FINAL Flashcards
The reasons physical therapists learn about law (9)
- Right to practice granted by state statutes = each state’s statutes differ.
- Conflicts btwn federal gov + states’ rights
- Legal oversight bc gov fund healthcare (fraud and abuse).
- Business relationships often contractual =breach of contract
- Reduces risk potential/actual malpractice claims
- Become better contract negotiator= independent practitioner
- Jurisprudence knowledge required for licensure
- Cannot claim ignorance of law as defense
- Professional ethics requires obeying laws
Who is the right to practice granted by ?
The reasons physical therapists learn about law
The right to practice is a right granted by a STATE’s statutes, and at present each state’s statutes DIFFER.
Do conflicts occur between the federal government and states’ rights?
(The reasons physical therapists learn about law)
Conflicts occur between the federal government and states’ rights.
Why can legal oversight occur?
The reasons physical therapists learn about law
Government funding of health care results in increased legal oversight (fraud and abuse).
What type of business relationships do we have?
The reasons physical therapists learn about law
Business relationships are often contractual (breach of contract).
What does learning about the PT law help with?
The reasons physical therapists learn about law
Reduces the risk associated with potential or actual malpractice claims
What will learning about the law help PTs negotiate?
The reasons physical therapists learn about law
Become a better contract negotiator (independent practitioner)
What kind of knowledge is required for licensure?
The reasons physical therapists learn about law
Jurisprudence knowledge is required for licensure
Can ignorance of the law be used as a defense?
The reasons physical therapists learn about law
Claiming ignorance of the law is not a defense
What does professional ethics say about obeying laws?
The reasons physical therapists learn about law
Professional ethics requires obeying laws
What does jurisprudence mean?
Jurisprudence means knowledge of law.
define “Act”
Act = legislation signed by the President/Governor
define:
“Law”
Law =
statute = regulation = formal written law
Define:
“Regulations”
Regulations =
set of rules, legal restrictions
Define:
“Administrative law”
Administrative law = deals with enforcement of statutes
Be able to define the following terms: act, law, administrative law, regulation
Act = legislation signed by the President/Governor
Law = statute = regulation = formal written law
Regulations = set of rules, legal restrictions
Administrative law = deals with enforcement of statutes
Administrative law-
CLAIMS brought against INDIVIDUAL / GROUP
by ADMINISTRATIVE AGENCIES (eg. Licensing board ), created by the government
to ADMINISTER and ENFORCE a particular set of statutes.
Civil law-
claims brought against INDIVIDUAL/ GROUP/STATE
- -> to RECOVER DAMAGES against a PERSON/PROPERTY
- -> or a BREACH IN CONTRACT has occurred
(Eg. When a wrong (tort) has been committed)
Criminal law-
when an EVENT is considered an act
against SOCIETY, FEDERAL or STATE GOVERNMENT
Review the three different types of law under the United States court system ‘
ADMINISTRATIVE LAW- claims brought against individuals or groups by administrative agencies (eg. Licensing board ), which were created by the government to administer and enforce a particular set of statutes.
CIVIL LAW- claims brought against individuals, groups, or the state to recover damages
Eg. When a wrong (tort) has been committed against a person or property or a breach in contract has occurred
CRIMINAL LAW- when an event is considered an act against society, federal or state government
claims brought against individuals or groups by administrative agencies (eg. Licensing board ), which were created by the government to administer and enforce a particular set of statutes.
ADMINISTRATIVE LAW
logistics behind enforcement of these things
claims brought against individuals, groups, or the state to recover damages
Eg. When a wrong (tort) has been committed against a person or property or a breach in contract has occurred
CIVIL LAW-
when an event is considered an act against society, federal or state government
CRIMINAL LAW
Administrative Law
what it does:
—Protection public by state level: issuing licenses to health care and other professionals.
— Health service providers must be licensed to provide reimbursable clinical services
= evidence state qualified individuals a privilege to practice
— No one guaranteed a license, qualified individuals (as defined by practice act), must apply for a license and show evidence that they have met the state’s qualifications
— Once received, a licensee must abide by the state’s practice act and corresponding regulations.
