Filing HIPPA Complaint

Cassinia · Mar 10, 2005

I'm a nurse case manager for an independent company and we deal with numerous independent health plans. Here's the check list of what needs to be done...

1. Call the collection agency & inform them the claim has not be sent to your insurance company and is still under investigation as to why it wasn't sent. Inform them there may be upcoming litigation re: hospital not following standards of procedure for filing claims.

2. Call the insurance company claims department & see if the claim did actually go through & if it was denied for any reason. Then, inform them of the matter and see if they can have their case managers (if they have them) or who contact the hospital and request the claim.

3. Find out who certs the hospitals in your state, contact them, and make a grievence. Most states have a grievence committe and they go out to investigate the claims. You may not be the first.

4. Don't play with the little guys, go straight to the TOP! Contact the CEO & inform him of the problem and the actions that you are taking. Send him a letter as well as we know if it is not in writing, it never happened. CEO's don't like it when their hospital is reported to the certification agency.

5. Get a lawyer involved if all else fails.

Make sure you have all names and dates of contact with hospital & collection agency written down; if not, start writing them down.

nursex20 · Mar 10, 2005

I'm a nurse case manager for an independent company and we deal with numerous independent health plans. Here's the check list of what needs to be done...
1. Call the collection agency & inform them the claim has not be sent to your insurance company and is still under investigation as to why it wasn't sent. Inform them there may be upcoming litigation re: hospital not following standards of procedure for filing claims.
2. Call the insurance company claims department & see if the claim did actually go through & if it was denied for any reason. Then, inform them of the matter and see if they can have their case managers (if they have them) or who contact the hospital and request the claim.
3. Find out who certs the hospitals in your state, contact them, and make a grievence. Most states have a grievence committe and they go out to investigate the claims. You may not be the first.
4. Don't play with the little guys, go straight to the TOP! Contact the CEO & inform him of the problem and the actions that you are taking. Send him a letter as well as we know if it is not in writing, it never happened. CEO's don't like it when their hospital is reported to the certification agency.
5. Get a lawyer involved if all else fails.
Make sure you have all names and dates of contact with hospital & collection agency written down; if not, start writing them down.

The insurance company is now out of business and that tells you how long I have been messing with this.

How would I go about number 3?

I have Googled the CEO's name but what in the world would I say in the letter? I am assuming this would be sent registered with return receipt request to prove it was received?

Thanks so much for your help, I am truly sick of these people.

Cassinia · Mar 10, 2005

Start with the State of Texas Department of Health (or Department of Licensing if you have one. Check the internet, or where your RN license came from) and ask which division licenses hospitals. Contact them and inq. about where to file a grievence against a hospital. Contact them and find out what is needed to file the grievence.

As for the CEO, I have a bit of experience in this with the state of NJ. First, the office staff will try to divert you to other offices and other supervisors. Hold your ground and demand to speak w/CEO; inform them you are sending the letter and want to make CEO aware. And, yes, send it registered to make sure he gets it. Inform him of the problem with the claim not being sent to the health plan and the current status of what is being done. Inform him you have contacted the above mentioned places, provide him with dates, times and names. Inform him of the letter he will be receiving and that you would like to have this resolved by the hospital within 3 weeks (include this in the letter as '3 weeks from the time of receiving this letter'). Inform him if there is no resolution within that time, then you will be seeking legal recourse. Try to remain calm; I know how this can be very frustrating. Let him know you have a plan and it will be followed out.

Once the letter has been verified as being received, then start calling every week to find out where they are in resolution. As you get to the second week, again remind them if it is not resolved by the following week, legal recourse will be taken. At which time, you should be seeking recourse.

Another thought just crossed my mind as well, contact the Better Business Bureau for your state and let them know of the problem; file the complaint there. Indicate to the CEO you have notified them as well.

After many dealings with different hospitals and CEO's in NJ, I found if you go in level headed, present the facts, let them know you have a plan of action and will be sticking to the plan of action, you have a good chance of getting things cleared up. And, keep to your timeline.

