How does an individual receive health care services?
Dec 01, 2021 · HIPAA, or the Health Insurance Portability and Accountability Act of 1996, covers both individuals and organizations. Those who must comply with HIPAA are often called HIPAA-covered entities. HIPAA-covered entities include health plans, clearinghouses, and certain health care providers as follows: Health Plans
What is a covered entity under the Affordable Care Act?
First-tier entity is any party that enters into a written agreement to provide administrative services or health care services. Downstream entity is any party that enters into a written arrangement with persons or entities below the level of the arrangement …
What is a HIPAA covered entity?
The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program; called the Health Care …
Which providers are covered by HIPAA?
CMS stands for the Centers for Medicare and Medicaid Services within the Department of Health and Human Services that administers Medicare and Medicaid policies. CMS used to be called the Health Care Financing Administration (HCFA). In Florida, CMS may also refer to Children's Medical Services within the Florida Department of Health.
Who is the administrator of Medicare?
Chiquita Brooks-LaSureChiquita Brooks-LaSure is the Administrator for the Centers for Medicare and Medicaid Services (CMS), where she will oversee programs including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the HealthCare.gov health insurance marketplace.
What is Entity healthcare?
A covered entity is anyone who provides treatment, payment and operations in healthcare. Covered Entities Include: Doctor's office, dental offices, clinics, psychologists, Nursing home, pharmacy, hospital or home healthcare agency. Health plans, insurance companies, HMOs.
What is the role of the CMS?
The CMS oversees programs including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the state and federal health insurance marketplaces. CMS collects and analyzes data, produces research reports, and works to eliminate instances of fraud and abuse within the healthcare system.
What does CMS do for Medicare?
The Centers for Medicare and Medicaid Services (CMS) provides health coverage to more than 100 million people through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.
What is an example of a healthcare entity?
Examples of other health care entities may include health maintenance organizations (HMOs), preferred provider organizations (PPOs), group practices, nursing facilities, rehabilitation centers, hospices, renal dialysis centers, free-standing ambulatory care and surgical service centers, patient-centered medical homes ( ...
What do you mean by entity?
Definition of entity 1a : being, existence especially : independent, separate, or self-contained existence. b : the existence of a thing as contrasted with its attributes.
What do CMS administrative actions include?
CMS took administrative action against 938 providers based on information from FPS, including revocation of billing privileges, implementation of prepayment review edits, referrals to law enforcement, and suspension of payments. both providers and suppliers enrolled in the Medicare fee-for-service program.
Whats CMS stand for?
The Centers for Medicare & Medicaid Services, CMS, is part of the Department of Health and Human Services (HHS).
What is CMS in medical billing?
The term CMS stands Centers for Medicare & Medicaid Services—an agency established to oversee various numbers of medical care programs within the U.S. The agency falls under the Department of Health and Human Services (HHS) to ensure smooth administration of all the major medical care programs like Medicaid, Medicare ...
Is CMS a regulatory agency?
Although FDA and CMS regulate different aspects of health care—FDA regulates the marketing and use of medical products, whereas CMS regulates reimbursement for healthcare products and services for two of the largest healthcare programs in the country (Medicare and Medicaid)—both agencies share a critical interest in ...
What is CMS accreditation?
CMS grants “deemed status” to these organizations to allow them to survey and "deem" that a health care organization meets the Medicare and Medicaid certification requirements through its accreditation process.
Background
Section 1877 of the Social Security Act, also known as the physician self-referral law, prohibits the following: (1) a physician from making referrals for certain designated health services (''DHS'') payable by Medicare to an "entity" with which he or she (or an immediate family member) has a direct or indirect financial relationship (an ownership/investment interest or a compensation arrangement), unless an exception applies; and (2) the entity from presenting or causing a claim to be presented to Medicare (or billing another individual, entity, or third party payor) for those referred services.
Solicitation of Comments
Following the publication of the IPPS final rule, we received a number of inquiries concerning whether we planned to issue additional guidance on the revised definition of entity, including the meaning of "performed services that are billed as DHS." To determine if further guidance was necessary, we solicited comments in the CY 2010 Physician Fee Schedule final rule (74 FR 61933–34).
Comments Received
We received only nine comments responding to our solicitation, and there was no consistent approach regarding whether we should revise the definition of entity and if we did, the manner in which the definition should change.