— A governing board has authority to issue, renew, restrict, or revoke licenses as well as censure licensees when a licensee fails to meet these responsibilities
State licensing boards:
—-Adopt rules and regulations necessary for administration of the practice act
—- Follow administrative rules and regulations
Each state reserves the right to pass laws for the protection of residents within the state
Licensure laws are enacted through each states legislative process to protect residents within the state for incompetent and unscrupulous health services and other practitioners
—- Follow administrative law procedures, which allow infraction investigations and decisions to be made by a hearing panel rather than a court
Who does issuing licenses to health care and other professionals protect?
Protection of the public at the state level includes such things as issuing licenses to health care and other professionals.
Be able to define malpractice, negligence, and fraud
Negligence/Negligent tort = omission (does not perform) or commission (does perform) an act that a reasonable, prudent person would or would not do under given circumstances
What does “Tort” mean?
2 types
Tort = an injurious act committed against a person or property or a contract breach
Two general types of torts:
Negligent torts
Intentional torts
What is Negligence/Negligent tort?
omission (does not perform) or commission (does perform) an act that a reasonable, prudent person would or would not do under given circumstances
What 4 things must plaintiff (the injured party) demonstrate for negligence?
- There was a duty OWED to the plaintiff by the defendant (the accused)
Defendants can include the referrer, manager, or employer, or all of them - There was a BREACH – the duty was not met either by failure to act or failure to meet the standard of care for the circumstance at the time
- The party who was owed a duty INCURRED DAMAGE directly (loss of wages) or indirectly (pain)
- CAUSATION – the breach of duty caused injury or there was a causal connection between the breach and the damages
proving negligence, what is a Breach ?
breach – the duty was not met either by failure to act or failure to meet the standard of care for the circumstance at the time
what would be causation in proving negligence?
CAUSATION – the breach of duty caused injury or there was a causal connection between the breach and the damages
What is “Malpractice”?
= professional negligence
When does “Malpractice” occur?
–
Occurs when the alleged wrongdoer is a
- ->Professional
- ->With the necessary or required action within the scope of practice
- ->Requires special knowledge and skills to practice
Duty, breach, damages, and causation are required for proof in a malpractice case;
expert testimony is required because the ordinary person is not capable of determining what the professional standard of care should be.
What 4 things needed for proof of causation?
- Duty
- breach
- damages
- causation
Intentional tort
INTENTIONALLY committed knowing that HARM LIKELY a result
(PT-relevant examples)
- -> ASSAULT – a threat to touch another without consent
- -> BATTERY – actual, intentional touching of another without his or her consent
- -> FALSE IMPRISONMENT – unnecessary confinement of a person, e.g., physical restraint
- -> FRAUD- Intentional misrepresentation in a manner than can harm
Fraud
= Knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program.
= Fraud- Intentional MISREPRESENTATION in a manner than can HARM
- Examples of fraud in health care may include:
1. Knowingly billing for services that were not furnished
2. Knowingly altering claim forms to receive a higher payment amount
3. Falsifying documentation
4. Using unlicensed individuals to provide services
What does every lawsuit begin with?
Every lawsuit begins with a triggering event
- -Misunderstanding
- -Dissatisfied client
- -Unusual sign or symptom
- -Accident or a clearly defined injury from substandard care
Lawsuits can last up to 7 years or longer
WHAT IS THE SEQUENCE OF THE LAWSUIT?
1) EVENT
2) PATIENT COMPLAINTS
3) SUMMONS AND COMPLAINT
4) PRETRIAL DISCOVERY
5) TRIAL
What you should do
document what is happening
call and update the doctor
notify clinic risk manager/owner
When is a lawsuit formally initiated?
A lawsuit is formally initiated when two separate legal documents are filed with the court by the patient or his/her attorney
–> Summons- names the defendant(s), the plaintiff , the jurisdiction of the lawsuit and when and where the named defendant should appear
–> Complaint- gives details about the case against the defendant and outlines the basis for the suit.
Both the summons and complaint must be given to the defendant and filed in a court in the jurisdiction where the alleged malpractice occurred
What is a Summons?
–> Summons- names the defendant(s), the plaintiff , the jurisdiction of the lawsuit and when and where the named defendant should appear
What is a Complaint?
–> Complaint- gives details about the case against the defendant and outlines the basis for the suit.
What 2 separate legal documents are filed with the court by the patient or his/her attorney when a lawsuit is formally initiated?
–> Summons- names the defendant(s), the plaintiff , the jurisdiction of the lawsuit and when and where the named defendant should appear
–> Complaint- gives details about the case against the defendant and outlines the basis for the suit.
