State Medicaid Case Management Vs Private Hospital Billing

State Medicaid Case Management vs Private Hospital Billing

S115969

University of the People

September 9, 2017

Case Study:

 This paper will consider if a fiduciary and HIPAA conflicts of interest exist between a State Medicaid case management position and a private hospital billing position as well as any laws which govern billing and employee access to patient information.

State Medicaid Case Management vs Private Hospital Billing

Overview: I am friends with an employee currently working as a billing registrar at a private hospital who was hired full-time at a state approved Medicaid billing case management department. She would be responsible for reviewing Medicaid cases for case management and billing purposes. This position is homebased which allows her the flexibility as a single mom to assist with her four kids. However she wants to remain at the private hospital on a part-time weekend only status when her kids are with their father. This would allow her additional income.

The conflict of interest: The conflict arising is the State billing company is not sure if her position at the private hospital is a financial and confidential-medical conflict of interest of patient information.

The issue, which is still not resolved, is the question, “Is her access to patient information at the private hospital in conflict with her new job’s Medicaid billing case management requirements?” A patients insurance and then Medicare are billed first, then Medicaid. If she knows a particular patient has other means of insurance because she can see that information in the private hospital setting, would she disclose that information for Medicaid billing purposes, or is she even required to? Would she steer the patient to services at the private hospital over promoting other Medicaid benefits and providers? Is her access to share this information a violation of protected patient’s medical rights?

Laws governing these COI: Per the Centers for Medicare and Medicaid Authorities (Kako & Cooper, 2016) Person Centered Planning (PCP) is critical. This system finds the happy medium between the system benefits and the patient’s needs that is free from budget decisions. Her involvement at the private hospital may guide the patient to services at the private hospital, rather than promote choice which is Medicaid’s focus.

To help guard against these two particular conflicts of interest, both the private hospital and the State have polices in place that regulate case management access. Under Section 1915(i) [State Plan HCBS Option] and 1915(k) [Community First Choice Option] this policy states: 1) Case management representative cannot be family to the patient, caregiver or receive any financial incentives from the patient. 2) The private hospital has stakeholder polices in place for reviews of grievances and 3) The State has an oversight management team that oversees eligibility and business practices (Donica, 2013).

Employer/Manager role: The managers of these departments must exercise the laws in place to discourage this employee from seeking out confidential financial and medical information she has access to at one place of business to be used at another. To help avoid this conflict of interest, the managers at both places must always keep the patients best interest at the center of the service.  As the law states each facility must review records, validate performance and hire independent persons for oversight (Donica, 2013).