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QIO TRANSMITTAL SERIES
ISSUE: Confidentiality and Disclosure of
Information - Printable
pages Process for Disclosure of Information The Foundation will
disclose specific information upon receipt of an acceptable data request for
such information, provided that 1) the information can be released to the
requestor in accordance with confidentiality requirements and 2) the
Foundation either possesses the information in the form requested or is able
to produce the information from data in its possession. An acceptable data
request must in general be 1) in writing, 2) specific as to the precise data
required and 3) accompanied by prepayment of the anticipated cost of
fulfilling the request. Disclosure of Nonconfidential Information Non-confidential
information includes any of the following: 1.
The norms, criteria and standards used in review activities; 2.
Winning technical proposals for contracts for the Department of
Health and Human Services and winning technical proposals for subcontracts
under those contracts; 3.
Copies of documents describing administrative procedures, agreed to
between the QIO and institutions or between the QIO and the Medicare
intermediary or Medicare carriers; 4.
Routine reports submitted by the QIO to CMS to the extent that they
do not contain confidential information; 5.
Summaries of the proceedings of QIO regular and other meetings of
the governing body and general membership except for those portions
containing confidential information; 6.
Public information (information which has already been disclosed to
the public); 7.
Aggregate statistical information that does not implicitly or
explicitly identify individual patients, practitioners or reviewers; 8.
Quality review study information including summaries and conclusions
from which the identification of patients, practitioners and institutions has
been deleted; and 9.
Information describing the characteristics of a quality review
study, including a study design and methodology. If the requested data identifies
an institution or institutions, the Foundation will notify each identified
institution of its intent to disclose information about the institution
at least thirty (30) calendar days
prior to the disclosure. The notice
will include a copy of the information to be disclosed. If the institution
submits comments to the Foundation, the comments will be attached to the
information when it is disclosed or, if the comments are received after
disclosure, the comments will be forwarded separately to the requestor. Exceptions
to the 30 day comment period requirements exist in cases of imminent danger
to individuals or public health and in cases to be disclosed to an agency
investigating potential fraud and abuse.
In these cases, notification to the identified institution(s) will be
simultaneous with the disclosure.
Any comments received on the disclosed information will be forwarded
to the agency to which the information was disclosed. Disclosure of Confidential Information Confidential
information includes any of the following: 1.
Information that explicitly or implicitly identifies an individual
patient, practitioner or reviewer; 2.
Sanction reports and recommendations; 3.
Quality review studies which identify patients, practitioners or
institutions (including HCQIP projects); and 4.
QIO deliberations. The Foundation will
disclose patient identified information in its possession to the identified
patient or the patient's representative if the patient or patient's
representative requests the information in writing and, in the case of a
request by a patient's representative, the request includes the designation,
by the patient, of the representative.
Fifteen days prior to direct disclosure of information to a patient,
the Foundation will seek the advice of the attending practitioner who treated
the patient regarding the appropriateness of direct disclosure to the
patient. If the attending
practitioner states that the released information could harm the patient, the
Foundation will disclose the information to the patient's designated
representative. If the patient is
mentally, physically or legally unable to designate a representative, the
Foundation will disclose the information to a person whom the Foundation
determines is responsible for the patient, based on information provided by
the medical record, attending practitioner or other reliable source. If the request is in
connection with a denial decision the Foundation need not seek the advise of
the practitioner who treated the patient regarding the appropriateness of
direct disclosure to the patient. In this case, only the information used to
support the denial determination will be disclosed. Procedures will be
adopted to assure that a person requesting access to his own record, is, in
fact, the individual on whom the record is maintained. Minimal requirements will be put into
effect to verify the identity of the individual. Upon request, the
Foundation will disclose to particular practitioners, reviewers and
institutions, information about themselves. Upon request, the
Foundation must disclose to an institution information on a practitioner to
the extent that the information displays practice or performance patterns of
the practitioner in that institution. The Foundation may disclose
to any person, agency or organization, information on a particular
practitioner or reviewer with the consent of the practitioner or reviewer
provided the information does not identify other individuals. Upon request, the
Foundation must disclose to Federal and State agencies responsible for the
investigation of fraud and abuse of the Medicare program and licensing and
certification information that displays practice or performance patterns of a
practitioner or institution. Except for cases involving
fraud and abuse, the Foundation will notify a practitioner or institution of
the information to be disclosed (including a copy of the information) at
least thirty (30) calendar days before disclosure. Any comments submitted by the practitioner or institution will
be forwarded with the information, if received before disclosure, or
forwarded separately, if received after disclosure. The Foundation's
deliberations concerning patients, practitioners and facilities, which serve
as a basis of the Foundation's QIO decisions, shall not be disclosed outside
the Foundation, except to the Health Care Financing Administration, the
Office of the Inspector General, or the General Accounting Office, as
specified in the regulations governing disclosure of QIO information. Redisclosure of
Confidential Information by Recipient Disclosure of
confidential information by the Foundation will be accompanied by a written
statement informing recipient about unauthorized redisclosure. The Foundation will
identify those individuals who improperly disclose information to the Office
of the Inspector General. Individuals convicted
of unauthorized disclosure could be fined up to $1,000 or be imprisoned up to
six months or both and liable for costs of prosecution. Redisclosure of
confidential information by a recipient is permitted under the following
conditions: 1.