Statute of limitation for being sued
In general Summons and Complaint documents are delivered (service of process) to the defendant by a sheriff or other law official
The deadline (statute of limitations) for filing the summons and complaint vary from state to state, but is generally 2 years from the date of the negligent action or omission and may be 3 years for the date of the intentional tort -->Minors have a extended statute of limitation
What does one do if they get a summons or complaint? (3)
What should they not do? (3)
Upon receipt of the summons and complaint the defendant should
- Notify his or her insurance carrier and employer
- Review all medical records
- Preserve all records
What should NOT be done
- Distribute original records without advice from legal counsel
- Make changes to the medical record
- Talk about the case with colleagues, family, or friends- avoid emotional interaction which could effect decisions and actions
***The plaintiff’s attorney can depose (take testimony) from anyone who knows about the case, therefore by talking about the case with may enable the plaintiff’s legal counsel to obtain unintended or misconstrued information or inconsistent statements
What is a Pretrial discovery?
At this stage both parties research relevant facts to be presented to the court
This includes
- -> Oral depositions
- -> Written depositions
- -> Requests for documentation, office calendars, correspondence, personal notes, etc.
The accused clinician(s) (PT, PTA’s) may be fact witnesses as well as the named defendant in a lawsuit
If called for a deposition its important to:
- ->Stay calm, alert and be well groomed
- ->Maintain your composure – the plaintiffs legal counsel is looking to catch the defendant off guard and elicit a response
- —->Avoid getting angry and honestly answer ONLY the questions being asked.
If called for a deposition what is it important to do?
–>Stay calm, alert and be well groomed
–>Maintain your composure – the plaintiffs legal counsel is looking to catch the defendant off guard and elicit a response
—–>Avoid getting angry and honestly answer ONLY the questions being asked.
what happens at the trial?
Begins with opening statements presented by the plaintiff’s and defendants attorneys
The statements outline the case and respective arguments
The trial is meant to be adversarial with each side trying to persuade the jury in its favor
Credibility of the parties and witnesses throughout the presentation of the evidence can result in crucial turning points for or against the parties
If the judgement is in favor of the plaintiff in a malpractice case, the defendant may receive several consequences
If the judgement is in favor of the plaintiff in a malpractice case, the defendant may receive several consequences
Financial consequences
- direct damages to the plaintiff for lost earnings, current or future medical expenses, indirect damages for pain, emotional distress, and loss of consortium, punitive damages
Employment consequences
- unusual carelessness, intentional actions, or gross negligence may result in disciplinary action or dismissal
Licensure consequences
- licensure boards may investigate and take disciplinary action including censure, suspension, or revocation
Settlement
–> Is considered an option until a case goes to trial
–> A settlement is not an admission of fault
–> There are two advantages of settlements
–It is less expensive than paying for attorneys, expert witnesses, and court costs throughout the lengthy process
–A settlement amount may be significantly less that what a jury might award
Fraud
definition
Knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program.
Examples of fraud in health care may include:
1. Knowingly billing for services that were not furnished
2. Knowingly altering claim forms to receive a higher payment
amount
3. Falsifying documentation
4. Using unlicensed individuals to provide services
Abuse
definition
Payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Sequence of a lawsuit: (5)
1) EVENT
2) PATIENT COMPLAINTS
3) SUMMONS AND COMPLAINT
4) PRETRIAL DISCOVERY
5) TRIAL
Ant kickback laws, False claims act, whistleblower laws
Anti-Kick Back Laws
Prohibits individuals/entities from knowingly and willfully offering, paying soliciting or receiving remuneration or induce referrals of items or services covered by federally funded programs. A violation of this law can result in fines up to $25,000 and imprisonment up to five years.
False Claims Act
Parties who knowingly present fraudulent claims for payment to the government can be fined as much as $10,000 per violation.
Whistleblower Laws
Whistleblower laws permit private individuals to initiate false claims actions on the government’s behalf. Whistleblowers may share a percentage of recovery.
Anti-Kick Back Laws
Prohibits individuals/entities from knowingly and willfully offering, paying soliciting or receiving remuneration or induce referrals of items or services covered by federally funded programs. A violation of this law can result in fines up to $25,000 and imprisonment up to five years.
False Claims Act
False Claims Act
Parties who knowingly present fraudulent claims for payment to the government can be fined as much as $10,000 per violation.
