Unit 2 Exam Flashcards
What is required for a medical malpractice suit against a doctor?
A Physician-Patient Relationship
The relationship between physician and patient may be based on a contract that is what?
Expressed or Implied
What may contracts between the physician and the patient contain?
Exculpatory Clauses
What did the court do in the case of Tunkl v. Regents of the University of California?
In this case, the court refused to recognize exculpatory clauses.
What did the court decide in the case of Tunkl v. Regents of the University of California?
In this case, the court ruled that a release waiving any malpractice liability of a non-profit is unenforceable.
What do physicians have a duty to regarding the information given to them by patients?
Confidentiality
What is the confidentiality of medical records protected by?
State and Federal Statutes
Why is confidentiality and privacy protection desirable?
It encourages HIV/AIDS testing.
When was HIPAA passed?
1996
What was an issue that the passing of HIPAA addressed?
The privacy and security of “Protected Health Information” (PHI).
What are the three main regulations issued under HIPAA?
1.) Privacy Rule
2.) Security Rule
3.) Breach Notification Rule
How does a healthcare provider become subject to the Privacy Rule?
A healthcare provider must engage in certain electronic transactions, such as claim filing.
What is the Administrative Simplification Compliance Act?
This legislation, passed by Congress in 2001, requires electronic Medicare billing.
What did the Center for Medicare and Medicaid do on October 1, 2005?
The CMM ended its HIPAA “contingency plan,” meaning only standard electronic transactions would be accepted for payment through the Medicare System.
What did the Privacy Rule provide for covered entities?
Covered entities may without patient consent, authorization, or permission, use Protected Health Information (PHI) for treatment, payment, and healthcare operations (TPO purposes).
What can covered entities adopt?
A formal document called a Notice of Privacy Practices.
What is the Notice of Privacy Practices used for?
It is used to advise patients of their HIPAA privacy rights and how to file complaints about the misuse of their PHI.
What are covered entities required to do when the inspection and copying of their PHI is needed?
Covered entities must provide access and permit patients to conduct such activity.
What does a patient have the right to ask a covered entity to do regarding their PHI?
Patients can ask a convered entity to amend their PHI.
What are providers not required to do if they find a health record to be complete and inaccurate?
Providers are not required to ammend the PHI, but patients still have the right to append a “Statement of Disagreement” to their medical record.
Patients have a right to request a covered entity to list all disclosures of their PHI in a how many years-long period?
6-year period, through routine disclosure for TPO is exempt from the accounting requirement.
Who are patients allowed to file complaints against regarding a provider’s misuse of PHI?
The covered entity and the Secretary of Health and Human Services.
Covered entities must train who regarding the Privacy Rule (HIPAA)?
All members of their workforce.
Who must covered entities appoint and what does this individual do?
A Privacy Officer who must maintain files to demonstrate compliance in the event of a compliance review by HHS.
What does HIPAA’s Security Rule address?
It addresses the technical, physical, and administrative safeguards that covered entities must implement to ensure the integrity and security of the PHI.
What are the technical safeguards within the Security Rule?
Covered entities must use screen savers to ‘black out” a computer when idle, and requires the use of passwords to ensure only authorized persons have access to PHI.
What are the physical safeguards within the Security Rule?
Covered entities must deal with security of buildings and facilities where PHI is stored, and require only personnel with a legitimate need for access to PHI can enter a storage area.
What is an administrative safeguard regarding the Security Rule?
The involvement of policies, procedures, traiing, enforcement, and organizational issues about the way the workforce handles PHI.
What does the TCS (Transaction and Code Set) Rule require?
It requires that covered entities must submit electronic healthcare claims in a HIPAA-approved translation format known as: ANSI 837 (ASCX12N837 version 4010).
Under HIPAA, what are health insurance payors allowed to do if they receive electronic claims in non-approved formats?
If this occurs, health insurance payors may deny claims. Unless their claims are TCS compliant, electronic billers cannot be paid.
What does HIPAA not mandate the submission of electronic claims to?
They do not mandate such claims to other payors, like commercial insurers or HMOs.
What percent, roughly, have most suppliers been billing Medicare electronically since 2006?
83%
What is a powerful weapon beyond HIPAA?
State invasion of privacy laws.
What does informed consent deal with?
It deals with the right of individuals to regulate the medical treatment they receive.
What have hospitals and other healthcare providers implemented due to the need for informed consent?
Healthcare providers now use consent forms, referred to by lawyers as “General Deterrence,” and “Risk Avoidance” by insurance companies.
Informed consent cases may be based on what two causes of action?
Battery and negligence.
What was the matter in the case of Mattocks v. Bell?
In this case, a mother took her child to the hospital to treat a lacerated tongue. As a medical student was treating the patient, their finger was bit in the process. The student slapped the patient, causing their finger to be released. The mother sued for assault and battery.
What did the court decide in the case of Mattocks v. Bell?
In this case, the court decided that:
1.) The student’s action was not malicious.
2.) The slap was not severe.
3.) The child was not injured.
4.) An emergency situation existed.
5.) Student exhibited poor/hasty judgement, but was not exceedingly bad.
What was the matter in the case of Mohr v. Williams?
In this case, a patient had consented to an operation on her right ear, but was treated on her left ear as the surgeon deemed that neccessary instead. The patient sued for assault and battery, citing a lack of informed consent.
What did the court decide in the case of Mohr v. Williams?
In this case, the court decided that did not provide consent to surgery on her left ear, determining the surgery wrong and unlawful.
What was the matter in the case of Kennedy v. Parrott?
