Health Law Flashcards
Medical Malpractice is for the most part (blank) Law
State
With Federal Money comes what kind of jurisdiction?
Federal
When did the Federal Government become a major payer of health care?
The 1960s
Physicians are not employees of hospitals in which states?
Texas, California, Colorado, Ohio, Iowa.
You cannot be insured for what kind of cases?
Criminal
Civil cases are for what?
Suits brought to enforce, refdress or protect private rights
HIPAA
Health Insurance Portability and Accountability Act of 1996
Where did the HITECH Act come from?
American Recovery and Reinvestment Act of 2009
Omnibus rule adds what to HIPAA?
THe language/ manner that HIPAA regulations is posted to
What does HIPAA require?
Privacy Officer, Policies & Procedures, Notice of Privacy Practices Posted, Releasing only what is minimally necessary, and Business associate agreements if not an employee, not already covered by HIPAA, Can not do their job without access to PHI.
When does HIPAA come into play?
WHen patient information leaves the office.
WHo is a business associate in terms of HIPAA and when is business associate agreement needed?
Cannot do their job without access to PHI, Not an employee, and not already covered by HIPAA (transcription
You may release PHI to another provider for what?
Treatment, Payment, Operations. All other disclosures require patient authoirzation.
Mental Health Record is defined as?
Any recorded that is created by a pychiatrist or pyschologist.
HIPAA is a floor not a ceiling?
Some states like California go beyond federal. TX just meet the minimum of federal.
What wins, patient safety or privacy?
Patient safety
What are the penalties for HIPAA
100$ penalty per incident, 25,000$ for identical violations per year. this is a civil viloation.
Crimnal penalties of HIPAA do exist. What is an example and what are the penalties?
ARRA increased/added penalties to HIPAA in 2009. Selling patient information is criminal. Up to 50K$ and 1 year in prison. 250K and 10 years.
What is the ARRA?
American Recovery and REinvestment Act
If you have a breach, you need to inform patient within how many days?
60 days.
If there is how many patients to be required to notify the secretary of human services?
500 patients they will be added to a list on the Human services
If you can enrycpt (high grade) how will mistakes in HIPAA be addressed?
Null
Hospitals are starting to be held liable for independent contractor physicians…true or false
True. Regardless of employee or not an employee…the credentialling process is to protect the hospital.
Credentialling includes highly confidential…why? WHich is more confidential…Re-credentialling or initial condentialling?
Health info, criminal back ground check, national practitioner data bank, Re credentialling.
Waiver in the credentialing process does what?
If hospital doesn’t have a waiver, you give them name, rank and serial number. Waiver releases you of liability as a reference.
Credential process is ulimately the decision of the?
Governing authoirty or the board of directors.
Patents, trade marks, and copy rights, writtings, inventions are protected how?
A well written contract.
Peer review is how confidential?
HIghly. Anti-trust violation. Strict adherence of the HCQIA (Healthcare quailty improvement act) will help with these allegations. Peer review must be protected.
What is the purpose of a corporate compliance plan?
High regard for privacy, confidentiallity….sets the rules of the hospital. Reduces the likelihood of violations. We have to meet 7 minimum objectives. .
Fraud is what?
INTENTIONAL deception. You are getting money you know you did not earn.
What is abuse?
Mistakes. Incidents or practices of providers that are inconsistent with accepted sound medical practes directly or indeirectly resulting in unnecessary costs to the government. Can be honest mistakes.
HOw do providers get caught with fraud?
Statisical outlyers = high number of claims per one procedure…unusual volume, compares with other local providers. Audits are random
What is a qui tam plantif?
a whistle blower
As of Jan 2007, hospitals/providers must inform their employees about what law if they receive over 5 million a year in federal funds
Qui Tam. THere is a small incentive 1000$ if you whistle blow.
Fraud and abuse…what are the possible fines and penalties?
Criminal always requires intent….if you are happily ignorant or dumb on purpose. Not insured.
Civil…this is abuse. AN honest mistake. $11,000 for each inappropriate claim submitted (up to three times amount of false claim). No jail time.
Exclusion: period of exlusion…you can’t take one cent medicare, tricare, medicaid. One year of exculsion is going to kill you…it is the medicare death penalty. If you obstruct an investigation + one year exclusion. Fraud = Mandatory is 5 years. 2 or more occasions = Permanant is 10 years. If we particpate with an excluded provider, we owe the fed 10K. We can see who is excluded by DHHS data base.
If you notice abuse with billing, what should you do?
give funds back.
Kickback?
SOmething of value is given for a referral. THere must be an exchange for our benefit.
If it is too good to be true….
it is probably not legal. You do not want happy doctors :)
What are some high risk kick back scenarios?
Hospitla to phsyican referrals, phsyican to hospital referrals, joint ventures, inappropriate incentives from pharm or DME companies, Physician recruitment and retainment.
What is fair market value?
No one is excited.
What is the pentalty of a kick back?
It is a felony to offer or accept a kickback. NOt more than 5 year in prison or 25K fine, Exlusion. Civil monetary penalties up to 50K. There has to be intent.
Why Stark?
Meant to prevent financial relationships that result to over utilization of referrals.
Law of Exception?
There has to be an exception….at least one to be released from complying. (Stark Law is good example).
What is the difference between Stark and Kickback laws?
Stark is Civil (no intent needed) and Kickback is Criminal (intent needed)
and (applies to all).
