Hi All, We (at my insurance company) are having a debate on the Private Communications portion of the Privacy Regulations. We all agree about sending the EOB to the person requesting Private Communications, the concern revolves around how to pay the claim.
Let me set the scenario, we have a large number of providers that we contract with, but still have a significant number in our state that we don't have a contract with. Our contract with our providers specifies that we have to pay a contracting provider directly. As a part of the contract with the subscriber, we pay the subscriber directly if they go to a non-contracting provider. Paying the subscriber directly is where the problem comes in..... Dependent B (part of subscriber A's contract) requests private communications. If the provider is a contracting provider, everything works... we pay the provider and send the EOB to dependent B. If the provider is non-contracting, we send the EOB to dependent B but cut a check to subscriber A. The concern is that subscriber A will figure out that something's up, after getting a check with no EOB attached. He calls in to our customer service, and we will have to tell subscribe A that we can't talk about that... that's where the stuff hits the fan if subscriber A is an abusive parent. My thoughts on how to resolve this issue is: The regulation says that the individual making the request (dependent B) must make payment arrangements if the covered entity requests. I interpreted this to mean the a hospital could require the individual to sign for the obligation or an insurance company could send payment directly to the individual who requested private communications (dependent B) and not subscriber A... Part of the debate here, is that some people think that it seems to be referring to ONLY the provider when the provider is asked for private communications. However, it seemed to me that since it doesn't say "provider" (it uses the term "covered entity") that when an insurance company is asked for private communications, maybe the insurance company could use the same clause: "A covered entity may condition the provision of a reasonable accommodation on: When appropriate, information as to how payment, if any, will be handled; " ... (Whole section of the regulation is quoted at the end of this email). Since it doesn't say provider, maybe we could fit an insurance company into the "covered entity" label? And since it doesn't say what kind of payment, maybe an insurance company could fit cutting a check under the payment label.... ergo we could cut the check to member B, not subscriber A for a visit to a non-contracting provider. The biggest problem is that we have a contractual obligation to cut the check to either the provider (contracting provider) or to the subscriber (non-contracting). Now, I finally gotten to the questions: 1) Is the interpretation that an insurance company can require payment arrangements if dependent B requested private communications (payment made to dependent B if provider is non-contracting)? In other words, could we require Dependent B sign something to the effect that they become responsible for paying/reimbursing any parties owed money, if we send them a check 2) If dependent B goes to three different providers, but dependent B only really wants private communications with one of the providers (ob/gyn for birth control pills for a minor). Do we have to maintain the Private Communications flag at the dependent level for just that one claim, for all the providers that the dependent B uses now or in the future, or is it provider specific (just the ob/gyn)? 3) Will the HIPAA Law/Regulations override contractual obligations (like paying the subscriber), like it does state law when it is less stringent than the HIPAA Regulations? Jim Moores - HIPAA Team Leader - Privacy Antares Management Solutions 23700 Commerce Park Road Beachwood, Ohio 44122-5832 [EMAIL PROTECTED] Phone: (216)292-1605 Fax: (216)292-1619 _____________________________________________________________________ CONFIDENTIAL COMMUNICATIONS REQUIREMENTS SECTION 164.522(b) As Contained in the HHS Final HIPAA Privacy Rules HHS Regulations Confidential Communications Requirements - � 164.522(b) 1. Standard: confidential communications requirements. i. A covered health care provider must permit individuals to request and must accommodate reasonable requests by individuals to receive communications of protected health information from the covered health care provider by alternative means or at alternative locations. ii. A health plan must permit individuals to request and must accommodate reasonable requests by individuals to receive communications of protected health information from the health plan by alternative means or at alternative locations, if the individual clearly states that the disclosure of all or part of that information could endanger the individual, 2. Implementation specifications: conditions on providing confidential communications. i. A covered entity may require the individual to make a request for a confidential communication described in paragraph (b)(1) of this section in writing. ii. A covered entity may condition the provision of a reasonable accommodation on: A. When appropriate, information as to how payment, if any, will be handled; and B. Specification of an alternative address or other method of contact. iii. A covered health care provider may not require an explanation from the individual as to the basis for the request as a condition of providing communications on a confidential basis. iv. A health plan may require that a request contain a statement that disclosure of all or part of the information to which the request pertains could endanger the individual. ------------------------------------------------------------------------------ CONFIDENTIALITY NOTICE: This message is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential or exempt from disclosure under applicable law. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering the message to the intended recipient, you are hereby notified that you are strictly prohibited from printing, storing, disseminating, distributing or copying this communication. If you have received this communication in error, please notify us immediately by replying to the message and deleting it from your computer. Thank You, Antares Management Solutions. ============================================================================== ********************************************************************** To be removed from this list, go to: http://snip.wedi.org/unsubscribe.cfm?list=privacy and enter your email address.
