Navigating Medical Records Release Laws: Ensuring Patient Privacy and Access

medical records

In the realm of healthcare, medical records are invaluable documents that contain vital information about an individual’s health history, diagnoses, treatments, and medications. Access to medical records is not only essential for providing quality healthcare but also for patients to understand their health status and make informed decisions about their care. However, the release of medical records is governed by specific laws and regulations to protect patient privacy, ensure confidentiality, and promote transparency. Let’s explore the laws surrounding the release of medical records, including access rights, retention requirements, and the importance of compliance.

Access to Medical Records Law

Patient Rights

Under access to medical records laws, patients have the right to access their medical records and request copies of their health information. This right is fundamental to patient autonomy, empowering individuals to take an active role in managing their healthcare and making informed decisions about their treatment options.

HIPAA Compliance

The Health Insurance Portability and Accountability Act (HIPAA) establishes federal regulations governing the privacy and security of protected health information (PHI), including medical records. HIPAA ensures that patients have the right to access their medical records and sets standards for healthcare providers and organizations to safeguard patient privacy and confidentiality.

Release of Medical Records Law

Authorization Requirements

The release of medical records is subject to authorization requirements, whereby patients must provide written consent or authorization for the disclosure of their health information to third parties. This authorization must specify the purpose of the disclosure, the types of information to be released, and the duration of the authorization.

Exceptions

While patients generally have the right to access their medical records, there are exceptions under release of medical records laws. For example, healthcare providers may withhold certain information if they believe it could harm the patient or others, or if disclosing the information would violate state or federal law.

Medical Records Retention Law

Retention Periods

Medical records retention laws dictate the length of time healthcare providers and organizations must retain patient medical records. These retention periods vary by state and may be influenced by factors such as the patient’s age, the type of healthcare provider, and the nature of the medical treatment provided.

Compliance Requirements

Compliance with medical records retention laws is essential for healthcare providers to ensure they retain patient records for the required period and maintain documentation in accordance with legal and regulatory standards. Failure to comply with retention requirements can result in legal consequences, including fines, sanctions, and loss of licensure.

Importance of Compliance

Patient Privacy

Compliance with medical records release laws is critical for protecting patient privacy and confidentiality. Healthcare providers must adhere to strict protocols for releasing medical records to authorized individuals or entities to prevent unauthorized access or disclosure of sensitive health information.

Legal Obligations

Healthcare providers have legal and ethical obligations to comply with medical records release laws and safeguard patient health information. Failure to comply with these laws can result in legal liability, lawsuits, and damage to the provider’s reputation.

Conclusion

Medical records release laws play a crucial role in protecting patient privacy, ensuring access to health information, and promoting transparency in healthcare. Healthcare providers and organizations must understand and comply with these laws to maintain patient trust, uphold legal and ethical standards, and provide quality care. By adhering to authorization requirements, retaining medical records for the required period, and implementing robust privacy and security measures, healthcare providers can safeguard patient confidentiality and maintain compliance with medical records release laws.

Importance of Communication During Care Transitions

care transition doctor patient

Over nearly the last two years, nothing has become more evident that the importance of clear and concise communication during care transitions.  As health care facilities struggled to manage the burgeoning demand for inpatient beds, and in particular ICU beds, care transitions were fast and furious.  To facilitate care delivery and expedite care transitions, CMS issued numerous 1135 COVID-19 Emergency Declaration Blanket Waivers.  Examples (not an exhaustive list) of those blanket waivers related to required communications that may have affected the quality or safety of care during and immediately after care transitions include:

  • Allowance of audio-only telehealth for certain services.
  • Waiver of the requirement to authenticate verbal orders within 48 hours.
  • Restrictions on patient rights regarding visitation, particularly where an outbreak of COVID exists.
  • Limitations on detailed information sharing for discharge planning for hospitals and critical access hospitals.
  • Extension of time within which to complete medical records following discharge.
  • Expansion of role of allied health professionals, reduction in physician supervision requirements in certain settings, and
  • Waiver of requirement to develop and keep current a nursing care plan for each patient.

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Avoiding HIPAA Violations During COVID-19

telehealth laws after covid-19

telehealth laws after covid-19By: Steven Boyne

The COVID-19 virus has and will probably continue to change the way healthcare providers and business associates interact and help their patients. As many providers are aware, a HIPAA violation is a serious issue, and can cost a healthcare entity large amounts of time and money to respond to any regulatory investigation. Recognizing that the COVID-19 pandemic has strained every corner of the economy and is THE MOST IMPORTANT issue for almost every industry, the federal government has rolled back some HIPAA protections. It is unclear how long these rollbacks will last, and it is possible that some of them may be permanent, but for now healthcare providers and their business associates can take some comfort that they can focus on delivering care and not dealing with overly burdensome regulations and investigations. The major changes include:

  • Telehealth. Changes include allowing physicians and other healthcare providers to offer telehealth services across State lines, so State licensing issues should not be a concern. Additionally, Providers are essentially free to choose almost any app to interact with their patients, even if it does not fully comply with the HIPAA rules. The HHS allows the provider to use their business judgment, but of course, such communications should NOT be public facing – which means DO NOT allow the public to watch or participate in the visit!
  • Disclosures of Protected Health Information (PHI). A good faith disclosure of such information will not be prosecuted. Examples include allowing a provider or business associate to share PHI for such purposes as controlling the spread of COVID-19, providing COVID-19 care, and even notifying the media, even if the patient has not, or will not grant his or her permission.
  • Business Associate Agreement (BAA). As most healthcare providers know, a BAA agreement between a provider and an entity that may have access to PHI is required by law. During the COVID-19 pandemic, the lack of a BAA is not an automatic violation.