Whistleblower Laws
Whistleblower Laws
Whistleblower laws permit private individuals to initiate false claims actions on the government’s behalf. Whistleblowers may share a percentage of recovery.
Knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program.
Fraud
Payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
abuse
Prohibits individuals/entities from knowingly and willfully offering, paying soliciting or receiving remuneration or induce referrals of items or services covered by federally funded programs. A violation of this law can result in fines up to $25,000 and imprisonment up to five years.
Anti-Kick Back Laws
Parties who knowingly present fraudulent claims for payment to the government can be fined as much as $10,000 per violation.
False Claims Act
Whistleblower laws permit private individuals to initiate false claims actions on the government’s behalf. Whistleblowers may share a percentage of recovery.
Whistleblower Laws
Be able to define a clause
A contract clause will address an aspect of the contract between parties, detailing the agreement to ensure all parties understand what is expected of the other.
A contract clause will address an aspect of the contract between ____, detailing the ____ to ensure all parties understand ________.
A contract clause will address an aspect of the contract between parties, detailing the agreement to ensure all parties understand what is expected of the other.
What is a clause?
A contract clause will address an aspect of the contract between parties, detailing the agreement to ensure all parties understand what is expected of the other.
A contract clause will address ________ between parties,
detailing the agreement to ensure all parties understand what is expected of the
other.
A contract clause will address an aspect of the contract between parties,
detailing the agreement to ensure all parties understand what is expected of the
other.
Common clauses in a contract
1) Integrated agreement clause (contract is the final terms)
2) At-will employee (fire with/out reason, any time)
3) Restrictive covenants or non-compete clause (prohibit from working certain area)
4) Indemnification (hold-harmless) clause (other party agree assume liability RED FLAG))
**Professional liability insurance (considered a contract )
Characteristics of a Contract
1) Defined as a written or spoken agreement and is intended to be enforceable by law
2) Begins with negotiations between two or more parties
3) It is recommended that that the contract be
signed and to seek legal counsel when drafting contract
4) Typically covered under civil law
5) A contract is formed when the parties have mutually agreed on terms.
CONTRACTS INCLUDE
- Rental agreements
- Non-compete clauses- is a term used in contract law under which one party (usually an employee) agrees not to enter into or start a similar profession or trade in competition against another party (usually the employer)
- Sale of property
- Loan agreements
Contract is defined as a written or spoken _____ and is intended to be enforceable by ____
Defined as a written or spoken agreement and is intended to be enforceable by law
Contract begins with ______ between two or more parties
Begins with negotiations between two or more parties
It is recommended that that the contract be
____ and to seek ____ counsel when drafting contract
It is recommended that that the contract be
signed and to seek legal counsel when drafting contract
Under what law is a contract typically covered?
Typically covered under civil law
A contract is formed when the parties have _____________
A contract is formed when the parties have mutually agreed on terms.
Integrated agreement clause-
What is it?
states that the writing in the contract is the final representation of all agreed terms.
If the parties on the contract agreed on terms that are not included in the writing, courts generally will not interpret what is not written
At-will employee
What is it?
this term or clause gives the employer the right to dismiss an employee with or without reason at any time without advanced notice.
Important to know if the contract has such a clause
Restrictive covenants or non-compete clause
What is it?
a clause prohibiting professional employees from working within a certain geographical area for a specified time period
- -May or may not be enforceable based on if the time and area limitations are reasonable
- -If they are not, courts often enforce the clause to protect the employers business interest and will alter the limitations to reasonable time and area
Indemnification (hold-harmless) clause
What is it?
party offering a contract is attempting to have the other party agree to assume liability
Should be viewed as a red flag and definitely should be reviewed by legal counsel
- –The clause could be overly broad by asking the other party to assume unreasonable liability
- –Liability insurance will not cover incidents that are assumed under contract, because the insurance carrier is not a party to the contract
Professional liability insurance
What is it?
is considered a contract and should be viewed as such
**Important to review policy and to make sure that coverage is adequate even after carefully reading the policy
- –Profession liability policies may not cover general health and wellness, fitness related services, management or consulting roles
- –May not also cover services when used as an expert witness
What does the contract need to say in In consultant agreements?
