Compliance Update

Written by Jeffrey Segal, M.D., J.D. & Michael J. Sacopulos, J.D.   
Monday, 24 January 2011 18:20

Understanding the law before you send your patients any e-mail

Snail mail is becoming less popular as the calendar pages turn. E-mail and social media networks have changed how we communicate. Before clicking the send button in an e-mail template, healthcare professionals should better understand that HIPAA violations have also entered a new era. More cases are prosecuted with assessment of both statutory civil fines and criminal penalties.  

A little background: Even though HIPAA passed in 1996, little prosecution followed when patient privacy was violated. Since the law took effect in 2003, nearly 45,000 complaints were filed with the Health and Human Services (HHS) Office for Civil Rights. Of these complaints, only 775 cases were referred to the Department of Justice or the Centers for Medicare and Medicaid Services for investigation. None resulted in direct civil monetary penalties (1).

Then, in 2009 the HITECH Act ("HIPAA on steroids") was enacted (2). This act intended to increase HIPAA confidentiality protections of Electronic Protected Heath Information (ePHI), instill tough civil and criminal penalties for violations, mandate notification of breaches of HIPAA protected heath information, and extend the definition of covered entities to include business associates (3). A tall order indeed.

For example under the tougher HITECH Act, in April 2010 a former employee of a hospital was sentenced to four months in prison for accessing the medical records of his coworkers and various celebrities. He had no "valid" reason for accessing these records (4).

According to the Health and Human Services (HHS), penalties have increased. Prior to the HITECH Act, the HHS Secretary could not impose a penalty of more than $100 for each violation or $25,000 for all identical violations of the same provision. Section 13410(d) of the HITECH Act strengthened the civil money penalty scheme by establishing tiered ranges of increasing penalty amounts, with a maximum penalty of $1.5 million for all violations of an identical provision.

Just how "high tech" are physicians when it comes to communicating with patients?

A survey by the health information firm Manhattan Research in 2009 found that 42 percent of physicians had some online communication with patients. The American Academy of Family Physicians reported in a 2009 survey that just 6 percent of responding members had performed a Web-based consultation - that number was more than double the 2.6 percent who had done so in 2008 (5).

But is all of this electronic communication legal?

The HITECH Act requires that all communications involving ePHI be encrypted. HHS recently adopted National Institute of Standards and Technology guidelines for encryption. This means that if a physician wants to consult, refer, or prescribe for a patient by e-mail, the e-mail had better be encrypted. Of course most patients do not have software to decrypt. So what alternatives do healthcare providers have? And, more importantly, how can this be made easy and pragmatic? Email was designed to simplify, not complicate.

Healthcare providers may seek their patient's consent to communicating via unencrypted e-mail. While HHS does not provide a standard form for securing patient consent, basic "informed consent" strategies should apply. First, get the patient's consent in writing. The patient should not be given just a binary choice - but a menu of choices. For example, a patient may wish to electronically receive information on appointment dates but not test results. The consent document - as is standard with most routine HIPAA forms -should also note that the patient may withdraw his or her consent at a later time. This can be part of an expanded HIPAA form the patient signs when first seeing you in the office.

Here are some more recommendations when communicating with patients electronically:

1. A physician may be held responsible for a delay when responding to a patient's e-mail. Solution: A physician that wishes to accept e-mail from patients should use an auto response feature that informs the patient that a) the physician typically responds to e-mail within XXX number of hours/days; b) if the patient requires immediate attention, the patient should telephone the physician's office or contact an emergency healthcare provider.

2. If a patient initiates an e-mail with a physician, Rachel Seeger of HHS Office for Civil Rights says that it is assumed that the patient consents to unencrypted communication. "If this situation occurs, the healthcare provider can assume (unless the patient has explicitly stated otherwise) that e-mail communications are acceptable to the individual (6)."

3. If a physician does end up sending a patient an e-mail, double check the recipients' e-mail address before clicking the send button. This is to prevent the e-mail from being sent to the wrong person, therefore sharing private information to an unintended party. Good advice also in the non-healthcare world.

