law and ethics lecture + important reading Flashcards
1
Q
What is the difference between morality and the law?
A
Morality refers to principles and rules concerning how a person ought and ought not to behave, which can come from religion or personal/cultural secular origins. The law, on the other hand, comes from officials of the government voting or decreeing them and has the enforcement power of the state behind it. Violating moral rules affords one shame, while violating legal rules affords one fines or jail.
2
Q
What is legal positivism?
A
Legal positivism is the belief that the laws of a country are what the government says they are. They are based on reasoning and deciding but do not need any further validation than that of being sanctioned by a legitimate government.
3
Q
Are all laws tied to ethics?
A
No, laws are not necessarily closely tied to ethics. There might be unjust, unfair, or discriminatory laws.
4
Q
How do hospitals distinguish between ethical and legal issues?
A
Hospitals and related institutions make an implicit distinction between morality and the law by distinguishing between ethical and legal functions and personnel. There may be hospital attorneys or a risk management department that handles legal and some ethical issues, while clinical ethical questions are referred to groups of physicians, clergy, and sometimes an ethics committee consisting of participants from various parts of the organization.
5
Q
What is clinical medical ethics?
A
Clinical medical ethics is a discipline or methodology for considering the ethical implications of medical technologies, policies, and treatments, with special attention to determining what ought to be done (or not done) in the delivery of health care. It is related to the identification, analysis, and resolution of moral problems that arise in the provision of healthcare to individual patients.
6
Q
What do practitioners need to know regarding the intersection of ethics and the law?
A
Practitioners need to have knowledge of their legal responsibilities, the limitations of professional practice, and the implications of their personal actions. They also need to understand the “the law of ethics” behind prominent ethical debates, protect healthcare professionals, patients, co-workers and healthcare facilities, and organizations/systems through risk management, and observe ethical behavior to ensure and promote quality patient care, positive work relationships, and effective, efficient workplaces.
7
Q
What is medical law?
A
Medical law is the body of laws concerning the rights and responsibilities of medical professionals and their patients.
8
Q
What are the main areas of focus for medical law?
A
The main areas of focus for medical law include confidentiality, disclosures, standard of care, patient-provider relationship, professional conduct, management and disclosure of medical errors, negligence, and other torts related to medical treatment (especially medical malpractice) and criminal law.
9
Q
What is the regulatory system in medical law?
A
The regulatory system is the law that clinicians will interact with most often during the course of their practice throughout their careers. It refers to regulations concerning medical practice rather than malpractice.
10
Q
What should clinicians be well-versed at in medical law?
A
Clinicians must be well-versed at navigating the complex legal, regulatory/enforcement, and business realities of modern medical practice. For example, they need to understand complex reimbursement schemes and provider contracts, Medicaid and Medicare statutes, insurance company administrative authorizations for proposed care, basic principles of malpractice law, management of a clinical practice, healthcare finance, basic risk management principles, as well as managing patients from special or vulnerable populations.
11
Q
What does regulation encompass in medical jurisprudence?
A
Regulation cuts the broadest swath in medical jurisprudence, encompassing all areas where the government interacts with and regulates the practice of medicine.
12
Q
What are some examples of regulatory agencies in medical law?
A
Regulatory agencies from the FDA, HHS, CMS to the Department of Justice exercise great power over the practice of medicine in the United States. This also includes state licensure boards, certification agencies, and credential verification authorities.
13
Q
What types of law exist in medical law?
A
The types of law in medical law include common law, statutory law, and tort law. Common law is the traditional civil law of an area or region based on a judge’s rulings of cases. Statutory law is enacted by legislatures and enforced by courts; statutes command or prohibit something or declare policy. Tort law is a wrongful act causing harm that requires restitution and can be intentional or unintentional.
14
Q
How have some states expanded Medicaid under the ACA?
A
Some states, like Missouri and Oklahoma, have expanded Medicaid under the ACA through direct democracy by voting to endorse state constitutional amendments rather than legislation or executive decisions.
15
Q
What is Medicaid expansion and how has it impacted health outcomes?
A
Medicaid expansion is a policy accomplishment of the ACA. More than 21 million people have gained insurance coverage within 10 years since the law’s passage, and more than half have received it through Medicaid expansion. Medicaid expansion has been linked to considerable improvements in health outcomes, with one life saved annually for every 239 to 316 adults gaining insurance.