—> The contract should clearly describe the services to be rendered
—> Ownership of any intellectual property that arises out of the project
—> Responsibilities of each party to the contract
E.g.. specifying who provides space and equipment
What clause
states that the writing in the contract is the final representation of all agreed terms
Integrated agreement clause-
What clause
gives the employer the right to dismiss an employee with or without reason at any time without advanced notice.
At-will employee
What clause
prohibits professional employees from working within a certain geographical area for a specified time period
Restrictive covenants or non-compete clause
What clause
party offering a contract is attempting to have the other party agree to assume liability
Indemnification (hold-harmless) clause
What is Independent Contractor Physical Therapist ?
A licensed PT/PTA who contracts to do work for another person according to his or her own processes and methods
The contractor is not subject to another’s control except for what is specified in a mutually binding agreement for a specific job.
An independent contractor contracts with an employer to do a particular piece of work. This working relationship is a flexible one that provides benefits to both the worker and the employer.
If you are contracted as a consulted, can you treat the patient?
It is important that the healthcare provider avoid any temptation to provide clinical treatment
If treatment is anticipated at any time, it should be stipulated in the contract.
What is Independent Contractor Physical Therapist ?
PT/PTA who contracts to do work for someone according to their processes and methods
PT can leave if doesnt like it (except for what is specified in a mutually binding agreement for a specific job)
Job is specific of what contracted for
Consultant PT
what you hire them for
Consultants paid to share expertise + knowledge to help businesses reach goals / solve problems.
Businesses hire them to supplement their staff and save the $ of hiring a full-time employee.
They view the situation from a fresh perspective.
B/c consultant isn’t part of the culture, co-worker scrutiny or morale, consultants can act as the catalyst for change.
Consultant PT
$ to share expertise + knowledge to reach goals / solve problems. View the situation from a fresh perspective. Can be bold-no consequences for them.
–> teach employees: new software, other skill to increases productivity/revenue
–>advice, recommendations and problem solving.
Before, during, start-up of a new business /re-energize a flailing business. When needs reorganization/ termination of individual employees or entire departments.
**A client will retain a consultant’s services until the goal or obligations of the particular endeavor have been met.
Do the roles of a contract or consultant therapist differ in a facility vs. private practice?
CONTRACT THERAPISR
1. May be treated as a per-diem (per day) employee paid hourly vs. salaried
- Required to meet daily productivity standards of salaried employees
- Typically are not entitled to same benefits as salaried employee (i.e. continuing education, mandated breaks, etc.)
- May or may not be viewed as integrated member of team
- May be difficult to maintain or encourage staff moral and interest
CONSULTANT THERAPISTT
1. Typically has extensive experience working with a particular patient population or populations
- Is hired on a per-diem or hourly basis to assist existing staff on a project or to improve clinical skills
- May be referred to as “master clinician” or “advance clinician”
- Usually viewed as a resource for evaluation and treatment ideas for complicated patient populations
Do the roles of a contract or consultant therapist differ in a facility vs. private practice?
CONTRACT THERAPIST
- per-diem (per day) employee paid hourly
- Must meet daily productivity standards
- Not entitled same benefits as salaried
- Not usually integrated member of team
- hard to get staff moral and interest
CONSULTANT THERAPIST
- extensive experience with a population
- hired hourly to assist staff w/ project / skills
- “master clinician” or “advance clinician”
- resource for eval and tx ideas for complicated patient populations
Independent Contractor (4)
–> A licensed physical therapist or physical therapist assistant who contracts
to do work for another person according to his or her own processes and
methods
–> The contractor is not subject to another’s control except for what is
specified in a mutually binding agreement for a specific job.
–> An independent contractor contracts with an employer to do a particular
piece of work. This working relationship is a flexible one that provides
benefits to both the worker and the employer.
–> Businesses often hire contractors to supplement their staff and save the
costs of hiring a full-time employee.
Consultant PT (9)
1) Consultants are paid to share their expertise and knowledge to help
businesses attain goals and solve problems.
2) Consultants are paid to share their expertise and knowledge to help
businesses attain goals and solve problems.
3) As a person new to the company or organization, consultants view the
situation from a fresh perspective.
4) Because a consultant isn’t beholden to any particular corporate culture,
co-worker scrutiny or morale, consultants can act as the catalyst for
change.
5) Consultants may sometimes be asked to teach a business’ employees
how to manipulate a new software program or some other skill that
increases productivity or generates more revenue.
6) They’re also expected to provide advice, make recommendations and
excel at problem solving.
