Hi All,
I've asked these questions before, but didn't get much response (or
any at all on some). Since we're all getting close to THE DATE, I
thought re-asking might get more/better response, so I'm re-posting a
digest of the questions. Any discussions of what you are doing and / or
suggestions are welcome.....
_____ Private Communications
____________________________________________
These questions are about Private Communications (PC) &
Customer Service:
1) How do you respond to a Customer Service Inquiry from the contract
holder (subscriber) when someone on that contract has invoked PC? Do
you just say, "I can't give any further information" or "I've released all the
information to which you are entitled" or .... some other sentence/phrase
with similar meaning? I realize you can't just say, "Someone on your
contract has requested Private Communications".
Possible scenario: Jane, the wife of Joe Contractholder requests PC,
primarily because she's going to a psychologist. Because Jane has
requested PC, the insurance company (or provider) routes ALL her claim EOBs (or
bills) to an alternate address. Joe calls customer service to
ask where the Explanation of Benefits (EOB) is for his wife's recent visit to
the Emergency Room for a twisted ankle. How should the customer
service rep answer....?
2) How do you send out the EOB when you have a non-custodial and custodial
parent getting EOBs and one of the children has invoked PC? We have a
number of these situations where we have received a Domestic Relations Court
Order to send the underage dependent EOBs to both the custodial and
non-custodial parents. As long as they haven't reached 18, we comply with
the order (or if a dependent is in college, until they graduate).
Possible scenario: Joe Doe (Contractholder) and Jane Doe (Joe's
former wife and mother of Donna Doe) have both been receiving Donna's EOBs
pursuant to a court order. Donna's in college and goes to her OB/Gyn and
asks for birth control pills. Donna doesn't want her father to know (he
has a temper), so she invokes PC with both the Provider and the insurance
company. All of a sudden, neither Joe or Jane are getting copies of
Donna's EOB's. Jane knows that Donna went to the OB/Gyn but doesn't get a
copy of the EOB. She calls Joe and asks if he has gotten the EOB yet... of
course he says no. So she calls customer service. How should the
customer service rep answer? Does HIPAA Privacy override the
Domestic Relations Order or vice versa?
3) How do you respond to a 12 year old who asks for PC when calling/writing
to Customer Service? Do you explain and direct her to go to court to get a
court order giving her the right to invoke PC? Do you grant the request
absent the court order even though she isn't 18 (or what ever the age of
majority/emancipation is in the your state)?
We are primarily concerned with inadvertently cluing in a
parent/spouse that there has been a PC request, where the contractholder thinks
that they have the right to get such information (people can get pretty irate in
these situations). We want to avoid the situation where an abusive
spouse/parent figures something funny is going on, and injures the person
who requested PC in trying to get them to tell the abusive person what's going
on. What are our responsibilities when an underage dependent asks for
PC?
There doesn't seem to be any good answers here, only compromises
that have varying degrees of risk. How are you people out there planning
on handling these situations? Any help / advice / suggestions would be
welcome.
_____ Amendments ____________________________________________
Say that you do turn down an amendment request (for good
and legitimate reasons... ie amending medical data that came from somewhere
else). The regulation says that (after going to an appeal process) the
patient/member has the right to file a statement giving their side of the story
and make it a part of the record or just have it noted in the record that
an amendment request was filed. The CE that receives the request/statement
must then include that an amendment was filed and (if supplied) the statement in
all disclosures of that claim data from that point forward... and have it sent
to specified entities that have already received the data. There is even a
point in the reg where it says that the amendment flag and statement must be
sent along with a standard transaction, even though there is no place for
it.
_____ How detailed must my Designated Record Set
be?________________________
Should the DRS be at the level of the EOB or should you give the
most of the data elements in all patient/subscriber related systems? The
Regulations clearly state that we must show all data that we used to make a
decision about the subscriber / patient.... But at what level?
I vote for somewhere in between. Clearly, as an insurance
company, we don't have to disclose confidential corporate data (like how much
the discount %/$ are for any given procedure for that provider or our
rating formulae).
All opinions expressed are my own and should not be construed to be Medical
Mutual or Antares Management Solutions official policy.
Jim Moores - HIPAA Team Leader - Privacy
Antares Management
Solutions
23700 Commerce Park Road
Beachwood, Ohio
44122-5832
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