Lesson 9: Medical Contracts, Ethics,
and HIPAA
Introduction
Reading Assignment
Medical Contracts and Ethics
-- Understanding Contracts
- MCO Contracts and Reimbursement
-- Ethics in Managed Care
- NCQA
- Medical Office Specialists and Ethics
Check Your Learning 3
Reading Assignment
HIPAA
-- The HIPAA Privacy Rule
- Transaction and Code Sets
- The HIPAA Security Rule
- Working with HIPAA
- Verification of Information
-- HITECH
Career Services Corner: Cover Letter
Check Your Learning 4
[09] Lesson 9: Medical Contracts, Ethics, and HIPAA Exam
,Introduction
As you can imagine, along with the MCOs come a complicated set of contracts. MCO contracts, or legal
agreements between the provider and insurer, are necessary to ensure that all parties are fulfilling
what was agreed upon during negotiations for coverage, such as patient loads needed for discounts
and accurate and adequate reimbursements. In this lesson, we'll discuss medical contracts and
standards of ethics for medical office specialists of all kinds.
We'll also discuss HIPAA in-depth in this lesson. The Health Insurance Portability and Accountability
Act, or HIPAA, closely regulates protected health information (PHI) and how it's used and disclosed.
HIPAA addresses PHI through the Privacy Rule, which regulates the use and disclosure of both
electronic and paper-based PHI.
One of the things that HIPAA provides is the patient's right to contest information in his or her medical
record. A patient can request that amendments or corrections be made, and the provider needs to
follow them according to how it is covered under HIPAA.
HIPAA also has a section called the Security Rule. The Security Rule requires covered entities, or CEs, to
provide reasonable administrative, physical, and electronic safeguards to protect the confidentiality,
integrity, and availability of PHI maintained in an electronic format.
In this lesson, we'll also talk about HITECH, or the Health Information Technology for Economic and
Clinical Health Act. It was enacted as part of the American Recovery and Reinvestment Act of 2009 and
then signed into law on February 17, 2009. HITECH was created to promote the adoption and
meaningful use of health information technology.
Lesson Objectives
After completing this lesson, you will be able to...
• Understand the key elements of a managed care contract that dictate the
provider's compensation for services
• Identify covered services for patients, which can include preventive medical services and type
of office visits
• Recognize the obligation of a medical office specialist to uphold a standard of ethics
• Define terms utilized in a managed care contract in order to understand the contract and
discuss claims issues with the patient and carrier.
• Describe the responsibility of the medical office specialist to protect all protected
health information (PHI)
, • Discuss what's required to disclose patient information to family members, friends, and
when ordered by courts or government entities
• Understand the patient's right to request access or correction to his or her medical records
• Explain HIPAA security standards that require a healthcare provider to have security policies
and procedures
• Discuss the penalties and fines involved for not being in compliance with HIPAA regulations
• Understand HITECH's mandatory requirements for healthcare providers to implement
"meaningful use" by managing patient information and treatment through electronic
health records (EHR)
Reading Assignment
Textbook Reading
In your textbook, entitled Comprehensive Health Insurance: Billing, Coding, and Reimbursement, by D.
Vines, A. Braceland, E. Rollins, and S. Miller, carefully study:
• Chapter 3 (pages 54–72)
Medical Contracts and Ethics
and HIPAA
Introduction
Reading Assignment
Medical Contracts and Ethics
-- Understanding Contracts
- MCO Contracts and Reimbursement
-- Ethics in Managed Care
- NCQA
- Medical Office Specialists and Ethics
Check Your Learning 3
Reading Assignment
HIPAA
-- The HIPAA Privacy Rule
- Transaction and Code Sets
- The HIPAA Security Rule
- Working with HIPAA
- Verification of Information
-- HITECH
Career Services Corner: Cover Letter
Check Your Learning 4
[09] Lesson 9: Medical Contracts, Ethics, and HIPAA Exam
,Introduction
As you can imagine, along with the MCOs come a complicated set of contracts. MCO contracts, or legal
agreements between the provider and insurer, are necessary to ensure that all parties are fulfilling
what was agreed upon during negotiations for coverage, such as patient loads needed for discounts
and accurate and adequate reimbursements. In this lesson, we'll discuss medical contracts and
standards of ethics for medical office specialists of all kinds.
We'll also discuss HIPAA in-depth in this lesson. The Health Insurance Portability and Accountability
Act, or HIPAA, closely regulates protected health information (PHI) and how it's used and disclosed.
HIPAA addresses PHI through the Privacy Rule, which regulates the use and disclosure of both
electronic and paper-based PHI.
One of the things that HIPAA provides is the patient's right to contest information in his or her medical
record. A patient can request that amendments or corrections be made, and the provider needs to
follow them according to how it is covered under HIPAA.
HIPAA also has a section called the Security Rule. The Security Rule requires covered entities, or CEs, to
provide reasonable administrative, physical, and electronic safeguards to protect the confidentiality,
integrity, and availability of PHI maintained in an electronic format.
In this lesson, we'll also talk about HITECH, or the Health Information Technology for Economic and
Clinical Health Act. It was enacted as part of the American Recovery and Reinvestment Act of 2009 and
then signed into law on February 17, 2009. HITECH was created to promote the adoption and
meaningful use of health information technology.
Lesson Objectives
After completing this lesson, you will be able to...
• Understand the key elements of a managed care contract that dictate the
provider's compensation for services
• Identify covered services for patients, which can include preventive medical services and type
of office visits
• Recognize the obligation of a medical office specialist to uphold a standard of ethics
• Define terms utilized in a managed care contract in order to understand the contract and
discuss claims issues with the patient and carrier.
• Describe the responsibility of the medical office specialist to protect all protected
health information (PHI)
, • Discuss what's required to disclose patient information to family members, friends, and
when ordered by courts or government entities
• Understand the patient's right to request access or correction to his or her medical records
• Explain HIPAA security standards that require a healthcare provider to have security policies
and procedures
• Discuss the penalties and fines involved for not being in compliance with HIPAA regulations
• Understand HITECH's mandatory requirements for healthcare providers to implement
"meaningful use" by managing patient information and treatment through electronic
health records (EHR)
Reading Assignment
Textbook Reading
In your textbook, entitled Comprehensive Health Insurance: Billing, Coding, and Reimbursement, by D.
Vines, A. Braceland, E. Rollins, and S. Miller, carefully study:
• Chapter 3 (pages 54–72)
Medical Contracts and Ethics