7) Consultants are often used prior to, and during, the start-up of a new
business or to re-energize a flailing business.
8) Consultants are also brought in when a business needs reorganization,
including the termination of individual employees or entire departments.
9) A client will retain a consultant’s services until the goal or obligations of
the particular endeavor have been met.
Be familiar with the roles that external oversight provides for an organization (3)
Oversight by parties external to an organization can:
1) Prevent waste and fraud (intentional misrepresentation)
2) Protect civil liberties and individual rights
3) Accumulate information to ensure compliance with laws and evaluate performance
4 categories of oversight entities
1) Government agencies
2) Nongovernment organizations operating under government contracts
3) Private organizations acting under agreement with health service providers
4) Private organizations acting independently of the government or the health service provider
Government oversight occurs at the federal, state, and local level as mandated by laws.
What are government entities are responsible to? (2)
Develop specific regulations to ensure the enforcement of the law
Ensure compliance with the regulations either directly or in collaboration with other government entities
Who does government oversight look at? (7)
- Business and financial management practices
- Facility design, construction, and operation
- Organization structure
- Patient accounts management
- Personnel practices
- Service delivery, documentation, and evaluation
- Cooperation with the regulatory review process is mandatory.
*** Failure to participate and/or cooperate could result in cancellation of a provider’s participation agreement with government-funded health programs or loss of license to operate (state government).
Centers for Medicare and Medicaid Services (CMS)
What do they oversee? (5)
- Assures programs properly RUN by contractors + state agencies
- Establishes PAYMENT policies
- Does RESEARCH on methods of health care management, treatment, and financing
- Assesses QUALITY of health care facilities and services
- Enforces its REGULATIONS
Agency for Healthcare Research and Quality (AHRQ)
what it does (5)
HHS division supporting research designed to:
(department of health and services, CMS is under it)
- Improve health care QUALITY
- Reduce COST
- Improve patient SAFETY
- Reduce MEDICAL ERRORS
- Improve ACCESS to essential services
National Institutes of Health (NIH)
- Funds and oversees research projects
- Advance the nation’s capacity to protect and improve health
Efficiently expand knowledge base to enhance the nation’s economic well-being
Promote highest level of scientific integrity, public accountability, and social responsibility in science
Department of Health and Human Services (HHS):
is the principal federal agency for the enforcement of laws related to protecting the health and providing essential human services
There are 11 divisions of HHS
Medicare Payment Advisory Commission (MedPac)
MedPac is an indp federal body: advises U.S. Congress on issues affecting Medicare–>
- long term survival of Medicare
- health care needs met for Medicare beneficiaries.
Relevance to physical therapists includes:
- Durable medical equipment payment system
- outpatient therapy services payment system
YEARLY CAP for outpatient:
=The Middle Class Tax Relief and Job Creation Act of 2012
PT + SLP: $1940
OT: $1940
Multiple Procedure Payment Reduction (MPPR) if >1 billing unit: 1st billed normally, 2nd unit billed at a % less (i.e.. 50%)
Occupational Safety and Health Administration (OSHA)
4
This agency is responsible for assuring the safety and health of America’s workers by:
- Setting and enforcing standards
- Providing training, outreach, and education
- Establishing partnerships
- Encouraging continual improvement in workplace safety and health
Medicare Payment Advisory Commission (MedPac)
most important aspect in PT
Establish yearly cap for outpatient services =The Middle Class Tax Relief and Job Creation Act of 2012
PT + SLP = $1940
OT = $1940
is the principal federal agency for the enforcement of laws related to protecting the health and providing essential human services
There are 11 divisions of HHS
Department of Health and Human Services (HHS):
- Assures programs properly RUN by contractors + state agencies
- Establishes PAYMENT policies
- Does RESEARCH on methods of health care management, treatment, and financing
- Assesses QUALITY of health care facilities and services
- Enforces its REGULATIONS
Centers for Medicare and Medicaid Services (CMS)
HHS division supporting research designed to:
(department of health and services, CMS is under it)
- Improve health care QUALITY
- Reduce COST
- Improve patient SAFETY
- Reduce MEDICAL ERRORS
- Improve ACCESS to essential services
Agency for Healthcare Research and Quality (AHRQ)
- Funds and oversees research projects
- Advance the nation’s capacity to protect and improve health
Efficiently expand knowledge base to enhance the nation’s economic well-being
Promote highest level of scientific integrity, public accountability, and social responsibility in science
National Institutes of Health (NIH)
independent federal body: advises U.S. Congress on issues affecting Medicare–>
- long term survival of Medicare
- health care needs met for Medicare beneficiaries.