4. Add any e-mail a patient sends (and any response) to the patient's chart.

5. In the HITECH Act code 170.210 section B states that the date, time, patient identification and user identification must be recorded when electronic health information is created, modified, deleted, or printed; and an indication of which actions occurred must also be recorded. This means if you send an email to a patient with protected health information - and delete it - you will need a record of what was deleted and when. This is not dissimilar to crossing out a line in a paper medical record- updating the record - with a date of the update.

6. Since communicating with patients via e-mail is becoming stricter, more physician offices and hospitals are using portals as a means of communication. This allows the patient to sign in with a secure username and password to view their records and communicate with their physicians. The security rule allows for Electronic Protected Heath Information (e-PHI) to be sent over an electronics open network, as long as it is adequately protected (7). Of course, this is more complicated than using Outlook or gmail.

The HITECH Act has ushered in a new era of technology requirements and standards that must be met by physicians. Given HHS's recent enforcement efforts, physicians should use caution when electronically communicating with patients. By working within the boundaries of the six points above, physicians should comply with the HITECH Act.

Jeffrey Segal, MD, JD, a neurosurgeon, is the founder and CEO of Medical Justice Services. Mike Sacopulos serves as general counsel for Medical Justice.  For more information email or visit



(1) Elizabeth S. Roop, Pulling It Together- The HITECH Act and HIPPA, For The Record Vol.21, No. 17 at 10 (Sept. 14, 2009), URL: http:// Click here to view source.


(2)Click here to view source 


(3) Click here to view source

(4) DOJ Press Release (Jan. 8, 2010), URL: Click here to view source 


(5) Article (Dec 10, 2010) URL Click here to view source


 (6) Personal correspondence between author and Rachel Seeger, Senior Health Information Privacy Outreach Specialist, HHS Office of Civil Rights, December 28, 2010.


(7) Click here to view source

Last Updated on Thursday, 27 January 2011 15:56
The good, the bad, and the ugly - 2011 Final Policy and Payment Changes for Medicare Print E-mail
Written by Joe L. Miller   
Thursday, 09 December 2010 15:04

The Good

Believe it or not, there are some good things, particularly for primary care physicians, coming out of the 2011 Medicare Policy and Payment changes:

  • Elimination of Deductible and Coinsurance for most preventative services
  • Addition of reimbursement for an Annual Wellness visit
  • Incentive payments - 10% paid quarterly - to primary care physicians for primary care services - applies to all physicians with a primary care designation as well as nurse practitioners, clinical nurse specialists or physician assistants (primary care services must account for at least 60% of their Part B allowable charges)
  • Incentive payments - 10% paid quarterly - to general surgeons for Major Surgical Procedures in Health Professional Shortage Areas (HPSAs)

Not So Good to Downright Bad

  • Advanced imaging services (CT and MRI) will be paid less due to an adjustment in the equipment utilization rate assumption
  • Therapy services will be reimbursed 25% less for the second and subsequent services provided in the same visit
  • Medicare claims must be submitted in twelve (12) months or less from the date of service

Just Plain Ugly

"...the rule calls for Medicare physician payments to be slashed by 23% -- 25% on Dec. 1, 2010 and 2% on Jan. 1, 2011." (from AMA)

Click here to view the CMS Fact Sheet. 

About the author - Mr. Miller is a Principal at PYA and concentrates his practice on healthcare; providing tax planning, consulting and compliance services.  In September, PYA was listed by Modern Healthcare as a top 20 consulting firm.   

For more information, please visit

Last Updated on Thursday, 23 December 2010 06:57
House passes Red Flags Program Clarification Act Print E-mail
Written by Sandra Greenblatt, Esq.   
Thursday, 09 December 2010 00:00

Is it time to celebrate the New Year?  On 12/8, the U.S. House of Representatives passed S. 3987, the "Red Flag Program Clarification Act of 2010"-legislation that limits the type of creditor that must comply with the "red flags" rule and  appears to permanently exempt physicians. Because the U.S. Senate unanimously passed the bill on Nov. 30, it is being sent to the White House where President Obama is expected to sign it into law before the Jan. 1, 2011, deadline.   Assuming the President signs the legislation, providers would still have to wait for the FTC's blessing before uncorking the bubbly.  For more information click here:  

A Red Flag Reprieve for Health Care Providers? The Door Remains Open Pending Federal Agency Action

Update 12.22.10 - The President has signed the legislation. We await the FTC's interpretation.