16
Q
What is the outcome of the November 2022 Election in South Dakota regarding Medicaid?
A
South Dakota voters voted to broaden Medicaid to roughly 42,500 low-income residents starting in mid-2023. The measure passed 56% to 44%.
17
Q
What was the outcome of the Kentucky Constitutional Amendment 2 regarding women’s reproductive rights protections?
A
The amendment, which would state there is no right to abortion or any requirement to fund abortion in the state constitution, was not approved.
18
Q
What was the outcome of Vermont Proposal 5 regarding women’s reproductive rights protections?
A
The proposal was approved, creating a constitutional right to personal reproductive autonomy.
19
Q
What was the outcome of Michigan Proposal 3 regarding women’s reproductive rights protections?
A
The proposal was approved, creating a state constitutional right to reproductive freedom, including decisions “about all matters relating to pregnancy,” such as abortion and contraception.
20
Q
What was the outcome of California Proposition 1 regarding women’s reproductive rights protections?
A
The State Constitution would be amended to protect a person’s reproductive freedom “in their most intimate decisions,” including the right to abortion and contraceptives.
21
Q
What was the outcome of Montana Legislative Referendum 131 regarding born-alive infants regulation?
A
The measure was not approved. It would have enacted a law making any infant “born alive” at any gestational age a legal person and criminalized health care providers who do not make every effort to save the life of an infant “born during an attempted abortion” or after labor or C section.
22
Q
What is the Kansas Legislature considering in April 2023 regarding transgender rights?
A
The Kansas Legislature is considering a sweeping transgender bill that is among several hundred measures aimed at rolling back LGBTQ rights across the United States. The measure deals with bathrooms, locker rooms, and other facilities and defines “sex” as “either male or female, at birth,” which LGBTQ rights advocates say would legally erase transgender people and deny recognition to nonbinary, gender fluid, and gender nonconforming people.
23
Q
What are examples of crimes against the state under criminal law?
A
Examples of crimes against the state under criminal law include treason and sedition.
24
Q
What are examples of criminal acts under criminal law?
A
Criminal acts under criminal law are felonies or misdemeanors. Examples of felonies include murder, arson, sexual assault, and burglary.
25
What are crimes against the person under civil law?
Crimes against the person under civil law include a general category of laws known as torts.
26
What are the two types of torts under civil law?
The two types of torts under civil law are intentional (willful) and unintentional (accidental).
27
What is criminal law?
Criminal law deals with wrongs against a person, property, or society, and involves the prosecution of individuals who commit crimes. Examples of criminal law in healthcare include practicing without a license, use of narcotics, theft, extortion, and murder.
28
What is civil law?
Civil law involves legal relationships between people and the protection of a person's rights, including torts, which are wrongful acts that do not involve contracts. In healthcare delivery, civil law mainly affects contractual and torts relationships.
29
What is a contract?
A contract is an agreement between two or more parties that outlines the obligations and responsibilities of each party. In healthcare, contracts typically involve an offer, acceptance, and consideration, which is the payment made by the patient for services rendered. Contracts can be either implied or expressed, and can be either verbal or written.
30
Who is considered legally disabled in terms of forming a contract?
Those lacking the legal capacity to form a contract include minors, mentally incompetent individuals, semi or unconscious individuals, and people under the influence of drugs.
31
What is the relationship between an agent and a principal?
An agent is a person working under an employer (the principal), and the principal is responsible for the actions of the agent. If an agent causes injury to others, the principal can be required to pay or compensate those who have been injured by the agent.
32
When is a patient-provider relationship established?
As a general rule, physicians are under no obligation to treat a patient unless they choose to, except in emergency situations or when refusal to treat is based on discrimination. However, a patient-physician relationship is generally formed when a physician affirmatively acts in a patient’s case by examining, diagnosing, treating, or agreeing to do so. Once the physician consensually enters into a relationship with a patient in any of these ways, a legal contract is formed in which the physician owes a duty to that patient to continue to treat or properly terminate the relationship. It is recommended that physicians consult with their local medical boards to determine the law for their particular state.
33
What are conscience clauses?