As for lawyers, you'll probably want a lawyer who specializes in insurance or corporate law.

flashpoint · Mar 10, 2005

This doesn't sound like a HIPAA problem to me. Facilities can release information for purposes of TPO (treatment, payment, and operations) without permission from the patient. Also...if this started before April 15, 2003, you are not protected by HIPAA anyway...

Not sure what else to tell you, but this does not sound like a HIPAA issue.

Gennaver, MSN · Mar 10, 2005

Hello and thank you in advance for this thread, (and the piggybacking here).

A year and a few months ago the biller at the women's health center where I was both a patient and an employee really violated my privacy, big time.

See, it involved my current boyfriend and her best friend, (which I was clueless about as he saw her when we were seperated and before I worked at this facility).

Thing is, the lab tech that I worked with was friends with the biller who was best friends with the 'other woman' who worked in another hospital,(the same one my boyfriend works at-now he is my husband.)

One day the lab tech asks me my boyfriends last name, I tell her, unknowingly. She walks me back to the biller and says to her, "guess what, Gen's boyfriend is so and so."

Biller blurts out, "HE is seeing my best friend" and proceedes to call her best friend and work at the other hospital and gives the phone to me. I was stunned to say the least. Next the biller calls up the hospital were he works too, (she herself used to work there) and so on.

Down to the point, I quit there after about five more months of that. The other woman was a patient there too, the biller told me, and she came up one day to have a 'look' at me.

When I moved in with my boyfriend, (we were neighbors before) I sent my change of address to the women's center. The biller got a hold of it obviously because I started receiving bills to the correct address for a procedure that was already paid for, (my colposcopy for some CIN level 1).

Now, I know this biller shared information as she did it to me and about me. Me and my boyfriend are now married. I am now on his insurance but, even though I really like my doctors there, (primary and gyne) and the nurses I really do not feel like having my life be fodder for this biller and her best friend.

I want to know is there any way I can get my 'file' out of there. I know from working there that when people want their file that they don't really get it but, only get a copy of it. I do not want my personal gynecological history there at all. Ugh, the thought of the biller and the other woman knowing all my private and personal medical history!!!

Please, any advice would be appreciated.

Oh, we have caller ID and after the biller sent me erroneous bills to the new address the 'other' woman started to call for a while.

Well, I do like my current doctors but, what about this catty and gossipy biller?

Gen

Cassinia · Mar 11, 2005

Gen, first of all, you need to inform this biller's supervisor of what she's been doing and for how long. She is definitely breaking all HIPPA regulations with providing information to this other person, as well as her using it for her personal business. File a complaint on paper as a patient. You need to contact medical records (I'd say go in person) and request you get your orginal medical records; you'll need to sign a ROI (release of information). Inform your md of the problem as well; we all know doctors have a lot of pull, especially if they're going to lose a patient.

Again, if the immediate supervisor will not handle the issue, then keep going up the ladder. For every time you get a contact from the other person or a 'misbilling' from the biller, report it to the supervisor in writing. Let the supervisor know with your first contact you will be reporting any infraction of the HIPPA laws the bill does to you.

Gennaver, MSN · Mar 11, 2005

Gen, first of all, you need to inform this biller's supervisor of what she's been doing and for how long. She is definitely breaking all HIPPA regulations with providing information to this other person, as well as her using it for her personal business. File a complaint on paper as a patient. You need to contact medical records (I'd say go in person) and request you get your orginal medical records; you'll need to sign a ROI (release of information). Inform your md of the problem as well; we all know doctors have a lot of pull, especially if they're going to lose a patient.
Again, if the immediate supervisor will not handle the issue, then keep going up the ladder. For every time you get a contact from the other person or a 'misbilling' from the biller, report it to the supervisor in writing. Let the supervisor know with your first contact you will be reporting any infraction of the HIPPA laws the bill does to you.

Hello Cassinia,

Thanks for the reply.

Number one thing I am going to do IS take it to the MDs! They are aware of this biller and this violation. They are my doctors and I am willing to leave their care because of this situation.

I have a strong feeling they will be able to nip this.

Possibly the post won't be important but I am going to leave it in.

Unfortunately I know from working there that when people fillout a ROI that they are only given copies of their record. I used to help the office workers out sometimes and actually did that job.

This happened a year ago February, I ended up leaving there and transferring to another department in another facility in May.