About the author:  Ms. Greenblatt is a Board Certified Health Law Attorney practicing in Miami.

Last Updated on Sunday, 02 January 2011 17:44
Health Law Update Print E-mail
Written by Sandra P Greenblatt, Esq,   
Thursday, 21 October 2010 14:28


My partners and I are planning to go to the concierge business plan to cope with declining reimbursements and to restore our quality of life.  We are a three doc, primary care group (all internists in Broward county).  We would like to retain several patients who have limited incomes and would not be able to pay the annual fee.  Are there Stark issues associated with accepting some patients without charging them the annual fee?

Internal Medicine Group

Fort Lauderdale


Stark Law is not your issue. There are no referrals here. The primary legal restriction on concierge practices is that you must not charge the membership fee for access or any service covered by Medicare (or private insurance). Most VIP practices thus focused the fee on preventive health care, such as a free annual physical, and amenities such as faster and longer appointments, etc.

The problem is that the new Health Care Reform laws significantly expanded Medicare coverage for preventive services and you must be aware of these changes in structuring your new program. You need a good patient contract spelling out your new relationship and its limitations.

Although it is difficult to say goodbye to old patients, also consider how the paying concierge patients will feel and react should they learn others are not paying.

Sandra P Greenblatt is a Board Certified Health Lawyer practicing in Miami, FL.

Contact Ms. Greenblat at 305.305.577.9995 or

via E mail

EHR & Meaningful Use Update Print E-mail
Written by Scott C. Quinn   
Thursday, 21 October 2010 14:24

The Office of the National Coordinator for Health Information Technology (ONC) named the Chicago-based Certification Commission for Health Information Technology (CCHIT) and The Drummond Group, Inc. of Austin, TX as the first technology review bodies authorized to test and certify EMR (electronic medical record) software and systems for compliance with the standards and certification criteria issued by the U.S. Department of Health and Human Services (HHS) earlier this year.  HHS/ONC-certified EMR software users are eligible for financial incentives and higher Medicare/Medicaid reimbursements.

The announcement means that EMR software vendors now can have their products certified as meeting the HHS' "meaningful use" criteria. HHS/ONC certified EMR software must pass 45 tests covering critical issues such as encryption, access management and reporting. For healthcare providers, using HHS/ONC certified EMR software not only helps ensure compliance, it may help boost your practice's revenues as well.

CCHIT Certification is good for two years, and several companies have had their solutions certified at one stage or another since 2006.  However, in order to qualify for "meaningful use" reimbursement, those solutions must receive 2011 CCHIT Certification or a comparable certification from the Drummond Group.  As of August 20, 2010, only 32 EMR products have achieved 2011 CCHIT Certification.

EMR software certification is part of a broad initiative undertaken by President Obama and Congress under the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act (ARRA) of 2009. The HITECH Act provides for upwards of $27 billion in incentives to help health care providers recoup costs of transitioning from paper-based medical records to EMRs. Individual physicians and other eligible healthcare professionals can receive up to $44,000 through Medicare and almost $64,000 through Medicaid. Hospitals can receive millions of dollars.

To qualify, healthcare providers must implement and demonstrate meaningful use of HHS/ONC-certified EMR software systems as defined by the Centers for Medicare and Medicaid Services in July.  Physicians must also accept Medicare and must have at least $24,000.00 in total Medicare allowable charges per year.

About the author: Mr. Quinn works with a variety of healthcare organizations throughout Florida and nationwide to assess their individual, financial, operational and strategic challenges and to develop tailored solutions designed to streamline administrative, billing and coding functions, free up resources to focus on core competencies and boost revenue.

Scott C. Quinn |  Iatros Healthcare Solutions

(904) 296-1160, option 1 |


Last Updated on Thursday, 28 October 2010 10:56
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