Question

You are working in a clinic that provides counseling for mental and chemical health issues. Most of the clients in your clinic have insurance or medical assistance. There are times when the payer (insurance company or providing agency) will want to get progress reports from the provider. The payer uses this information to decide whether or not to continue funding. How much information does the insurance company have a right to obtain? How much privacy does the individual have? Should the provider have the sole right to determine if their client still needs treatment?

Answer 1

The United States of America has stringent laws in place to protect the privacy of the medical patients. There was a separate legislation enacted in 1996 during Clinton's regime, which is called as Health Insurance Portability and Accountability Act.

This would prohibit the hospitals from sharing the information to even the relatives. In fact, during Indiana air mishap, the hospital authorities denied to provide the details of the plane crash victims who were being treated in the hospital.

However, Health Insurance Portability and Accountability Act has also laid down certain provisions to prevent the fraud in medical insurance. This was mentioned in chapter 2 of the act. According to 2.1 of the act, the protected health information (also called as PHI) can be shared with the law enforcement authorities, payers (health insurance bodies) etc.

So, insurance company can obtain the information pertaining to the treatment, cost of medication and the days the patient has been at the hospital. If required, the medical insurance company can also carry out an inspection and in case of any fraud, both healthcare provider and patient would face legal consequences.

Individuals have complete privacy over their healthcare information. Even your relatives cannot telephone and know about the treatment plans and medication.

About the amount of information can be sought, EDI Healthcare Claim of this act mandates hospitals to provide all the billing information to the insurance companies only through electronic form named EDI 837.

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