Case Study A Long-Term Care Facility Billing Services In an effort to gain monetary and operational efficiencies, an Ontario long-term care facility, called ElderCare, managed and operated by Ms. Jane Smith, is planning to outsource its medical billing service to a company located in the United States, called ClaimsRUs. Today, medical billing is done within ElderCare using an old IT system to issue invoices and track payments from three main insura

Case Study A
Long-Term Care Facility Billing Services
In an effort to gain monetary and operational efficiencies, an Ontario long-term care facility, called ElderCare, managed and operated by Ms. Jane Smith, is planning to outsource its medical billing service to a company located in the United States, called ClaimsRUs.
Today, medical billing is done within ElderCare using an old IT system to issue invoices and track payments from three main insurance companies as well as residents/families of residents. Currently, the system is only used for non-OHIP billings (where OHIP does not pay for the services).
ElderCare uses the legal name, birth date, and health number of the resident to differentiate records from other residents. Billings include set fee per room, and financial charges for medical services such as diabetic foot care (received once per week), additional supplies beyond those included in room fee (such as diapers, hand cream and throat lozenges).
A typical invoice would contain the following information:
· Name of resident
· Resident’s date of birth
· Resident’s health number
· Invoice date, payment due date
· Type of medical service/supply and total monetary amount
· Medical diagnosis related to required service/supply
· Health care professional who authorized each medical service
· Total financial payment required, (in Canadian dollars) with HST separated out for tax purposes
· Name and mailing address of payee (Insurance Co #1, #2 or #3 or family member identified on ElderCare’s system)
Case Study A Page 1 of 3
These case studies have been created for educational purposes only – names of individuals and organizations are fictitious. There also may be information deliberately missing. This material does not reflect the administrative policy or operating position of the professor’s current or past employers.
As part of its orientation process, ElderCare provides the following information in a brochure format to residents and their family members:
For more information about our handling ofyour personal health information:
Upon request, ElderCare will provide you with specific information about its policies and practices relating to the management of personal health information.
By law, you have the right to know what personal information we hold about you and the right to request access to it. Upon request, ElderCare will inform you of the existence, use and disclosure ofyour personal information and give you access to that information at a reasonable cost and within a reasonable time. You may challenge the accuracy and completeness of the information and have it amended as appropriate.
Please contact our Privacy Coordinator by phone at 123-456-7890 or in writing
at:
ElderCare
Privacy Coordinator
1010 Somewhere Street
Hometown, Ontario
A1A 1A1
Invoices are prepared every two weeks directly from the transactional data. ClaimsRUs offers electronic services for coding medical services to automatically derive invoices to the appropriate party (insurance companies and residents) with minimal manual intervention. No other facility in Ontario currently uses ClaimsRUs.
ClaimsRUs indicates that it would require unlimited access to ElderCare’s entire system to copy the information into ClaimsRUs’ software program. ClaimsRUs proposes to keep the copied information onsite at their US office in encrypted form and access by three roles (which may be up to 10 individuals):
· Database administrator
· Claims processor
· Quality assurance
All employees of ClaimsRUs are required to pass a security clearance check prior to hire and must use their user ID/password to access the system. A photo ID badge is required to enter the premises. A security guard is onsite at the front entrance.
The software program will code the medical services provided by all health care providers within Eldercare derive an invoice for ClaimsRUs’ manual check before
Case Study A Page 2 of 3
These case studies have been created for educational purposes only – names of individuals and organizations are fictitious. There also may be information deliberately missing. This material does not reflect the administrative policy or operating position of the professor’s current or past employers.
mailing the invoice to the appropriate party. ClaimsRUs will follow up (etelephone call and/or written letters) with the 3rd party until payment is received or payment is overdue by 90 days. Once overdue, Claims RUs offers to take the invoice to small claims court directly or to redirect back to ElderCare for further action.
You are the employee of ElderCare who has been asked to identify the privacy risks of this relationship.
Case Study A Page 3 of 3
These case studies have been created for educational purposes only – names of individuals and organizations are fictitious. There also may be information deliberately missing. This material does not reflect the administrative policy or operating position of the professor’s current or past employers.