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Role of HIPAA in Workers Comp Claims

Since 1996, strong laws have protected people’s right to privacy regarding their medical records and related information. Thanks to the Health Insurance Portable Accountability Act of 1996, known as HIPAA, medical care providers must uphold high standards in protecting an individual’s privacy.

However, there are exceptions to these privacy laws that apply in workers’ compensation cases. Various entities involved in your case will need access to some of your private information to grant you benefits.

Exceptions to HIPAA’s Privacy Rule in Workers’ Compensation Cases

hipaa in workers comp claims

When it comes to HIPAA in workers’ comp claims, the strict privacy law creates a problem. The insurance company and other parties need access to your medical records. They need to follow along with your diagnosis, treatment, and rehabilitation to know if you have a qualifying injury, what bills they owe, and when your doctor releases you to return to work. Therefore, there are exceptions to HIPAA for workers’ compensation claims.

According to the U.S. Department of Health & Human Services (HHS), HIPAA’s rules on privacy do not apply in their entirety to several entities involved in workers’ comp cases, including:

  • The insurer
  • The applicable administrative agency
  • The employer

These are the parties that need access to an individual’s health information. They could request documents and information several times, including to adjudicate a claim, determine a claimant’s benefits, coordinate their care, and take other steps as a part of the workers’ compensation claims process.

However, there are still some limits in place. These entities should only request disclosures that are absolutely necessary to evaluate your claim and handle your case. Your employer cannot request your entire medical record from your doctor and expect to receive it. That would still be a HIPAA violation unless you signed a release, allowing this to occur.

When and How Can Approved Parties Get a Worker’s Health Information?

Because of HIPAA, doctors and other healthcare providers generally cannot release medical records or other information to anyone except their patient or someone with a signed release form.

However, when an entity needs these records for a workers’ compensation claim, federal law allows the doctor to release the information. This is true even without the individual’s authorization, so long as they are filing a workers’ compensation claim. They are also authorized by federal and state laws to release the necessary information to obtain payment for the injured worker.

Many healthcare providers still take the steps of asking for authorization early on in this process. This provides additional legal protection for their practice. This is often a common part of the paperwork completed during the initial office visit. Sometimes, the insurer or employer will ask the injured worker to sign an authorization form to disclose this information. This is very common in workers’ comp claims. While they have a legal right to access the information, having written authorization is preferred.

What Health Information Is Available to Those Who Request It?

Under 45 CFR 164.512, entities who can request and receive private health information for a workers’ comp claim must only provide necessary information. They should only gather the required records and documents to handle the claim and pay the worker’s bills.

Most healthcare providers take patient privacy and HIPAA seriously. They do not want to face legal trouble for violating this federal law by handing over too much information to a third party, even if an exception allows them access to private health details.

Many doctors, clinics, and hospitals have standard protocols, policies, and procedures related to how they handle these requests for information. They know what the insurance companies and other approved entities need to do their jobs and what they do not. They release only certain documents and limit the protected health information they disclose. Any other documents require additional paperwork and requests.

What Health Information Should Be Kept Confidential? 

The involved entities in your workers’ compensation claim only need information related to your present claim. Again, they don’t have the right to request information that has nothing to do with securing benefits. For instance, imagine that you underwent cosmetic surgery a few years ago. The insurer does not have the right to request information related to this procedure.

Here’s another scenario. Imagine that you were hospitalized a few years ago for alcohol poisoning. You don’t want your employer to learn about that event, fearing they could assert that you were intoxicated when the workplace accident happened. If your previous hospitalization is completely unrelated to your claim, other entities don’t need to know about it. Still, they may push to access that information.

When you partner with a workers’ compensation lawyer, they can ensure that the involved parties only have the necessary information to process your claim.

They Are Asking Me to Sign a Health Information Release. Should I?

You will likely have someone ask you to sign a health information disclosure form at some point during the claims process. This form authorizes the doctor’s office to disregard parts of HIPAA in the workers’ comp process.

Several entities will need your medical information to process your claim and provide the related benefits. However, be aware that you should not sign a blank release form. Also, do not sign a release that allows them access to your medical records from other doctors or otherwise unrelated to their treatment of your workplace injury. Only sign detailed authorization forms that include the care provider’s name and wording related to their limitations.

A Workers’ Compensation Attorney Can Help You Protect Your Rights

Role of HIPAA in Workers’ Comp Claims

Having a knowledgeable workers compensation lawyer Los Angeles on your side can make handling concerns like this more manageable. Your lawyer will answer your questions, protect your rights, and manage your claim from start to finish. If necessary, they can appeal a denial or even take action against an employer or insurer who crosses the line and tries to gain access to private health information.

Workers’ compensation lawyers do not charge upfront fees. Injured workers do not have to pay for them out of their pocket, making it possible to secure legal help regardless of their current financial circumstances. Workers’ compensation lawyers are paid from the compensation recovered for their clients.

Discuss Your Workplace Injury and Workers’ Comp Claim With Our Team 

At KJT Law Group, our team offers free case consultations for injured workers in California. We can help you understand your rights, available benefits, and options after you run into hiccups with your claim. Our Los Angeles personal injury lawyers handle these claims, negotiations, settlements, and court cases regularly. We understand California’s workers’ comp laws and how to navigate the claims process. Contact us now for your free case review. Call (818) 507-8525 to get started.

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