CMS Response
The comments we received did not convince us to provide additional guidance or to engage in rulemaking to amend the definition of entity.
Confidentiality
Delegated entities must not share credentialing and recredentialing information to anyone without the care provider’s written permission or as required by law.
Initial credentialing process
When credentialing is delegated, applicants must use the medical group’s/IPA’s application form and process or as prescribed by law.
Delegation oversight
We perform an initial assessment to measure the delegate’s compliance with the established standards for delegation of credentialing. Every year after that, we assess the delegate to monitor its compliance with established standards. This includes NCQA standards and state and federal requirements.
Improvement action plans
If delegates are not compliant, we may require an improvement action plan. If compliance is not reached within a determined time frame, we continue oversight. We may revoke delegated functions if delegates remain non-compliant with our credentialing standards.
Credentialing reporting requirements for delegates
In addition to complying with state and contractual requirements, we require all delegates to adhere to the following standards for notification procedures. The delegate provides prior written notice to us of the addition of any new care providers or other licensed independent health care professionals.
About BLUE VISTA HOME HEALTH INC
Blue Vista Home Health Inc. is a provider established in Miramar, Florida specializing in home health. The NPI number of Blue Vista Home Health Inc. is 1407073075 and was assigned on April 2007. The practitioner's primary taxonomy code is 251E00000X. The provider is registered as an organization and their NPI record was last updated 13 years ago.
Business Address
BLUE VISTA HOME HEALTH INC.#N#3590 S. STATE RD.#N#SUITE 219#N#MIRAMAR, FL#N#ZIP 33023#N#Phone: (954) 962-1993
Mailing Address
BLUE VISTA HOME HEALTH INC.#N#3590 S. STATE RD.#N#SUITE 219#N#MIRAMAR, FL#N#ZIP 33023#N#Phone: (954) 962-1993
NPI Footnotes
What is the National Provider Indentifier (NPI)?#N#The NPI is 10-position all-numeric identification number assigned by the NPPES to uniquely identify a health care provider.
What is the purpose of the 340B Medicaid Exclusion File?
The 340B Medicaid Exclusion File is posted on the public 340B database to enable 340B covered entities, States, and manufacturers to determine whether a covered entity purchases 340B drugs for its Medicaid FFS patients.
What is 340B in the PHSA?
Section 602 of Public Law 102-585, the “Veterans Health Care Act of 1992,” enacted section 340B of the Public Health Service Act (PHSA) “Limitation on Prices of Drugs Purchased by Covered Entities, ” codified at 42 U.S.C. 256 b. The intent of the 340B Program is to permit covered entities “to stretch scarce Federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.” H.R. REP. No. 102-384 (II), at 12 (1992). Eligible covered entity types are defined in section 340B (a) (4) of the PHSA, and only include health care organizations that have certain Federal designations or receive funding from specific Federal programs. These include Federally Qualified Health Centers, Ryan White HIV/AIDS Program grantees, and certain types of hospitals and specialized clinics. Section 7101 of the Patient Protection and Affordable Care Act ( Pub. L. 111-148) (“Affordable Care Act”) expanded the types of covered entities eligible to participate in the 340B Program. As of January 1, 2015, there were 11,530 registered covered entities participating in the 340B Program.
What is 340B drug pricing?
The Health Resources and Services Administration (HRSA) administers section 340B of the Public Health Service Act (PHSA), which is referred to as the “340B Drug Pricing Program” or the “340B Program.” This notice proposes guidance for covered entities enrolled in the 340B Program and drug manufacturers that are required by section 340B of the PHSA to make their drugs available to covered entities under the 340B Program. When finalized after consideration of public comments solicited by this notice, the guidance is intended to assist 340B covered entities and drug manufacturers in complying with the statute.
How do covered entities use replenishment models?