This biller's direct supervisor was also my supervisor. She is well aware of this. She did give me a day or two to regroup and scheduled me to work in Medical records instead of patient care, (as I was very shocked and not completely in my right frame of mind and because the 'other woman' was coming in as a patient). The way this biller dumped this on me was a total surprise, with apparent intent to hurt, (not a nice lady).

However, the reason my boss was her supervisor is that the office manager was off in another department working as interm manager. When I transferred out my boss did say that she wouldn't have held it against me if I did contact HIPPA.

Two things:

1. I will not get my 'records' only a copy of them, (which means that my file will be copied and in the air in plain view of whoever walks by).

2. I am aware this was a HIPPA violation and so should the biller, I didn't even know "the other woman" existed nor that she was a patient there and never would have wanted to talk to her, (which I did when the phone was given to me) nor to see her, (which I did when the biller pointed me out to her)

Now there is a new director at that center. Since this happened a year ago last Feb and before she came there I wonder if that is too long ago. Truly, this was shocking to me, (its in perspective now but, the way it happened...I was at work to work and was a patient there, not interested in having any of this happen!)

I do wonder about filing a violation but, really want my file in entirity out of that office, (not a copy).

I was told as an employee by the office manager that they do not give people their actual records, that they keep them there.

Thanks,

Gen

Cassinia · Mar 11, 2005

By rights, the medical records are about you and, therefore, belong to you. You have the right to the original, not just a copy. Get your doctor behind you. They have the charts when you're seeing them, have the doctor give it to you then if you must. But, you are entitled to the original documentation of the files. If you know anyone who's a lawyer, check on this for your state, as this may be a state to state issue.

As for the supervisor being the same for the two of you and knowing about the situation, then, shame on her for not doing anything about it! She is just as guilty for not taking action. Reprimand was required since the HIPPA laws were being broken, big time! If your manager didn't do anything about it, then you needed to move up, possibly to the ADON or DON. From the sounds of it, it hasn't stopped. You need to take control and get it to stop one or another. This biller needs to be put on probation or suspension. Ever wonder how many other people she may be doing something similiar to? Doesn't it bother you that basically you are being stalked by the two of them?

Remember, for any good service, a person may tell only five friends who may only tell three. But for any bad service, the person will tell ten, who will then tell ten, and so on. I'm sure the doctors don't want to have it out there clinic can't keep confidentiality.

Gennaver, MSN · Mar 11, 2005

By rights, the medical records are about you and, therefore, belong to you. You have the right to the original, not just a copy. Get your doctor behind you. They have the charts when you're seeing them, have the doctor give it to you then if you must. But, you are entitled to the original documentation of the files. If you know anyone who's a lawyer, check on this for your state, as this may be a state to state issue.
As for the supervisor being the same for the two of you and knowing about the situation, then, shame on her for not doing anything about it! She is just as guilty for not taking action. Reprimand was required since the HIPPA laws were being broken, big time!

Cassinia,

Thank you so much for your replies.

Recalling this and communicating about it has me truly thinking.

I will let you know in a while what I decide.

Mainly, I am overdue for my follow up due to CIN level I. My husband called me today as he officially had me put on his insurance.

I will update later.

Thanks,

Gen

allnurses Guide · Mar 11, 2005

I don't believe the medical records "belong to you", sorry about that. You have a right to copies, but the records themselves belong to the company that created them, as records of what was done at their facility. Imagine what would happen if anyone could simply remove their records at will, what defense would MDs or nurses have if later accused of something with no notes to refer back to?

It sounds like you were in a really rough situation, I don't think you should let it go it you have the energy to follow up with it. Ask if your records can be sealed, and only opened by a health pro. directly involved with your care. When you sign the releases that allow your records to be sent for insurance and payment purposes, you can restrict what is allowed (although the forms don't tell you that!). You don't have to allow them to be sent, you can file insurance yourself, lot of trouble & hassle, but it is your option.

Nurse Ratched, RN · Mar 11, 2005

I agree with Jbudd that you don't have the right to originals - only copies.

I would advise my health care provider of these infractions and consider taking my care needs elsewhere if he/she does not take this seriously.