The HIPAA treatment, payment, and operations (TPO) exception allows healthcare organizations to use and share patient information for treatment, payment, and operations without patient authorization. It helps maintain privacy while facilitating efficient healthcare services, including sharing information among professionals, billing, quality assessments, and staff training.
The TPO exception explained
According to the HHS, "To avoid interfering with an individual’s access to quality health care or the efficient payment for such health care, the Privacy Rule permits a covered entity to use and disclose protected health information, with certain limits and protections, for treatment, payment, and health care operations activities."
The TPO exception, therefore, permits covered entities, such as healthcare providers, to use and share PHI without requiring patient authorization for specific purposes directly related to treatment, payment, and healthcare operations.
What is "Treatment" under the TPO exception?
The "Treatment" component of the TPO exception allows covered entities to use and disclose PHI for patient care purposes. That includes activities like:
- Diagnosing medical conditions
- Prescribing medication
- Coordinating care among healthcare providers
- Conducting diagnostic tests
- And sharing pertinent medical information.
For instance, when a primary care physician refers a patient to a specialist, they may share relevant medical records and test results to ensure the patient receives the best possible care. The TPO exception enables this sharing of PHI, as it directly contributes to the patient's treatment. However, sharing those records must still be done securely via HIPAA compliant email, for example.
Note: Patient consent or the absence of an objection typically guides the sharing of PHI for treatment purposes, ensuring that the patient's wishes are respected.
Related: What is the HIPAA treatment exception?
What is "Payment" under the TPO exception?
The "Payment" aspect of the TPO exception enables covered entities to use and disclose PHI for financial activities associated with healthcare services. This includes:
- Billing patients
- Processing insurance claims
- Verifying insurance coverage
- And coordinating benefits among different health plans.
Healthcare providers and insurance companies need access to patient information to accurately bill for services rendered and to facilitate the payment process. The TPO exception streamlines these payment-related activities, ensuring the financial aspects of healthcare run smoothly.
What are "Healthcare Operations" under the TPO exception?
The "Healthcare Operations" component of TPO encompasses a wide range of operational activities essential for the functioning of healthcare organizations. These activities include:
- Quality assessment and improvement
- Internal audits
- Staff training
- And planning for future operations.
For example, healthcare institutions regularly conduct quality assessments to ensure that their medical practices meet high standards of care. This requires analyzing patient data, which falls under the TPO exception. That helps enhance patient outcomes and improve overall healthcare quality.
Safeguarding patient information
While the TPO exception permits the use and disclosure of PHI for specific purposes, HIPAA places significant emphasis on safeguarding patient information. Covered entities must adhere to strict requirements to protect patient privacy and security. This includes implementing robust security measures to prevent unauthorized access to PHI and ensuring that only authorized individuals can access this information.
Patients' rights and Notice of Privacy Practices
Patients have rights under HIPAA concerning their health information. Covered entities are required to provide patients with a Notice of Privacy Practices (NPP) that explains how their PHI may be used and disclosed for TPO purposes. The notice also informs patients about their rights regarding their health information, including the right to access their records and request corrections.
Read more: What are patient rights under HIPAA?
FAQs
Can PHI be shared with family members under the TPO exception?
PHI can be shared with family members involved in a patient's care or payment for care if the patient consents or does not object.
Are business associates covered under the TPO exception?
Yes, business associates who perform functions on behalf of covered entities can use and disclose PHI under the TPO exception, provided they have a business associate agreement (BAA).
Does the TPO exception apply to mental health information?
Mental health information can be used and disclosed under the TPO exception, but additional state laws and privacy protections may apply.
Liyanda Tembani