Covered entities use replenishment models to manage drug inventory, including 340B drugs, which is permissible if the covered entity remains in compliance with all 340B requirements. For example, a 340B covered entity that sees many different types of patients ( e.g., inpatients, 340B-eligible outpatients, and other outpatients) would tally the drugs dispensed to each type of patient and then replenish the drugs used by reordering from the appropriate accounts. Some covered entities use software, referred to as accumulators, to track drug use for each patient type. The accumulator software would indicate which drugs are available to reorder on various accounts. In this example, the covered entity counts the units or amounts received by each 340B eligible patient. Once the covered entity has dispensed enough of a certain drug to equal an available package size, the covered entity could reorder that drug at the 340B price. Once drugs are received in inventory, the drugs lose their identity as 340B drugs, inpatient GPO drugs, or outpatient non-340B/non-GPO drugs. Each 340B drug order placed should be supported by auditable records demonstrating prior receipt of that drug by a 340B-eligible patient.
How long does a 340B program audit take?
General standards for manufacturers conducting a 340B Program audit include the use of an independent certified public accountant to perform the audit in accordance with Government Auditing Standards, the protection of confidential patient information, and a total audit duration of not more than 1 year. Pursuant to section 340B (a) (5) (C) of the PHSA, a covered entity must provide records pertaining to compliance of the covered entity, child sites, and any related contract pharmacy with the prohibition against duplicate discounts and diversion. Failure of a covered entity to provide auditable records within 30 days of the request is a violation of section 340B (a) (5) (C) of the PHSA. A covered entity and manufacturer must continue to meet all 340B Program requirements during an audit. At the completion of the audit, the auditors prepare a final audit report and submit it to HHS. The cost of the audit shall be borne by the manufacturer.
Can a hospital receive 340B?
In this case, the hospital cannot access 340B drugs for patients receiving care outside of those facilities and outside the scope of the Federal family planning project.
What happens if a covered entity loses 340B?
When a covered entity loses 340B Program eligibility, HHS will list that date on the public 340B database as the termination date. HHS will update the public 340B database as soon as the entity notifies HHS or HHS becomes aware that it no longer meets a 340B eligibility requirement. If a parent covered entity site is terminated, all child sites and contract pharmacy arrangements will be removed from the public 340B database with the same termination date. A covered entity is liable to manufacturers for repayment for the 340B discounts on any drugs purchased for itself, any child site, or any contract pharmacy when the covered entity was ineligible for the 340B Program for any reason. A non-hospital covered entity would lose 340B Program eligibility immediately upon loss of its qualifying Federal grant, contract, designation, or project or upon closing of the entity. A child site's 340B Program eligibility is tied to the eligibility of the parent covered entity; if a non-hospital parent covered entity loses eligibility to participate in the 340B Program, all registered child sites will simultaneously lose eligibility and must cease purchasing and using 340B drugs. A child site of a non-hospital covered entity will always lose eligibility if the child site closes, or if the child site no longer qualifies under the parent covered entity's grant, project, designation, or contract. If a parent or child site is registered under multiple covered entity types, loss of eligibility for any one covered entity type requires the parent and child sites to stop purchasing and using 340B drugs under the covered entity type for which the sites are no longer eligible. For example, if a site is registered for the 340B Program as a Federally qualified health center (FQHC) and tuberculosis (TB) clinic, and the parent site loses TB funding, both the parent and child sites must immediately stop purchasing and using 340B drugs under the TB grant and must have its TB 340B identification number terminated. The sites may continue purchasing and using 340B drugs under its registered FQHC 340B ID for eligible patients.
Background
- Section 1877 of the Social Security Act, also known as the physician self-referral law, prohibits the following: (1) a physician from making referrals for certain designated health services (''DHS'') payable by Medicare to an "entity" with which he or she (or an immediate family member) has a direct or indirect financial relationship (an ownership/...
Solicitation of Comments
- Following the publication of the IPPS final rule, we received a number of inquiries concerning whether we planned to issue additional guidance on the revised definition of entity, including the meaning of "performed services that are billed as DHS." To determine if further guidance was necessary, we solicited comments in the CY 2010 Physician Fee Schedule final rule (74 FR 6193…
Comments Received
- We received only nine comments responding to our solicitation, and there was no consistent approach regarding whether we should revise the definition of entity and if we did, the manner in which the definition should change. Several commenters asserted that a bright-line rule should be established to determine when a provider or supplier has "performed services that are billed as …
CMS Response
- The comments we received did not convince us to provide additional guidance or to engage in rulemaking to amend the definition of entity. We believe the guidance provided in the IPPS final rule is sufficient in most cases to identify when a provider or supplier has "performed the DHS." Providers and suppliers may seek further guidance through the advisory opinion process (42 CF…