If QIO approval for redisclosure is given. 2.
If CMS approval is given in order to carry out specific
responsibilities of the Secretary. 3.
If it is necessary for CMS to carry out specific responsibilities
for appeals. 4.
If a patient has more than one source of reimbursement for health
services, the sources (including Medicare and private insurers) may exchange
confidential information among themselves as necessary for the payment of
claims. 5.
If the person who receives the information can also obtain the
information on his/her own from the original source, that individual may
redisclose the information in accordance with the confidentiality rules or
the originator of the data. 6.
If it is necessary for the General Accounting Office to carry out
audit responsibilities. 7.
Information pertaining to a patient or practitioner may be disclosed
by that individual provided it does not identify any other patient or
practitioner. 8.
An institution may disclose information pertaining to itself
providing it does not identify an individual patient or practitioner. 9.
A Government fraud and abuse agency, state licensing or
certification agencies, and Federal and state health planning agencies
recognized by CMS may disclose information as necessary in a judicial,
administrative or other formal legal proceeding resulting from an
investigation conducted by the agency and if necessary for state and local
public health officials to carry out their responsibilities to protect
against an imminent danger to public health. 10.
If it is necessary for the Office of the Inspector General to carry
out its statutory responsibilities. Request for Onsite
Inspection of Existing Information The Foundation office
will be open to the public from 10:00 a.m. to 12:00 noon and from 2:00 p.m.
to 4:00 p.m. for inspection of existing information. An appointment will be
required. The appointment may be made
by telephone if the request is to inspect any of the following: · The norms, criteria and
standards used in review activities; · Winning technical
proposals for contracts for the Department of Health and Human Services; · Copies of documents
describing administrative procedures, agreed to between the Foundation and
institutions or between the Foundation and the Medicare intermediary; · Public information
(information which has already been disclosed to the public). Medicare beneficiaries
who have had a QIO denial have the right to review all information used by
the Foundation in connection with the denial determination; the beneficiary
may designate a representative to examine the information. (The appointment to review this
information may be made by telephone.)
The information to be made available includes the complete medical
record in the Foundation's possession, any additional information provided by
the physician or provider and any correspondence between the Foundation and
the physician and provided that was used in the denial determination. However,
records of Foundation deliberations and any identification of Foundation
reviewers or consultants cannot be made available to anyone outside of the
Foundation/QIO system. A written
request for an appointment must be made in order to inspect any information
other than that described above. Upon
receipt of the written request, the Foundation must determine whether the
requestor has the right to view the data (if the information is
confidential), whether time is required to prepare the information (e.g., to
remove identifiers or to collate materials) and whether a comment period is
required prior to releasing the information.
The Foundation will respond in writing to the requestor, indicating
its determination on the above items and establishing a date and time for the
requestor to inspect the data. No staff member will be
available to answer questions concerning the information being reviewed or to
make copies of any materials.
Requests for copies must be made in writing in accordance with the
procedures described above. The procedure for making inquiries regarding data
are described below. Inquiries Concerning
Information Furnished by the Northeast Health Care Quality Foundation All inquiries regarding
any information furnished by the Foundation, whether reviewed onsite at the
Foundation office or received in written form, must be made in writing and
must be as specific as possible.
Inquiries should be addressed to the Director of Review, who will
forward them to the appropriate staff member for response. Responses to inquiries which do not
require the provision of additional data will be made within 10 calendar days
of receipt of the inquiry, unless the Foundation requires written
clarification from the Health Care Financing Administration or some other
source in order to answer the inquiry.
If additional data is required to satisfy the inquiry or if copies of
materials viewed onsite are desired, procedures described above will be in
effect. November
2002 Next
Chapter: Medical Record Issues |
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
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