Conscience clauses are legal clauses attached to Federal laws & state statutes that permit healthcare providers not to provide certain medical services for reasons of religion or conscience.
34
What are the reasons that can give rise to conscientious objection in healthcare?
Conscientious objection in healthcare can arise from religious beliefs, ethical views, or moral principles.
35
What kind of medical services are most frequently associated with conscience protections?
Conscience protections are most frequently associated with issues relating to reproduction rights, such as abortion, sterilization, contraception, and stem cell-based treatments, but may include any phase of patient care.
36
Who do conscience protections apply to?
Conscience protections apply to healthcare providers who refuse to perform, accommodate, or assist with certain health care services on religious or moral grounds.
37
How are health care provider conscience rights protected by federal law?
Federal statutes protect health care provider conscience rights and prohibit recipients of certain federal funds from discriminating against health care providers who refuse to participate in these services based on moral objections or religious beliefs.
38
What is the Medical Ethics and Diversity Act in Arkansas?
The Medical Ethics and Diversity Act in Arkansas is legislation that allows doctors to refuse to treat someone because of religious or moral objections, even when a procedure is medically necessary, except in emergency situations.
39
What is the physician's duty in a patient-physician relationship?
In a patient-physician relationship, the physician has an ethical and legal duty to continue care and not to abandon the patient.
40
When does abandonment occur in a patient-physician relationship?
Abandonment occurs when the relationship between physician and patient is terminated either at an unreasonable time or without affording the patient time to find a qualified replacement.
41
What is the legal definition of tort?
A tort is a legal wrong committed upon the person or property independent of contract.
42
What are the different types of intentional torts?
The different types of intentional torts include assault, battery, false imprisonment, invasion of privacy, and defamation of character.
43
What are the different forms of abuse?
The different forms of abuse are physical, verbal, emotional/psychological, and sexual.
44
What is required by laws in all states when abuse is reported?
Laws in all states require reporting of any form of abuse to proper authorities. There may be civil and/or criminal penalties.
45
What are unintentional torts?
Unintentional torts are acts that are committed with no intent to cause harm but done with a disregard for the consequences.
46
What term is used to describe the actions of healthcare practitioners who fail to exercise ordinary care, resulting in patient injury?
The term negligence is used to describe such actions.
47
What is malpractice?
Malpractice is the negligent delivery of professional services.
48
What is the most common contributing cause of medical errors?
The most common contributing cause of medical errors is human error.
49
What are some factors that can contribute to medical errors?
lack of training, fatigue, or inattention can all contribute to medical errors. When medical professionals do not work carefully, or when they do not have the appropriate training, or work outside of or beyond their scope of practice, a medical error can occur.
50
What is iatrogenesis?
Iatrogenesis refers to harm experienced by patients resulting from medical care.
51
Is all iatrogenic injury due to negligence?
No, all harm resulting from negligence is iatrogenic, but not all iatrogenic injury is negligent.
52
What is the oldest and most famous rule of medical ethics?
The oldest and most famous rule of medical ethics is primum non nocere, or above all, do no harm.
53
What is the "To Err Is Human" report, and what did it conclude about medical errors in the United States?
The "To Err Is Human" report was a 2000 report by the Institute of Medicine that focused on medical errors in the United States. It took two studies and extrapolated their results to all hospital admissions in the United States, concluding that between 44,000 and 98,000 Americans must be dying each year as a result of medical errors.
54
What is the current thinking about solutions to medical errors, and why?
The current thinking is that solutions to medical errors are more likely to be found at the organizational level rather than expecting individual clinicians to be aware of all relevant facts at all relevant times and take all the right actions. The systems approach holds that the "system" controlling these interconnecting parts needs to be redesigned to make it harder for things to go wrong.
55
What is the most common error that involves healthcare professionals when working with a patient?
The most common error that involves healthcare professionals when working with a patient is a medication prescribing error, accounting for 46.5% of medical errors. Administration errors account for another 29% of medical errors.
56
: What is Threading the Needle in healthcare?
Threading the Needle refers to the process of determining whether a healthcare provider's actions or inactions can give rise to a claim of negligence, gross negligence, or medical malpractice, particularly when a patient suffers harm as a result.
