Ethics Review: Fraud, Abuse, Waste, RIPS Model Flashcards
Formal code of ethics
- Defines the professional obligation
- States publicly: promotes public good and minimizes harem
- Allows professionals to negotiate organizational and societal arrangements
- Establishes ethical ideal for practice
- Provide core values and ethical principles that lay the foundation for professional practice, provides standard of behavior
- Educate the general public and stakeholders about the principles and standards expected of professionals
- Assist professionals in recognizing and resolving ethical dilemmas
What is fraud
An intentional deception or intentional misrepresentation that a person makes to gain a benefit for which that person is not entitled
What is abuse
Payment for items or services when there is no legal entitlement to that payment, and the healthcare provider has not knowingly and/or intentionally misrepresented facts to obtain payment
What is waste
Over utilization of services or other practices that directly or indirectly result in unless are costs to the healthcare system
What is the false claims act
Imposes liability on any person who submits a claim to the federal government that he/she knows or should know is false
- intent is not required because “knowing” also includes deliberate ignorance or reckless disregard for the truth
- there is a criminal false claims action that can result in a criminal penalty
What is whistleblower provision
Allows a private individual to submit to file lawsuit on behalf of US for violation of the act
Person is allowed to share in a percentage of the recovered proceeds
Also provides protection for whistleblowers who are discharged, demoted, threatened, of discriminated on behalf of this action if it was in good faith
What is anti-kickback statute
Kickbacks can distort medical decision-making, cause over-utilization, increase costs, and result in unfair competition
Anti-kickback statute forbids receiving a payment for referring a patient for services, equipment, any item that would be covered by medicate
Stark law
Physican self-referral law
- prohibits physician referrals of designated health services for medicare and Medicaid if the physician or immediate family member has a financial relationship with that entity
Includes ownership, investment interest, and compensation
No need to prove specific intent
Exclusion statute
Department of health and human services is required to exclude health care providers and suppliers who have been convicted of the following crimes from participation in federal health care programs:
1. Medicare fraud
2. Patient abuse or neglect
3. Felony convictions for health care related fraud, theft, or misconduct
4. Felony convictions for unlawfully manufacture, distribution, prescription, or dispensing of controlled substances
Civil monetary penalties law
Office of the inspector general may seek civil monetary penalties for a variety of criminal violations
- presenting a claim that the person knows or should know is for a service or item that was not provided
- presenting a claim that the person knows or should know is for an item or service that is not eligible for payment
- violating the anti-kickback statute
Coding and billing
When you submit a claim for services you are attempting that you have earned the payment and are in compliance with all of the billing requirements
Documentation
- Documentation is a professional responsibility and a legal requirement
- Medicare and third party payers have established minimal standards for documentation
- Many state practice acts also define what is expected of licensees
- Falsified documentation is a violation of fraud and abuse laws.
Common PT documentation errors
- Missing or incomplete plan of care/treatment plan
- Missing physician signatures and dates
- Missing total time for procedures and modalities
- Missing certification and recertification of plan of care
Gifts to physicians?
PTs must be cautious about gifts to docs or referral sources, and cannot be with the intent to encourage referrals.
Gifts must be primarily educational to be permissible
PT relationships with patients
- Federal laws prohibit offering gifts to beneficiaries because it can be seen as inducing patients to come to one practice
- Providing free services or waiving patient co-pays or deductible is also generally prohibited by federal law
- Medicare requires providers, including physical therapists, submit claims for covered services
- Medicare does not pay for wellness or prevention programs and therefore the PT can collect out of pocket payment for those services.
Def of ethics
Systematic rational reflection on issues of right or wrong or regarding what we ought to do
Def of values
Subjective standards for what is right or wrong, good or bad
def of laws
Includes rules, administrative codes, and regulations created by administrative agencies to interpret or implement legislation
Ethics development
Personal ethics can be influenced by childhood beliefs and life experiences, social norms, authority figures, religion, and traditional and contemporary culture and beliefs
Professions are shaped by their underlying principles, values, and beliefs
Society expects health professions to provide competent services in an ethical manner
4 basic concepts of ethics
- Autonomy — right to self determination
- Beneficence — promote good
- Non-Maleficence — preventing harm
- Justice — fairness
What does informed consent mean
To respect the right of a patient to make a decision about his/her health care, based on an understanding of the necessary information. This includes the right to agree or refuse a course of action
— Competence
— Information
— Voluntariness
What is informed consent
Legally adequate disclosure includes information concerning
- diagnosis
- nature and purpose of treatment
- risk of treatment or non treatment
- treatment alternatives
What is fidelity
Faithfulness to the patient’s interests, considered a primary obligation for health care providers
Purtillo’s five reasonable expectations for healthcare
- Basic respect
- Adherence to professional statements/standards
- Competence
- Following policies/statements of org
- Honoring agreements reached between provider and patient
Conflict of interest
Exists when competing interests or obligations that prevent fulfillment of primary professional obligations
Professionals wherever possible should avoid conflicts of interests and the perception of Conflicts of interest
RIPS model
Allows for a step by step analysis which is most appropriate for situations in which there are 2 competing ethical principles at stake
4 steps
1. Recognize and define
2. Reflect
3. Decide
4. Implement, reassess, and evaluate
What does R stand for in RIPS model
REALM
1. Individual — primary concern is the good of the patient/client. Focus is rights, duties, relationships, and behaviors between individuals
2. Organization — primary concern is the good of the organization. Focus is on structures/systems that facilitate the organizational goals
3. Societal — primary concern at this level is the common good. Focus is on legal, financial, constitutional, and cultural goals.
What does IP stand for in RIPS model
INDIVIDUAL PROCESS
1. Moral sensitivity — involves recognizing, interpreting, and framing ethical situations
2. Moral judgement — requires deciding on right vs. Wrong actions. This process involves generation options, selecting, and applying ethical principles
3. Moral motivation — places a priority on ethical values over other values such as self-interests, status, or financial gain
4. Moral courage — involves implementing the chosen ethical action, including development of a plan and perseverance in the face of barriers and adversity
What does S stand for in RIPS model
SITUATION
1. Issue — important values are present
2. Dilemma — 2 courses of action may be taken, both of which fulfill a duty, but is not possible to fulfill both obligations
3. Distress — you know the right course of action but are not authorized or empowered to perform it
4. Temptation — involves a choice between right and wrong in which you may benefit from the wrong choice
5. Silence — ethical values are challenged but no one is speaking about this challenge to values
What is Kidder’s approaches to solving dilemmas
- Rule based — follow the rules, duties, obligations, or ethical principles already in place
- Ends based — determine the consequences or outcomes of alternative actions adn the good or harm that will result for all of the stakeholders
- Care based — resolve dilemmas according to relationships and concern for others
Healthcare ethics committee
Healthcare ethics — times when patients, families, and healthcare professionals confront difficult issues regarding medical treatments that can involve personal preferences, moral principles, religious beliefs, or professional guidelines
Ethics committees are available to assist in identifying, understanding, and if possible resolve these difficult situations
Consequences of ethics
Association membership can be reprimanded, suspended, revoked
State licensure level can be probation, loss of licenses, loss of employment/future employment implications
Potential legal actions
What are 3 behavior categories
- Human error — when a mistake was made that was not intended
- At risk behavior — when a person chooses to do something not knowing or not ascertaining the risk
- Reckless behavior — substantial non justified and or conscious disregard for safety or legal/ethical principles
