Medical Law, Ethics, and Compliance PDF

Medical Law, Ethics and Compliance Adhere to Professional Codes of Ethics As a licensed, registered, or certified medical professional there is a code of ethics to be upheld on a professional and personal level. Complying with the code of ethics can be accomplished with strong positive characterist...

Medical Law, Ethics and Compliance Adhere to Professional Codes of Ethics As a licensed, registered, or certified medical professional there is a code of ethics to be upheld on a professional and personal level. Complying with the code of ethics can be accomplished with strong positive characteristics such as integrity, respect, and consistency. Medical professionals use the code of ethics. Professionally Within their medical organization Individually Socially Networking A medical professional deemed less or non-compliant to perform or uphold the specific standards could result in legal action not limited to dismissal and/or credential removal. The National Health Career Association has a code of ethics that members must uphold. "As a certified professional through the NHA, I have a duty to: Use my best efforts for the betterment of society, the profession, and the members of the profession. Uphold the standards of professionalism and be honest in all professional interactions. Continue to learn, apply, and advance scientific and practical knowledge and skills, stay up to date on the latest research and its practical application. Participate in activities contributing to the improvement of personal health, our society, and the betterment of the allied health industry.  Continuously act in the best interests of the general public. Protect and respect the dignity and privacy of all patients." Ensuring compliance begins with the fundamental knowledge of the definitions and differences of the applicable regulatory agency information. Laws are an obligation imposed by the authority to protect patients, providers, and property, and non-compliance may lead to punishment. For example, the Food and Drug Administration (FDA) is a federal regulatory agency that protects people and animals from food, drugs, medical devices, and other products. Regulations are rules or orders issued by an executive authority or regulatory agency of a government with the force of law. An example of health care regulation is the Healthcare Quality Improvement Act (HCQIA), which gives immunity to medical providers who do peer reviews to investigate potential fraud or abuse. Guidelines are written recommendations of policy. For example, the official medical coding guidelines provide rules and conventions that support correct code assignment. Policies are written documents that specify responsibilities among boards, management, and medical staff. Health care organizations use health and safety policies to define how health care services are provided to their patients. Standards are criteria and practices established by authority as rules for measuring value, extent, or quality. Ethical standards are an expectation of health care organizations and medical professionals. Compliance with laws, regulations, guidelines, policies, and standards is enacted through the medical professional's efficient administration and competent performance. Many governing organizations establish, mandate, and/or provide measurable tools to establish, support, and monitor compliance. It is essential to know and understand the different governing organizations and their impact on ensuring medical services are provided in a legal, ethical, and competent manner. Responsibilities of Governing Organizations Governing Organizations Objective Occupational Safety and Health Enforces safety, a healthy workplace, and training. Administration (OSHA) The Joint Commission (TJC) Seeks to improve health care for the public, in collaboration with accreditation stakeholders, by evaluating health care organizations. National Patient Safety Goals (NPSG) Aims to improve patient safety. Centers for Medicare and Medicaid Ensures standards in federally funded medical programs are Serves (CMS) followed. Office of the Inspector General (OIG) Investigates all fraud and abuse cases suspected or reported for federally funded medical programs. Americans with Disabilities Act Ensures policies and practices that define disability, with the aim of Amendments Act (ADAAA) protecting people who have disabilities from discrimination. Basic Medical Law Medical law explains the rights and responsibilities of medical providers and patients. There are many components to the medical-legal relationship of patient care, and understanding concepts of medical law is the responsibility of everyone on the health care team. Medical laws protect patient and provider rights and set a precedence of expectations between the patient and the providers through various forms of contracts. Contracts are legally binding agreements, such as a managed care organization contract between a provider and a third-party payer. Medical laws are created to protect patients from harm and malpractice. Medical malpractice describes any treatment by a medical professional that does not follow general medical standards of care. Malpractice comes in many forms, such as patient abandonment or negligence. Patient abandonment is a form of malpractice that occurs when a provider stops treating a patient without a reasonable cause or reasonable notice. The reasonable notice includes sending written notice by certified mail with a return receipt. Patient abandonment can be harmful because it could lead to a lapse in the patient's medical care, which can include monitoring, medications, and/or medical procedures and can be detrimental to the patient’s health. Another form of medical malpractice is negligence. Negligence occurs when a patient does not receive adequate and appropriate care, which leads to suffering and harm. Although malpractice comes in many forms, medical laws set the standards for protecting patients. Americans with Disabilities Act Amendments Act Compliance Procedures There are many guidelines, laws, and regulations to uphold and enforce compliance in the health care setting. For example, the Americans with Disabilities Act Amendments Act (ADAAA) was passed in 2008 and protects individuals with disabilities. The ADAAA broadened the definition of what qualifies as a disability and removed many barriers to care that affected individuals with disabilities. Most notably, the ADAAA ensures that policies and practices to determine disability status are not discriminatory. The CMAA will encounter patients with various disabilities, and it’s important to understand that there are many barriers to health and wellness outcomes for the disabled population. Applying policies and practices that offer provisions or accommodations and effective forms of communication are integral to providing care to patients with disabilities. Stop Mandatory Reporting Laws, Triggers for Reporting, and Reporting Agencies Mandatory reporting laws protect vulnerable populations such as children, older adults, and those who have disabilities. These