Risk Assessment: Information Privacy and the Cost/Benefits of a Proposed Online

Question

Risk Assessment: Information Privacy and the Cost/Benefits of a Proposed Online System Happy Healthcare Systems of America (HHSA) is a third-party benefits administrator, providing a liaison between insurance companies and provider groups (physicians, hospitals, etc.). HHSA earns revenue by collecting from the insurance companies and then paying the provider groups for services rendered to eligible patients/members. Since HHSA’s operations are similar to that of an HMO, non-routine procedures, such as surgery or referral to a specialist, must be pre-authorized by HHSA in order for the service to be paid by HHSA. HHSA is considering acquiring an online service to expedite the authorization process. With this system, contracted providers would be allowed access to HHSA’s database to initiate and review the status of a particular authorization. Providers would be able to enter data into the system such as diagnosis, requested treatment/procedure, and other data needed to determine the necessity of the procedure. The determination of the suitability or necessity of these non-routine procedures is currently determined by HHSA case managers, who review and authorize the requested procedures or referrals. Under the proposed system, the provider would enter the data, allowing the case manager to pull up the data and start the authorization process. The new system would allow the entry of data or notes and would assign an authorization number to those procedures that are approved. Once the data is in the system, providers would be given access to check on the status of the authorization at any time. Another aspect of the online system that should be considered is how the system will comply with federal and state laws, such as the Health Insurance Portability and Accountability Act (HIPAA), which restricts the access to and/or distribution of a patient’s private health information to unauthorized persons. Therefore, some of those involved in the online system decision argue that providers should not have access to data for patients not under their direct care. You are the chairman of the committee charged with determining the feasibility/acceptability of the proposed online system, and you will oversee the implementation of this system if it is accepted. Questions 1. What recommendations would you make to HHSA regarding cost and benefits of an online authorization system? 2. How can HHSA ensure patient information confidentiality if this service is provided (for more information on regulatory requirements related to information confidentiality, visit http://www.hhs.gov/ocr/hipaa)?

Explanation / Answer

Solution.

1.

The recommendation for HHSA regarding cost and benefits of an online authorization system is one of the definitive elements of managed health care. It may be as basic as precertifiction of elective hospitalizations in an indemnity plan or preferred provider organization(PPO) or as complex as mandatory authorization for all non-primary care services in a health maintenance organization (HMO). The authorization system provides the key element of managing the deliver of health care services which is very helpful for the HHSA. It also help the the organization for growing more in the field of the main core area of it by providing the online authorization system.

There are many cost benifits of an online authorization system some of these are given below:

1. It provides direct care to the most appropriate setting (Inpatient vs. Outpatient or in the provider's office)

2. It provides timely informatio to the concurrent review utilization system and the case managemebt system.

3. It also assists in the finance estimate of the accruals for medical expenditures each month.

2.

HHSA can ensure patient information confidentiality if online authorization service is provided:

As an authorization system defines what services will require authorization and what will not. Hence it would provide all the necessary services whether that is confidentiality or not.

In an authorization system every authorization number is unique, the authorization system is able to generate and link the number to the specific data for which the number was issued. A claim mus include the authorization number in order to be processed for payment and the all records related to the patients. There are some of the basic feature of an authorization system which ensures patient information confidentiality some of these given below:

1. It submits patient referral and authorization requests

2. It verifies patient membership information

3. It search for participatin specialists, providers, hospitals, or other facilities

4. List historical referrals and authorizations for a patient or practice

5. It treacks utilization patterns for a practice.

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