Healthcare Claims and Processing

A current LCD for the regional Medicare intermediary (Michigan - Region V) is shown in the example below. This LCD is for Erythropoiesis Stimulating Agents, L25211. The LCD is active and became effective on 12/1/2007 with an date of 11/01/2013 for the 10/22/2013 revision (cms.gov, 2014b).

Question 8: Report on the Health Insurance Portability And Accountability Act (HIPAA) and its impact on healthcare claims processing.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was created, in part, to make health insurance portable in an attempt to address the problem of the growing amount of people that are uninsured and underinsured (NASW,2002). The Act allows a person with preexisting medical issues to get health insurance when changing jobs. HIPAA also addressed healthcare fraud and abuse. A significant impact to healthcare providers by HIPAA were the Administrative Simplification Provisions that were specified to improve healthcare quality and reduce costs by simplifying how health information is administered and managed. The provisions were also developed to protect the privacy and security of protected health information (PHI). Under the HIPAA provisions regulations have been issued to define standard electronic formats for transactions such as claims submission and billing that identify uniform data codes for diagnoses and procedures and security standards to maintain confidentiality and privacy of health information. Important parts of HIPAA include the Privacy Rule, Security Rule, and Electronic Transactions Rule (Casto & Forrestal, 2013).

• Privacy Rule o The HIPAA Privacy Regulations were published on December 28, 2000 to become compliant on April 14, 2003 (NASW, 2002). The in...

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...rsuant to section 1560(c) of the Affordable Care Act, specify certain Public Health Service Act and Affordable Care Act requirements as inapplicable to this type of individual health insurance” (Federal Register, 2014b).

An example of a final rule published in the Federal Register is the “FY 2013 Final Rule Tables” that contains links to tables that provide information regarding reimbursement adjustments (CMS.gov, 2014). Examples of items listed on the tables include:

• FY 2013 Operating and Capital National and Puerto Rico Specific Standardized Amounts

• Wage Index Final Rule and Correction Notice Tables

• List of Final MS-DRGs, Relative Weighting Factors and Geometric And Arithmetic Mean LOS

• New Procedure Codes, CC Exclusions List, Complete MCC List, Additions and Deletions

• Readmission Adjustment Factors Under the Hospital Readmissions Reduction Program