Stark penalties are?
Potential 15K, exlusion, denial of payment.
Anti Trust?
Protect the public’s economic interest. Protect the consumer. This is a scary law, when we do peer review or credentially.
Anti Trust laws are meant to do what?
Protect the public
EMTALA?
Emergency Medical Teratment and Active Labor Act. Provider Stabilizing care and do not transfer unstable patients. YOu need to accept transfers if it is medically beneficial.
EMTALA purpose:
Provided mandated medical screening examination for all persons presenting for a non-schedule visit. Main taon call system and provide stabalizing care.
EMTALA?
Complaint based exams not sufficient….must rule out emergency med conditions and no calls for pre-authorization until exam (MSE) is complete(
Can non-physicians assist with EMTALA compliance?
Yes, but it requires board approval, detailed descritpion on auhtorit to order tests and procedures and interpret results. Parameters when MD must be contacted.
What is considered “On-Campus” mean in regards of EMTALA?
250 yards
What other departments coudl fall under EMTALA?
Labor and delivery and pyschatirc clinic.
Even if a patient doesn’t request ER care, but it apears they need evaluation and or treamtemnt, what do we do?
EMTALA applies if a prudent layperson would believe that the person needed evaluaiton and or treatment.
Penalties for EMTALA are what?
HOspital Civil moeny 50K per violation. If hospital has fewer than 100 beds, 25K per violtion. and Revocation of provider agreement.
WHo controls patient’s experience when EMTALA?
Healthcare professional who saw the patient first.
WHo is the largest purchaser of healthcare?
The Government
What is another name for whistle-blower lawsuits?
Qui Tam Lawsuits
What is upcoding?
Assigning a higher payment than the procedure or diagnosis warrants
What is misrepresenting the time, location, frequency duration, or porvider of services?
Fraud
WHat is unbundling?
The practice of billing as seaparte items the services that are actually performed as a battery of services such as laboratory tests
What is the “three day rule” for outpatient diagnostic procedures?
Any outpatient diagnostic procedures performed on any of the three days before hopsitalziation are deemed to be part of the Medicare diagnosis related group paytment and are not to be billed separately
What are kickbacks?
Induce referrals or the purchase of goods or services
What is billing for services that were “incident to” a physician’s services but in fact were not provided under the physician’s direct supervision?
Fraud
What is self-referral?
The practice of physicians referring patints for services to entitites in which they have a financial interest.
WHat is filing claims for services that were not rendered or not necessary?
Fraud or abuse.
What is the False Claims Act (FCA)?
Federal statute to address fraud. Violations range from 5K to 10K per claim plus three times the amount of damages susatined by the ogvernment
What is scienter?
Knowledge by defendant that her acts were ilegal or statements were lies.
How much money can a whistle blower make on fraud charges?
15-25%
WHen did anti-kcikback law come into effect?
1 Jan 1997
Intra referrals are violoations of Stark laws?
Nope
Can you waive coinsurance or deductables?
Yes, but only under certain cirmstances. HIPAA difined renmeration as a way of trying to gain market share by rewarding the patient in an unethical manner.
Waiving co insurance or deductables could potentially violtate which statute?
Antikickback statue as an inducement for referrals.
EPRA
Ethics in Patient Referral Act. enacted in 1989.
Where does intent differe in antikcikback law and stark laws?
Antikcikback law requires proof that the defendant acted knowlingly and willfully, making a prohited referral is a per se violation of Stark and no proff of intent is required. YOu do not need to be aware of stark laws or act in good faith…not a defense.
Who do Stark Laws apply to?
Only physicians. Anti-kick back applies to everyone.
Stark laws do not apply in what situations?
If the physician is referring to the same group practice or if the referral is within a prepaid health plan (health maintenance organizations).
COBRA?
Consolidated Omnibus Budget Reconcilation Act
COBRA is an amendment of what law?
Employee Retirment Income Security Act of 1974
What does COBRA due?
Gives employees and their families the right to choose to continue to receive health benefits provided by the employer’s group health plan for a limited period of time in such circumstances as voluntary or involuntary job loss, reduction in hours worked, transition between jobs, death, divorce, and other life events.
Consumer Credit Protection Act (title III)?
Prohits an employer from discharing an employee because earnings are subject to garnishment and limits the amount of wages that can be withheld for garinshment in a single week to pay a debt or court order.
Drug Free WOrkplace act of 1988?
All organizations that recieve federal money of $25K or more must certify that they are providing a drug-free workplace.
Executive Order 11246/11375?
bars discrimination based on race, color, religion and national origin in federal employment.
FMLA
Family Medical leave act. 12 weeks of unpaid leave for medical emergencies, child birth and serious health conditions.
What is employement at wil prinicple?
assumes both employee and employer have the right to sever the work relationship at any time without notice, for any reason.
Civil rights act damages can be how much?
50K to 300K
ADEA?
Age Discriminiation in Empoloyment Acet of 1967 forbids discrimination against men and women aged 40 years and older. You can have a preference for older people without legal reprecussions.
BFOQ
Bonafide Occupational Qualification. protected class characteristic. Requirement a woman to work as an attendant in a women’s restroom.
WHat is respondeat superior?
holds that the employer is liable for the conduct of its employees because the emplyer enables the employee and is thus responsible.
What is the major statute for sexual harassment?
Civil Rights Act, Title VII
