Lecture 3 Flashcards
Trendy and popular words that come and go, some can be red flags while others are looked for by payor source.
Buzzwords
Abbreviation purpose =
communication
words specific to a group of people
Jargon
ways to shorten a word
Abbreviations
Be concise, keep sentences short and watch your jargon
Clarity
Documentation must be factually correct, done chronologically, and consistent with protocol. Should be done timely.
Accuracy
Write only what needs to be written, why OT was needed, what outcomes were achieved or worked towards,
Relevance
Unusual occurrences and events and what you did about it. Non compliance or refusal, why you deviated from the care plan.
Exceptions
Common errors in documentation
Unclear, too much or inappropriate jargon or abbreviations Failing to document
Missing documentation
Poor grammar and spelling
Wrong chart
Late documentation
How to correct a mistake
Addendum
an addition or revision to the note
Make an addendum or put a pen line through it
Make sure it has the date, the correction, why you’re making the change, initials
Addendum
Any ID of patient
Required ethically by AOTA
HIPAA
Confidentiality
Health insurance portability and accountability act
Rights, companies rights, complaints, contracts
HIPAA
Physician/pt privilege
Record/Therapy is confidential
Varies from state to state
Confidentiality law
Must have ok from patient in writing
Exceptions: peer reviews, legal procedures, request of govt, research protocol. Records are retained for 5 years or until the pt is 21.
In order to disclose information
Family education rights and privacy act of 1974
All documents that contain a student’s name, address, phone number, parents name, or identifying information.
FERPA
Keeping Files
Locked cabinets, copies must be secure
State law varies: statute of limitations for malpractice
Usually 5-10 years (til their 21 for children)
Shredded or burned to dispose of them
General precautions for Documentation
Do not change record without clarification
Beware of signatures
Avoid criticism to pts and other healthcare workers Avoid subjective comments about pt or pt family Use time stamps
Follow a sequence
Use proper grammar/abbreviations
Knowingly, willfully, and intentionally misrepresenting (lying) about the facts. “Up-coding” billing for things you didn’t do
Seeing a pt you never saw
Accepting kickbacks
Fraud
practice that is inconsistent with sound medical or business practice Over utilizing services
Excessive billing
Abuse
6 acts medicare prohibits
Making false claims
Making false statements for payment
Billing for visits never made
Billing for non face to face therapy sessions
Paying for or receiving kickbacks for goods and services Paying for referrals (soliciting for referrals)
Medicaid anti-fraud and abuse amendments
Established penalties for:
Knowingly and willingly making false statements to receive payment or benefits Knowingly concealing an event that could affect payment
Knowingly or willingly using someone else’s benefits or accepting someone else’s benefits.
Medicare
knowingly accepting payment (cash or gifts) for referrals
requires intent
Anti-Kickback statute of 1980
prohibits physicians from referring to a lab if they have or a family member has a relationship with that lab
Physician self referral Law of 1990 (stark 1)
Extended this same law to OTs, PTs, RT, DME, Home health services, Drugs, hospitals, prosthetics and orthotics.
different from the kickback laws because they do not require intent
Stark 2 law of 1993
Expecting to stark laws
no direct tx from physician, separate building
Safe harbor regulations
Set up to protect legitimate business relationships
3 strikes you’re out law
Hospitals must provide a list of all rehab and DME in the area
Balanced budget act of 1997
Commission of Standards and Ethics
Enforce the policies
3 members (act as court)
Jurisdiction over AOTA members
Ethical issues
Punishment
Judicial council
legal issues; police of profession before entering profession
NBCOT
state licensure board
ASBOT
Action involving a letter
Reprimand
When public disproves
Censure
Action requiring removal
Suspension
permanent removal
Revocation
Grounds for discipline by NBCOT/ASBOT
Incompetence, unethical behaviors, mentally/physically impaired
General jurisdiction
AOTA
NBCOT
state boards