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Access to Care via Telehealth Increases Again in Second Round of Changes Due to COVID-19

By: Susan St. John

Access to telehealth for Medicare beneficiaries was further increased by the Trump Administration April 30, 2020. These new changes allows all health care professionals eligible to bill Medicare for services to provide services via telehealth communications and to bill the Medicare program for such services. Additionally, certain services may now be provided using audio technology only.

For a list of services eligible for reimbursement by the Medicare Program, including services requiring audio technology only, download here. There are approximately 180 different codes reimbursable by Medicare if provided via telehealth communications.

The Case Against Cloning (Medical Records)

medical records cloning

medical records cloningBy: Jacqueline Bain

The transition from paper medical records to electronic medical records has brought with it many conveniences and some unintended consequences. One example of an unintended consequence is cloning in the medical record. Cloning is copying and pasting previously recorded information from a prior patient note into a new patient note.

Providing quality medical care is only one part of the job. Appropriately documenting that care in order to be paid for your efforts is another. And while medical professionals are trained at length to provide care, hardly any are aware of the potential pitfalls associated with improper documentation.

In late 2015, CMS advised that cloning “is a problem in health care institutions that is not broadly addressed.” CMS specified that cloning records may indicate fraud, waste and abuse in inquiries and audits and that each part of a “medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter.”Continue reading

New HIPAA Guidance for Substance Abuse and Mental Health Information

HIPAA PHIBy: Dave Davidson

In December 2016, the US Congress passed the 21st Century Cures Act, which, among other things, provided for increased funding for treatment and research of mental health and substance abuse disorders.  That law also required the HHS Office of Civil Rights (OCR) to provide guidance in regards to HIPAA compliance in regards to those types of treatment.  In October 2017, President Donald Trump declared the opioid addiction epidemic to be a public health emergency, which will also result in additional resources being allocated to addressing the crisis.

In connection with both the new law and the President’s declaration, OCR published its HIPAA guidance in December 2017.  The guidance is intended to clarify how and when protected health information (PHI) can be shared in regards to patients in substance abuse and mental health treatment.  According to OCR Director Roger Severino, “HHS is using every tool at its disposal to help communities devastated by opioids, including educating families and doctors on how they can share information to help save the lives of loved ones.”Continue reading

Healthcare Compliance: Understanding ZPIC Audits

By: Susan St. John

So, you’ve received a letter from the Zone Program Integrity Contractor or “ZPIC” to review for the accuracy and justification of services reimbursed by the Medicare program. In other words, a dreaded ZPIC Audit or ZPIC Investigation. Now What?!

First, remain calm. Chances are an audit by ZPIC will go well if you have been diligent in completing patients’ medical records, justifying medical necessity, and your billing is accurate and well supported by the patients’ medical records. Even if errors are discovered, most errors do not represent fraud, that is, the errors were not committed knowingly, willfully and intentionally. Still, a ZPIC audit can be daunting and if Medicare has noticed a pattern of billing that it considers suspect, or there has been a complaint against you, the ZPIC audit will be rigorous, and often adversarial. The ZPIC’s job is to protect the program from potential fraud. It will conduct data analysis, including statistical outliers within a well-defined group, or other analysis to detect patterns within claims or groups of claims that might suggest improper billing. Data analysis can be undertaken as part of a general review of claims pre or post submission, or in response to information about specific problems arising from complaints, provider or beneficiary input, fraud alerts, CMS reports, Medicare Area Contractors, or independent governmental or nongovernmental agencies.Continue reading

Healthcare Trade Secrets: How to Protect Your Practice’s Trade Secrets

dreamstimemaximum_51887081-flipBy: Shobha Lizaso

“Prevention is better than cure” is a maxim that has reigned in the healthcare industry for thousands of years; however, this phrase echoes through the halls of the legal profession as well.

Healthcare practices often neglect to appreciate the value of their confidential information as assets and the need to protect these assets. Although HIPAA and HITECH compliance aids in maintaining the confidentiality of patient records, it does not protect a provider’s trade secrets.

Trade secrets of a healthcare practice may include any of the following: patient lists, financial information, contract rates, contract terms client lists, collection rates, marketing tactics, pricing/discount information, and methods of doing business. If leaked, this information may be used by competitors to secure advantages over a healthcare practice. For example, patient lists could be used to solicit a practice’s patients or contract rates and terms can be used by a competitor to undercut the rates of a practice.Continue reading

Medical Necessity: It’s a Clinical Documentation Necessity

medical necessityBy: Jacqueline Bain

Recently, a Florida-based physician practice specializing in pain management was ordered to pay the Federal Government $7.4 after it was determined that the group’s physicians were ordering medically unnecessary drug screens and billing Medicare for those tests. Federal prosecutors contended that the group’s physicians had appropriately ordered initial drug screens on many patients, but had inappropriately ordered more extensive (and more expensive) follow up tests nearly 100% of the time. Moreover, patient medical records did not reflect the need for more extensive testing.Continue reading