the confidentiality of communications with individuals.  For example, an individual can ask to be called at his or her work number, instead of home or cell phone number.

The Privacy Rule requires covered entities to notify individuals of uses of their PHI.  Covered entities must also keep track of disclosures of PHI and document privacy policies and procedures.  They must appoint a Privacy Official and a contact person responsible for receiving complaints and train all members of their workforce in procedures regarding PHI.

An individual who believes that the Privacy Rule is not being upheld can file a complaint with the Department of Health and Human Services Office for Civil Rights (OCR).  However, according to the Wall Street Journal, the OCR has a long backlog and ignores most complaints.  "Complaints of privacy violations have been piling up at the Department of Health and Human Services.  Between April of 2003 and November 2006, the agency fielded 23,886 complaints related to medical-privacy rules, but it has not yet taken any enforcement actions against hospitals, doctors, insurers or anyone else for rule violations.  A spokesman for the agency says it has closed three-quarters of the complaints, typically because it found no violation or after it provided informal guidance to the parties involved." However, in July 2011, UCLA agreed to pay $865,500 in a settlement regarding potential HIPAA violations.  An HHS Office for Civil Rights investigation showed from 2005 to 2008 unauthorized employees, repeatedly and without legitimate cause, looked at the electronic protected health information of numerous UCLAHS patients

You know, I don't make it out to Massachusetts much but I would like to see the 'Chickadee' state bird.  I am a little familiar with the Massachusetts 'Mayflower' state flower as well.  However, I do not know much about Massachusetts's state tree the 'American Elm'.  Fishing is fun to me perhaps I would like reeling in the Massachusetts 'Cod' state fish.  Anyway, sorry I went off topic.  Let me continue.

What are Healthcare Security Rules?

The Final Rule on Security Standards was issued on February 20, 2003.  It took effect on April 21, 2003 with a compliance date of April 21, 2005 for most covered entities and April 21, 2006 for "small plans".  The Security Rule complements the Privacy Rule.  While the Privacy Rule pertains to all Protected Health Information (PHI) including paper and electronic, the Security Rule deals specifically with Electronic Protected Health Information (EPHI).  It lays out three types of security safeguards required for compliance: administrative, physical, and technical.  For each of these types, the Rule identifies various security standards, and for each standard, it names both required and addressable implementation specifications.  Required specifications must be adopted and administered as dictated by the Rule.  Addressable specifications are more flexible.  Individual covered entities can evaluate their own situation and determine the best way to implement addressable specifications.  Some privacy advocates have argued that this "flexibility" may provide too much latitude to covered entities.  The standards and specifications are as follows:

Administrative Safeguards - policies and procedures designed to clearly show how the entity will comply with the act:

1. Covered entities (entities that must comply with HIPAA requirements) must adopt a written set of privacy procedures and designate a privacy officer to be responsible for developing and implementing all required policies and procedures.
2. The policies and procedures must reference management oversight and organizational buy-in to compliance with the documented security controls.
3. Procedures should clearly identify employees or classes of employees who will have access to electronic protected health information (EPHI).  Access to EPHI must be restricted to only those employees who have a need for it to complete their job function.
4. The procedures must address access authorization, establishment, modification, and termination.
5. Entities must show that an appropriate ongoing training program regarding the handling of PHI is provided to employees performing health plan administrative functions.
6. Covered entities that out-source some of their business processes to a third party must ensure that their vendors also have a framework in place to comply with HIPAA requirements.  Companies typically gain this assurance through clauses in the contracts stating that the vendor will meet the same data protection requirements that apply to the covered entity.  Care must be taken to determine if the vendor further out-sources any data handling functions to other vendors and monitor whether appropriate contracts and controls are in place.
7. A contingency plan should be in place for responding to emergencies.  Covered entities are responsible for backing up their data and having disaster recovery procedures in place.  The plan should document data priority and failure analysis, testing activities, and change control procedures.
8. Internal audits play a key role in HIPAA compliance by reviewing operations with the goal of identifying potential security violations.  Policies and procedures should specifically document the scope, frequency, and procedures of audits.  Audits should be both routine and event-based.
9. Procedures should document instructions for addressing and responding to security breaches that are identified either during the audit or the normal course of operations.

Physical Safeguards - controlling physical access to protect against inappropriate access to protected data

1. Controls must govern the introduction and removal of hardware and software from the network.  (When equipment is retired it must be disposed of properly to ensure that PHI is not compromised.)
2. Access to equipment containing health information should be carefully controlled and monitored.
3. Access to hardware and software must be limited to properly authorized individuals.
4. Required access controls consist of facility security plans, maintenance records, and visitor sign-in and escorts.
5. Policies are required to address proper workstation use.  Workstations should be removed from high traffic areas and monitor screens should not be in direct view of the public.
6. If the covered entities utilize contractors or agents, they too must be fully trained on their physical access responsibilities.

Technical Safeguards - controlling access to computer systems and enabling covered entities to protect communications containing PHI transmitted electronically over open networks from being intercepted by anyone other than the intended recipient.

1. Information systems housing PHI must be protected from intrusion.  When information flows over open networks, some form of encryption must be utilized.  If closed systems/networks are utilized, existing access controls are considered sufficient and encryption is optional.
2. Each covered entity is responsible for ensuring that the data within its systems has not been changed or erased in an unauthorized manner.
3. Data corroboration, including the use of check sum, double-keying, message authentication, and digital signature may be used to ensure data integrity.
4. Covered entities must also authenticate entities with which they communicate.  Authentication consists of corroborating that an entity is who it claims to be.  Examples of corroboration include: password systems, two or three-way handshakes, telephone callback, and token systems.
5. Covered entities must make documentation of their HIPAA practices available to the government to determine compliance.
6. In addition to policies and procedures and access records, information technology documentation should also include a written record of all configuration settings on the components of the network because these components are complex, configurable, and always changing.
7. Documented risk analysis and risk management programs are required.  Covered entities must carefully consider the risks of their operations as they implement systems to comply with the act.  (The requirement of risk analysis and risk management implies that the act's security requirements are a minimum standard and places responsibility on covered entities to take all reasonable precautions necessary to prevent PHI from being used for non-health purposes.)