57
Does a patient's suffering of harm during treatment necessarily mean the healthcare provider did something wrong from a legal standpoint?
: No. Just because something goes wrong during a course of treatment or the treatment doesn't achieve the desired results, it doesn't necessarily mean that the healthcare provider did something wrong from a legal standpoint.
58
What is considered a breach of the standard of care in medical treatment?
Any act or omission by a physician during the treatment of a patient that deviates from accepted norms of practice in the medical community and causes an injury is considered a breach of the standard of care.
59
What is negligence?
Negligence is the failure of a person at fault to do what a "reasonable" and careful person would have done, or doing what a "reasonable" and careful person would not have done. It is also defined as a failure to take reasonable precautions to protect others from the risk of harm.
60
What is the Reasonable Person Standard?
The Reasonable Person Standard is the legal benchmark used to assess whether a person's behavior is negligent or not. It refers to what a reasonably prudent person would do under similar circumstances.
61
What is the standard of care in a medical malpractice case?
The standard of care in a medical malpractice case is what a reasonably prudent doctor, nurse, pharmacist, hospital or other healthcare provider would do under similar circumstances. A healthcare provider who fails to comply with the standard of care is negligent and can be held liable for damages.
62
What is medical malpractice?
Medical malpractice refers to a situation where a healthcare provider deviates from the recognized standard of care in the treatment of a patient, resulting in serious personal injury or death.
63
How are malpractice claims different from negligence claims?
Malpractice claims are lawsuits by a patient for errors in diagnosis or treatment, while negligence cases are those in which a person believes a medical professional's actions or lack thereof caused harm to the patient.
64
What must an injured patient demonstrate in order to hold a healthcare provider liable for medical negligence?
the injured patient must demonstrate the existence of a provider-patient relationship, the appropriate medical standard of care under the circumstances, exactly how the healthcare provider's conduct fell short of the applicable medical standard of care, and how the provider's mistake harmed the patient.
65
What are the Four D's of negligence?
The Four D's of negligence are Duty, Derelict, Direct Cause, and Damages. Patients must prove all four D's in order to move forward with a malpractice claim. Duty refers to showing that a provider-patient relationship existed, Derelict refers to showing that the healthcare provider failed to comply with the standards of the profession, Direct Cause refers to showing that any damages were a direct cause of a healthcare provider's breach of duty, and Damages refer to showing that the patient suffered injury.
66
What must be shown to hold a health care provider liable for medical negligence?
The existence of a provider-patient relationship, the appropriate medical standard of care, how the health care provider's conduct fell short of the standard of care, and how the provider's mistake harmed the patient.
67
What are the Four D's of Negligence?
Patients must prove Duty, Derelict (failure to comply with standards of profession), Direct (causation), and Damages (injury suffered).
68
What is the prudent doctor standard?
The standard requires that the physician exercise reasonable care "as measured against the conduct of his or her peers."
69
What is gross negligence?
It is more than just an egregious form of negligence and can be defined as willful misconduct or intentional wrongdoing.
70
Q: What are the four legal elements of negligence?
Duty, Breach of Duty, Causation (cause in fact/proximate cause), and Harm.
71
What is Duty?
Duty is a legal requirement that the accused (Defendant) conform to a certain standard of conduct to protect others from unreasonable risk of harm.
72
What is the locality rule?
The locality rule states that a professional/clinician's duty is tied to the customary practice in the same or similar locale or a national standard.
73
What is Breach of Duty?
It is the failure to follow the accepted standard of care or exercise reasonable care, knowledge, skills, and abilities commonly possessed by members in good standing within a given profession.
74
What are examples of Breach of Duty?
Failure to follow up on the patient's progress or clinical condition, failure to provide informed consent, failure to treat/diagnose/attend or refer, failure to make referrals when appropriate, failure to properly supervise staff/students, failure to review prior medical history or maintain the medical record, failure to consult members of the treatment team, failure to recognize and respond to patient complications, and failure to follow up on ordered tests.
75
What is Causation?
Causation is accountability and requires proof that the defendant's actions were the direct, factual cause of the plaintiff's injuries (cause in fact) and that the defendant's conduct was so closely connected to the plaintiff's injuries that the defendant should be held liable (proximate cause).