laws vary by state, and some states mandate reporting abuse (emotional, financial, physical, sexual, neglect) by an intimate partner. Health care providers are mandated reporters. Other mandated reporters usually include clergy, teachers, and law enforcement officers. Health care providers also report communicable diseases to the local county or state public health department. Centers for Medicare & Medicaid Services (CMS) The Centers for Medicare & Medicaid Services (CMS) established health care programs to improve the population's function and health. The program aims vary based on the type and intent. For example, some programs are intended to be payers of last resort, while others are designed to provide comprehensive coverage of health and wellness services. Some programs are jointly funded and managed at the state level. Government-funded programs include: Medicare Medicaid State Children’s Health Insurance Program (SCHIP) TRICARE and TRICARE for Life Veterans’ Health Administration (VHA)  Indian Health Service (IHS) CMS has identified Medicare fraud and abuse as a serious problem in the U.S. CMS defines Medicare fraud as submitting false medical claims for payment, receiving incentives for medical services or devices that are federally funded, or making inappropriate referrals. CMS defines Medicare abuse as any practice that may result in unnecessary costs to Medicare, such as misusing billing codes, excessive charging for services or medical equipment, and/or billing for unnecessary medical services. The Office of the Inspector General (OIG) cooperates with CMS to prevent unlawful operations in health care. The OIG is tasked with investigating all fraud and abuse cases suspected or reported for federally funded medical programs. Laws Specific to Medicare Fraud and Abuse Medicare Fraud and Abuse Examples Laws False Claims Act (FCA) Billing for medical services that were not provided. Anti-Kickback Statute (AKS) Medical providers financially benefitting from referrals. Physician Self-Referral Law (Stark Prohibits referrals to health care services that the provider (or family Law) members) has a financial interest in unless an exception applies. Social Security Act Payment and insurance for older retirees and individuals with disabilities. United States Criminal Code Protection with public behavior. Surprise Act Protection from unknown medical bills. The OIG maintains a hotline for reporting abuse, fraud, and waste. Reporting is also available through Medicare Advantage Contractors (MAC). The OIG also offers a self-disclosure protocol to report potential unintended fraud. An example is when an organization discovers a billing or coding practice is wrong and needs to address the issues caused by claims already submitted or paid. CMS and the OIG publish educational content to support a culture of compliance in health care organizations. Committing medical fraud or abuse has severe consequences, including steep monetary fines and federal criminal and civil penalties. CMAAs must understand fraud and abuse and how they relate to the revenue cycle. CMAAs can support the health care organization by knowing how to correct coding, billing, and documentation to prevent fraud and abuse. The Joint Commission’s National Patient Safety Goals The Joint Commission created a program to establish National Patient Safety Goals (NPSG). The National Patient Safety Goals are reevaluated annually to reflect the ever-changing medical landscape and patient needs. The program focuses on transforming health care by recognizing patient safety issues and gathering data to support the progress in correcting these issues. The CMAA plays a significant role in data collection for patient errors to contribute to the national patient safety goals for the following year. OSHA Guidelines The Occupational Safety and Health Administration (OSHA) aims to focus on workplace safety. OSHA has many guidelines designed to protect health care workers. An example of an OSHA guideline is Safety Data Sheets (SDS), which must be present in the workplace when hazardous materials are utilized. Another example of an OSHA guideline is the Needlestick Safety and Prevention Act, which protects health care workers from hazards associated with bloodborne pathogens. This act addresses universal precautions, personal protective equipment, and exposure plans for employees who experience a needlestick injury. Identification, first aid, accidental release, toxicology, hazard identification, handling and storage, firefighting, properties, composition, stability and reactivity, PPE, regulations, ecological information, disposal, transport, and other. The Needlestick Safety and Prevention Act aims to make the workplace safer by requiring procedures for the safe use of sharps and providing urgent care and treatment for those exposed to bloodborne pathogens. The CMAA may be responsible for: Ordering hazardous waste containers The provision and location of SDS Understanding protocols for needlestick injuries to rapidly access any needed information during a workplace injury Evacuation Plans and Emergency Procedures The CMAA is also responsible for patient safety by being aware of evacuation plans and emergency procedures. Emergencies and hazards often occur  without warning, so a thorough evacuation and emergency plan must be in place to ensure the safety of health care workers and their patients. Evacuation routes need to be clearly defined and posted. Emergency plans should account for environmental and human-made hazards, such as inclement weather and violent encounters. In an emergency, the CMAA will need to assist with the evacuation and instruction of patients. The Joint Commission Accrediting body that focuses on quality improvement and patient safety, certifying health care organizations and programs in the U.S. including hospitals and health care organizations that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory, and nursing care center services. National Patient Safety Goals (NPSG) Program that focuses on transforming health care by recognizing patient safety issues and gathering data to support the progress in correcting these issues. Medicare fraud Intentionally submitting false medical claims for payment, receiving incentives for medical services or devices that are federally funded, or making inappropriate referrals. Medicare abuse Any practice that may result in unnecessary costs to Medicare. Take Note Conducting internal audits is one way to identify fraud or abuse within the organization. medical law Laws that explain the rights and responsibilities of medical providers and patients. Contracts Legally binding agreements between parties. Malpractice Any treatment by a medical professional that does not follow the standards of care. patient abandonment Form of malpractice that occurs when a provider stops treating a patient without a reasonable cause and/or without reasonable notice. Negligence When a patient does not receive adequate and appropriate care, which leads to suffering and harm. Compliance Following mandated laws, policies, standards, and guidelines