Medicare Payment Advisory Commission (MedPac)
Relevance to physical therapists includes:
- Durable medical equipment payment system
- outpatient therapy services payment system
Medicare Payment Advisory Commission (MedPac)
YEARLY CAP for outpatient:
=The Middle Class Tax Relief and Job Creation Act of 2012
PT + SLP: $1940
OT: $1940
Medicare Payment Advisory Commission (MedPac)
Multiple Procedure Payment Reduction (MPPR) if >1 billing unit: 1st billed normally, 2nd unit billed at a % less (i.e.. 50%)
Medicare Payment Advisory Commission (MedPac)
This agency is responsible for assuring the safety and health of America’s workers by:
- Setting and enforcing standards
- Providing training, outreach, and education
- Establishing partnerships
- Encouraging continual improvement in workplace safety and health
Occupational Safety and Health Administration (OSHA)
Be able to define accreditation and the characteristics of the process
Rigorous and comprehensive evaluation process to assess how well a health care organization manages all parts of its care delivery system
Accreditation is based on an external group’s consensus quality standards
Example accreditation groups:
- -CARF
- -Joint Commission
- -National Commission on Quality Assurance (NCQA)
What is accreditation based on? (2)
Accreditation is based on an external group’s consensus quality standards
[Rigorous and comprehensive evaluation process to assess how well a health care organization manages all parts of its care delivery system]
Example accreditation groups:
–CARF, Joint Commission , National Commission on Quality Assurance (NCQA)
Concept of “Continuous Readiness”
Oversight often takes the form of onsite surveys, documentation, and financial audits.
Federal, state, and local government agencies or their representatives perform regulatory compliance reviews.
Surveys and audits may be a condition of continued licensure, operation, and/or reimbursement as an approved health care provider.
Private Watchdog Groups and Performance Ranking Services
Private watchdog groups commonly act independently of the government or health service providers
Examples:
Enloe Watch
HealthGrades
Example Professional Organizations That Set Standards
APTA
Concept of “Continuous Readiness”
Oversight often takes the form of onsite surveys, documentation, and financial audits.
–> Federal, state, and local government agencies or their representatives perform regulatory compliance reviews.
–> Surveys and audits may be a condition of continued licensure, operation, and/or reimbursement as an approved health care provider.
Successful reviews lie in the continuous management efforts to recognize and meet oversight requirements.
Satisfactory ratings on survey and audit information may be a condition of reimbursement or continued licensure to operate.
Assistance in meeting oversight requirements can be obtained from various professional organizations, oversight organizations, and professional consulting practices.
Be able to define accounting
Accounting is a process of identifying, recording, summarizing, and reporting in monetary terms, information about an organization during a specific period of time.
*** There are rules/conventions for systematically keeping records of financial activity
**Reporting requirements established by the Financial Accounting Standards Board (FASB) are called the Generally Accepted Accounting Principles (GAAP)
Accounting is a process of _____, ____, ____, and ____ in ___ terms, information about an organization during a specific period of time.
Accounting is a process of identifying, recording, summarizing, and reporting in monetary terms, information about an organization during a specific period of time.
Accounting is a process of identifying, recording, summarizing, and reporting in ______, information about an organization during a ________.
Accounting is a process of identifying, recording, summarizing, and reporting in monetary terms, information about an organization during a specific period of time.
What did the Financial Accounting Standards Board (FASB) do?
Created the Generally Accepted Accounting Principles (GAAP) which are rules/conventions for systematically keeping records of financial activity
Accounting is a process of identifying, recording, summarizing, and reporting in monetary terms, information about an organization during a specific period of time.