76
What are some examples of negligence other than malpractice?
Abandonment and delayed treatment are examples of negligence other than malpractice.
77
What are the legal terms used to classify negligence?
The legal terms used to classify negligence are malfeasance, misfeasance, and nonfeasance.
78
What are some common areas of malpractice?
Common areas of malpractice include misdiagnosis/failure to diagnose, delayed diagnosis, gross negligence in practice, surgical errors, nursing home malpractice, anesthesia malpractice, medication errors, malfunctioning medical devices, wrong record/wrong patient, failure to instruct patient for self-care, and birth injuries (such as cerebral palsy, shoulder dystocia, oxygen deprivation, hemorrhages, fractures, and cephalohematoma).
79
Is medical malpractice insurance required by federal law?
As of 2017, no federal law requires doctors to carry medical malpractice insurance, but some states do. Roughly 32 states require no medical malpractice insurance and have no minimum carrying requirements.
80
Why would a physician practice without malpractice insurance?
Even though many states have no requirement for medical malpractice insurance nor minimum carrying requirements, many physicians are required to obtain malpractice insurance, many hospitals require physicians with visiting privileges to carry malpractice insurance, and some healthcare insurance plans require any doctor who participates in their coverage to have malpractice insurance. The real question is: why would you practice without malpractice/liability insurance?
81
What is the law of agency in regards to medical malpractice?
Employees are considered to be agents of the physician while performing professional tasks. Physicians, pharmacists, and dentists are thereby responsible or liable for the negligence of employees. “Respondeat superior” is a Latin term meaning “Let the master answer.” Employees are legally responsible for their own actions and they can be sued directly.
82
What is medical malpractice tort reform?
Well over half of the states in America have passed some form of law that limits the amount of money a medical malpractice plaintiff can receive after a successful lawsuit meaning one in which the jury finds that a health care provider harmed a patient by committing medical negligence.
83
What are the social goals of medical malpractice litigation?
The social goals of malpractice litigation include serving as a deterrent to the improper practice of medicine, compensating persons injured through negligence economically and otherwise through a negotiated settlement or a trial, punishing perpetrators for their bad acts, and exacting “corrective justice.”
84
What are compensatory damages in a medical malpractice claim?
Compensatory damages in a medical malpractice claim are designed to compensate the victim for their losses and help restore them to the position they were in before they sustained their injuries. These damages may include economic and non-economic damages.
85
What are punitive damages in a medical malpractice claim?
Punitive damages in a medical malpractice claim are designed to punish the defendant for the result of their negligent actions.
86
What is tort reform in relation to medical malpractice?
Tort reform in relation to medical malpractice refers to laws and regulations that place a "cap" on damages, primarily non-economic damages, in medical malpractice cases. While some state legislatures have passed an umbrella cap on all forms of damages, others place caps only on non-economic damages.
87
Who is disproportionately impacted by damage caps and other strategies to discourage malpractice lawsuits?
Damage caps and other strategies to discourage malpractice lawsuits disproportionately impact women and families with infants because their economic damages are difficult to estimate and are typically underestimated.
88
How much of healthcare spending is attributed to defensive medicine?
According to a study led by Michael B. Rothberg, defensive medicine accounts for about 2.9% of healthcare spending, or approximately $78 billion annually.
89
What was the total payout amount for medical malpractice claims in 2018?
According to data from the National Practitioner Data Bank, the total payout amount for medical malpractice claims in 2018 was approximately $4,031,987,700.
90
What percentage of medical malpractice claim payouts were the result of settlements?
According to the report presented by LeverageRx, 96.5% of medical malpractice claim payouts were the result of settlements, with only 3.5% resulting from a court judgment.
91
What was the second highest number of medical malpractice claims filed in 2020?
Medical malpractice claims filed against MDs accounted for nearly 12,000, which was the second highest number of claims filed in 2020.
92
Against which healthcare professionals were the most medical malpractice claims filed in 2020?
More than 13,000 claims were filed against registered nurses in 2020, making them the healthcare professionals against whom the most medical malpractice claims were filed.
93
How many claims were filed against nurses and nursing paraprofessionals combined in 2020?
When claims against registered nurses and practical or vocational nurses, along with nursing paraprofessionals, were combined, the total was about 22,700, which was higher than the number of claims filed against physicians.