Created the Generally Accepted Accounting Principles (GAAP)
Financial Accounting Standards Board (FASB) created the Generally Accepted Accounting Principles (GAAP) which are rules/conventions for systematically keeping records of financial activity
These principles include:
- IDENTIFICATION OF THE ENTITY
- ->The business unit
- ->The person or business the financial information is being prepared for - MATCHING PRINCIPLE: Business must record the expenses that are associated with the revenues generated for a given period
- -> Matching is the only way an organization can determine the extent of how a specific service and/or product is contributing to the organization’s financial performance - IDENTIFICATION OF THE COST OF ANY QUANTIFIABLE RESOURCE:
- ->This is what the organization paid for that resource (historical or acquisition cost)
- ->Original cost may significantly underestimate the current value of a resource (replacement cost or market value) - AVAILABILITY OF OBJECT EVIDENCE:
The information in the financial reports is based on objective and verifiable evidence like receipts - ACCEPTANCE OF MATERIALITY:
Recognition that financial reports may have small or insignificant errors but not so great as to materially change a reviewer’s decision about the organization’s financial position - TRUST IN FULL DISCLOSURE:
In reference to the financial position and results of operations of a business in accordance with GAAP - APPLICATION OF CONSISTENCY:
Consistency in the accounting methods used in the business from year to year
Essential for comparisons
IDENTIFICATION OF THE ENTITY
Created the Generally Accepted Accounting Principles (GAAP)
- ->The business unit
- ->The person or business the financial information is being prepared for
*WHAT IS YOUR PURPOSE
MATCHING PRINCIPLE:
Created the Generally Accepted Accounting Principles (GAAP)
Business must record the EXPENSES that are associated with the revenues generated for a given period
–> Matching is the only way an organization can determine the extent of how a SPECIFIC SERVICE +/OR PRODUCTS is contributing to the organization’s financial performance
==> SHOWS IF IT IS VALUABLE
IDENTIFICATION OF THE COST OF ANY QUANTIFIABLE RESOURCE:
Created the Generally Accepted Accounting Principles (GAAP)
–>This is what the organization paid for that resource (historical or acquisition cost)
–>Original cost may significantly underestimate the current value of a resource (replacement cost or market value)
RECOGNIZE COST WILL CHANGE
AVAILABILITY OF OBJECT EVIDENCE:
Created the Generally Accepted Accounting Principles (GAAP)
The information in the financial reports is based on objective and verifiable evidence like receipts
HAVE INVOICES ON HAND
ACCEPTANCE OF MATERIALITY:
Created the Generally Accepted Accounting Principles (GAAP)
Recognition that financial reports may have small or insignificant errors but not so great as to materially change a reviewer’s decision about the organization’s financial position
ERROR IS OK AS LONG AS NOT A SIGNIFICANT EFFECT ON YOUR BOTTOM LINE
TRUST IN FULL DISCLOSURE:
Created the Generally Accepted Accounting Principles (GAAP)
In reference to the financial position and results of operations of a business in accordance with GAAP
INFO YOU ARE GIVING SHOULD BE VALID
APPLICATION OF CONSISTENCY:
Created the Generally Accepted Accounting Principles (GAAP)
Consistency in the accounting methods used in the business from year to year
Essential for comparisons
IF I COMPARE # TODAY SHOULD BE ABLE TO BE COMPARED TO NUMBERS IN FUTURE–SHOWS GROWTH/LOSS BC CONSISTENT ACCOUNTING METHOD FROM YEAR TO YEAR
Be able to define:
chart of accounts, ledger, assets, liabilities, expense, revenues, profit, loss, budget
ACCOUNT = simply a listing of all of an organization’s accounts by title and corresponding numerical code to classify and differentiate between accounts.
CHART OF ACCOUNTS = is the foundation for accounting information systems within an organization
–> Serves as the nucleus for the development of standard financial statements
LEDGER: A book of accounts.
Double entry = when a financial event (a transaction) occurs, it is recorded (posted) in a ledger in two places:
ASSETS: Assets are economic resources that are owned by a business and are expected to benefit future operations, such as:
- Inventories
- Accounts receivables
- Capital assets
- Cash
- Investments
LIABILITIES: debts: Total liabilities make up the amount of the organization’s assets owned by its creditors, e.g.,
- -> Accounts payable (credit purchase of plinth)
- -> Accrued expenses (salaries payable)
- -> Notes payable (borrowing $50,000 from bank)
EXPENSE: money spent to produce or purchase a service or product that is sold
REVENUE: is gross income
Gross = before anything is taken out or paid
When expenses > revenues, the difference is classified as a loss.
When revenues > expenses, the excess is classified as a profit.
BUDGET: budget is a financial statement that estimates income and expenditures for a specified future time period. There are several types of budgets: Operating budget (1 year) Strategic budget (3-5 years) Cash budget