94
In what percentage of medical malpractice claims did the defendant prevail in the verdict?
In 88% of the verdicts for medical malpractice claims, the defendant prevailed.
95
What percentage of medical malpractice payments were the result of settlements in 2018?
In 2018, 96.5% of medical malpractice payments were the result of settlements.
96
What was the total amount of medical malpractice payouts resulting from judgments in 2018?
The total amount of medical malpractice payouts resulting from judgments in 2018 was $142.6 million.
97
What was the average payout for cases in which plaintiffs had become quadriplegic or brain damaged, or required lifelong care?
The average payout for medical malpractice cases in which plaintiffs had become quadriplegic or brain damaged, or required lifelong care, was $961,185.
98
What was the average payout for cases involving major permanent injury?
The average payout for medical malpractice cases involving major permanent injury was more than $610,000.
99
What were the two approaches of alternative dispute resolution (ADR) typically included?
The two approaches of alternative dispute resolution (ADR) typically included were mediation and arbitration.
100
What are the names of some programs that allow for surrogate decision making?
Some programs that allow for surrogate decision making include POST (Physician Orders for Scope of Treatment), MOST (Medical Orders for Scope of Treatment), MOLST (Medical Orders for Life Sustaining Treatment), and COLST (Clinician Orders for Life Sustaining Treatment).
101
How is a treatment order from a program that allows for surrogate decision making different from an advance directive?
A treatment order from a program that allows for surrogate decision making is different from an advance directive because it is written up by the clinician in consultation with the patient, is a portable, actionable medical order, and follows the patient regardless of care setting.
102
What is the Good Samaritan Law?
Good Samaritan laws provide legal protection for those who assist a person who is injured or in danger. These laws protect the “Good Samaritan” from liability if unintended consequences result that could result from their assistance.
103
What is the "No Duty to Rescue" Doctrine?
The "No Duty to Rescue" Doctrine refers to the fact that in most states, individuals are not legally obligated to provide first aid unless it is part of their job description. However, if an unconscious victim cannot respond, a Good Samaritan can help them on the grounds of implied consent. If the victim is conscious and can respond, a person should ask their permission to help them first.
104
What are the requirements for the immunizing effects of the Good Samaritan statutes to take hold?
Several requirements must be met for the immunizing effects of the Good Samaritan statutes to take hold. First, the situation must represent a true emergency with the potential for loss of life or limb. Second, the care provided must be rendered free of charge. Third, the care must be provided in "good faith" and within the scope of practice of the provider.
105
What is the purpose of Good Samaritan legislation?
The purpose of Good Samaritan legislation is to encourage healthcare professionals to render emergency treatment when they have no duty to do so.
106
what is the relationship between ethics and law?
Ethics and law share the goal of creating and maintaining social good and have a symbiotic relationship. Ethics Committee plays a vital advisory role in assisting medical professionals in managing ethical dilemmas in healthcare delivery.
107
What are the emerging telemedicine laws?
Emerging telemedicine laws are one of the primary legal issues in healthcare today. As telehealth rapidly rises in popularity, it can be challenging to keep up with federal regulations. It’s important to review billed claims carefully and stay updated on the latest telemedicine laws, including ethical considerations as they relate to patient care.
108
What is the top ethical concern in the current healthcare system in the U.S. post COVID-19?
Most clinicians agree that balancing care quality and efficiency is the top ethical concern in the current healthcare system in the U.S. post COVID-19.
109
What is informed consent?Informed consent is a major ethical concern in healthcare. Making sure patients fully understand medical procedures before undergoing them is crucial to their health. It is the clinician's responsibility to get informed consent in writing.
Informed consent is a major ethical concern in healthcare. Making sure patients fully understand medical procedures before undergoing them is crucial to their health. It is the clinician's responsibility to get informed consent in writing.
110
What is another major ethical concern in healthcare?
Issues related to patient confidentiality are another major ethical concern in healthcare.
111
What is medical law?
Medical law is the body of laws concerning the rights and responsibilities of medical professionals and their patients.
112
What are the main areas of focus for medical law?
The main areas of focus for medical law include confidentiality, standard of care, patient-clinician relationship, management & disclosure of medical errors, negligence and other torts related to medical treatment (especially medical malpractice), and criminal law & ethics.
113
: Is conduct that is legally permissible always ethically acceptable?
No, conduct that is legally permissible may be ethically unacceptable.
114
Why is it critical for health professionals to integrate legal concepts into their applications of medical knowledge and practice of clinical judgment?
It is critical for health professionals to integrate legal concepts into their applications of medical knowledge and practice of clinical judgment in the delivery of evidenced-based medical care, because modern medical practice is dominated and subject to a multitude of laws and agency regulations (both state and federal), as well as complex business realities.
115
What is the form of "the law" that clinicians will interact with most during their careers?
Regulation is the form of "the law" that clinicians will interact with most during their careers, rather than malpractice.
116
Why is it vital for healthcare clinicians to understand the legal and regulatory system and possible legal issues they may face?
It is vital for healthcare clinicians to understand the legal and regulatory system and possible legal issues they may face for their professional development and practice.
117
What is the Stark Law?
The Stark Law prohibits care providers from referring a patient to a peer or family member and covers payments issued by Medicare and Medicaid. It prohibits claims for referrals, but does provide for specific exceptions.
118
What is considered a "financial relationship" under the Stark Law?
Under the Stark Law, "financial relationship" is a broad term that includes ownership, investment interest, and compensation arrangements.
119
What are the designated health services covered by the Stark Law?
The designated health services covered by the Stark Law include clinical laboratory tests, physical therapy services, occupational therapy services, radiology services, radiation therapy services and supplies, durable medical equipment and supplies, parenteral and enteral nutrients, equipment, and supplies, prosthetics, orthotics, and prosthetic devices, home health services and supplies, outpatient prescription drugs, and inpatient and outpatient hospital services.
120
What does the False Claims Act establish?
The False Claims Act establishes civil liability for offenses related to certain acts, including knowingly presenting a false or fraudulent claim to the government for payment and making a false record or statement that is material to the false or fraudulent claim.
121
What does "knowingly" include under the False Claims Act?
: "Knowingly" under the False Claims Act includes not only actual knowledge but also deliberate ignorance or reckless disregard for the truth or falsity of the information.
122
What are some potential False Claims Act violations in the health care fraud context?
Some potential False Claims Act violations in the health care fraud context include upcoding, billing for unnecessary services, billing for services or items that were not rendered, and billing for services performed by an excluded individual.
123
What penalties can individuals and entities face for making false claims under the False Claims Act?
Individuals and entities that make false claims are subject to civil penalties of up to $11,000 for each false claim, plus three times the amount of damages the government sustains by reason of each claim. Violation of the False Claims Act may lead to exclusion from Federal health care programs.
124
Who can bring legal actions for penalties and damages under the False Claims Act?
Civil legal actions for penalties and damages under the False Claims Act may be brought not only by the government, but by private persons, such as competitors or employees of a provider, on behalf of the government. If the legal action is successful, the private person is entitled to a percentage of the recovery.
125
What is the "qui tam" provision under the False Claims Act?
The "qui tam" provision under the False Claims Act allows people who are not affiliated with the government to file actions on behalf of the government, informally called "whistleblowing."
126
What happens if a person fails to report and return an overpayment from a Federal health care program within 60 days?
Failure to report and return an overpayment from a Federal health care program within 60 days may make the overpayment a false claim, leading to liability under the False Claims Act.
127
What is the Health Care Fraud Statute?
The Health Care Fraud Statute makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program. Health care fraud is punishable by imprisonment for up to 10 years and criminal fines of up to $250,000. Specific intent to violate this section is not required for conviction.
128
What is the Anti-Kickback Statute?
The Anti-Kickback Statute bars offering, receiving, or soliciting assets in return for federally subsidized medical patronage and covers referrals from anyone for any federal service. Prosecutors must prove that defendants committed an anti-kickback violation willingly and knowingly. A guilty verdict under this law can result in a fine up to $25,000 and five-year prison sentence per violation.
129
What are the consequences of violating the Anti-Kickback Statute?
Conviction of an Anti-Kickback Statute violation results in mandatory exclusion from participation in Medicare and Medicaid programs. Absent a conviction, individuals who violate the Anti-Kickback Statute may still face exclusion from federal healthcare programs at the discretion of the secretary of HHS. The law also exposes offenders to civil repercussions such as False Claims Act culpability and a fine up to $50,000 per offense.
130
What is the Emergency Medical Treatment and Active Labor Act (EMTALA)?
The Emergency Medical Treatment and Active Labor Act (EMTALA) is a law that requires care providers to deliver medical services despite the patients’ ability to pay. The act outlines specific guidelines for providers that deliver emergency services. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), regardless of an individual's ability to pay. If an individual has a medical emergency, such as an injury or active labor, the law obligates caregivers to stabilize the patient and provide treatment up to the point where the client remains stabilized. If the care provider cannot deliver this service, the law mandates that the provider transfer the patient to a capable facility.
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What is the Health Insurance Portability and Accountability Act (HIPAA) of 1996?
The Health Insurance Portability and Accountability Act (HIPAA) is a law that protects American workers by allowing them to carry health insurance policies from job to job. HIPAA also bars insurers from discriminating against policy applicants due to health problems. Additionally, the act preserves state laws that protect workers’ insurance rights. HIPAA provided for reducing and preventing health care fraud and abuse; administrative simplification; medial liability reform, the Privacy Rule, transactions and code sets rule, and the Security Rule.
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What is the National Provider Identifier Standard (NPI)?
The National Provider Identifier Standard (NPI) provides every physician with a unique number used in all aspects of healthcare to allow for identification of providers, health insurance plans, and employers.
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What is the Health Information Technology for Economic and Clinical Health (HITECH) Act?
The Health Information Technology for Economic and Clinical Health (HITECH) Act is a law created to promote effective technology implementation among care providers. It addresses privacy and security of electronic health records and reinforces parts of the civil and criminal sections of the Health Insurance Portability and Accountability Act (HIPAA).
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What are the liability levels outlined in the HITECH Act?
The HITECH Act outlines four liability levels, each with increased punitive responses. Offenders who violate the law unknowingly initially receive the lowest fine and the opportunity to correct the offense in 30 days to avoid fines completely. The minimum penalty increases greatly between each level, with the maximum fine amounting to $1.5 million.
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What is the Healthcare Quality Improvement Act (HCQIA)?
The Healthcare Quality Improvement Act (HCQIA) provides immunity for medical professionals and institutions during conduct assessments. The law originated partially due to a Supreme Court ruling involving abuse of the physician peer review process.
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What is the Children’s Health Insurance Program (CHIP)?
The Children’s Health Insurance Program (CHIP) provides health coverage to children living in low-income households. It originated with the Children’s Health Insurance Authorization Act of 2009 (CHIPRA) and has successfully provided services to many previously disqualified clients. The program has an extensive history of providing insurance to underprivileged children and receives funding from respective states and the federal government.
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What is the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)?
The Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) ensures that physicians are paid fairly, that Medicare Part B costs are controlled, and that healthcare is improved. It signals a move away from the Sustainable Growth Rate (SGR) Formula once used to determine physician reimbursement and toward a model based on the quality, efficiency, value, and effectiveness of the medical care provided.
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What is the Hospital Readmissions Reduction Program (HRRP)?
The Hospital Readmissions Reduction Program (HRRP) is an Affordable Care Act initiative that requires the Centers for Medicare and Medicaid Services (CMS) to reduce payouts to care facilities that experience excessive patient readmissions. The program launched in late 2012 and defines readmissions as ‘repeat patient admissions among participating CMS hospitals in a 30-day period; allowing exceptions for specific conditions, such as heart failure and pneumonia, as well as factors such as poor health and multiple illnesses.’
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What is the Patient Safety and Quality Improvement Act (PSQIA) of 2005?
The Patient Safety and Quality Improvement Act (PSQIA) of 2005 protects health care workers who report unsafe conditions. It encourages the reporting of medical errors while maintaining patients’ confidentially rights. To ensure patient privacy, the HHS levies fines for confidentiality breaches. The law also authorizes the Agency for Healthcare Research and Quality (AHRQ) to publish a list of patient safety organizations (PSOs) that record and analyze patient safety data. The Office for Civil Rights (OCR) enforces the law among national health care facilities.