In this case, a surgeon found enlarged cysts on a patient’s left ovary, during an operation regarding appendicitis, and punctured them. The patient later developed phlebitis in her leg, as the surgeon cut a blood vessel. The patient underwent another procedure to correct the damage. They then sued the surgeon for negligence based on the unauthorized operation.
What did the court decide in the case of Kennedy v. Parrott?
In this case, the court decided that because the patient voluntarily submitted themself for diagnosis/treatment, the procedure was expressly or implicitly authorized, as good surgery demanded.
For torts committed by hospital employees, what may a hospital be vicariously held liable under?
The Theory of Respondent Superior.
What did the court decide in the case of Canterbury v. Spence?
In this case, the court held that physicians have a duty to disclose all risks.
What was the matter in the case of Moore v. Regents of the University of California?
In this case, several physicians had extracted tissue from Moore with the intent of conducting research on it in the hope of achieving financial gain.
What did the court decide in the case of Moore v. Regents of the University of California?
In this case, the court decided that The court ruled that a physician’s intent to use a person’s body tissue for potentially profitable research must be disclosed.
Unless there is effective consent, a physician may be exposed to complaints about what?
1.) Breach of a fiduciary duty not to profit from a patient.
2.) A Tort claim of conversion. That is, the physician stole the patient’s T-cells.
3.) Misrepresentation
4.) Invasion of privacy.
What are the factors physicians need to disclose?
1.) Alternatives.
2.) Prognosis with treatment.
3.) Prognosis without treatment.
4.) Conflicts of interest and economic self-interest.
What are the expectations that do not require disclosure and informed consent?
1.) Emergencies.
2.) Patient waivers.
3.) Therapeutic privilege - where disclosure could be risky.
4.) Implied consent.
What may hospitals be held liable for?
Negligent acts that occur on their premises.
What was the matter in the case of Bing v. Thunig?
In this case, a hospital was sued for negligence of its medical staff. The hospital raised the defense that it had charitable immunity.
What did the court decide in the case of Bing v. Thunig?
The court disagreed with the hospital’s defense and sided with the plaintiff.
What was the matter in the case of Darling v. Charleston Community Memorial Hospital?
In this case, the patient broke his leg and was treated at the hospital’s ER. His leg was put in a cast, but the cast cut off his circulation and he lost part of his leg.
What did the court decide in the case of Darling v. Charleston Community Memorial Hospital?
In this case, the court held that a hospital may be liable for the negligence of its staff.
What was the matter in the case of Thompson v. Nason?
In this case, a patient was treated by a medical staff in the ER. She developed a positive Babinski - a neurological sign of an intra-cerebral problem. After developing paralysis, she sued the hospital, alleging that her injuries were caused by the negligence of the hospital acting through its agents, servants, and employees.
What did the court decide in the case of Thompson v. Nason?
In this case, the court utilized the theory of corporate liability and found the hospital liable.
What does the theory of corporate negligence (liability) state?
Under this theory, the hospital is liable if it fails to uphold the proper standard of care it owes to patients.
The theory of liability is a public policy that creates what?
A Non-Delegable Duty which the hospital owes directly to the patient.
What are the four areas the court classified the hospital’s duties into?
1.) Duty to use reasonable care in maintaining safe and adequate facilities.
2.) Duty to select and retain only competent physicians.
3.) Duty to oversee all persons who practice medicine at the hospital.
4.) Duty to formulate, adopt, and enforce adequate rules and policies.
What does the Doctrine of Vicarious Liability state?
A hospital may be held vicariously liable for the negligence of its employees, staff, and agents.
For torts committed by a hospital’s employees, the hospital may be vicariously liable under what theory?
The Theory of Respondent Supervisor, which is a master-servant employer-employee relationship.
For torts committed by the hospital’s agents, the hospital may be liable under what theory?
Theory of Vicarious Liability
For torts committed by an independent contractor, the hospital may be liable under what theory?
Theory of Ostensible Agency
What is a proposal to reform the tort system for medical injuries?
Insurance Reform
What is access to healthcare mandated by?
Law
What is in place to prohibit denial of care to certain class patients?
Statutes
What is a statute in place to prohibit denial of care to certain class patients?
Emergency Medical Treatment and Labor Act (EMTALA)
What does EMTALA apply to?
Only to hospitals that accept payment from Medicare and have an emergency department.
EMTALA is an anti-dumping statute that requires what?
1.) Medical Screening
2.) Necessary stabilizing treatment for emergency medical conditions and labor.
3.) Restrictions on transfer until an individual is stabilized.
4.) Enforcement in the form of civil monetary penalties.
5.) No delay in examination or treatment.
What did the court decide in the case of Barner v. Hospital Corporation of America?
In this case, the court held that the hospital must provide a medical screening examination that is appropriate, and within the capability of the hospital’s emergency medical department when determining the emergency medical condition.
What does EMTALA disallow?
It disallows patient transfers that may cause a deterioration in the patient’s condition via Howe v. Hull.
What does EMTALA prevent?
It prevents transfers, without stabilizing treatment, of patients who “come to” a hospital’s emergency room, via Arrington v. Wang.
What is the most important federal statute that affects health insurance?
Employee Retirement Income Security Act of 1974 (ERISA)
In an employee-derived benefit plan that is provided by an employer, what preempts state tort claims?
ERISA
What does ERISA wipe out state tort action for?
Administrative Remedies
What amounts to 60% of healthcare spending and 20% of the federal budget in the United States?
Medicare and (federal) Medicaid
What is one of the fastest-growing items in state budgets?
Medicaid
When was Medicare established and for what purpose?
It was originally established in 1965 for the elderly and disabled.
What are the four Medicare program divisions?
Part A - Hospital Payment
Part B - Physicians
Part C - Medicare Advantage Managed Care Program
Part D - Prescription Drugs
Medicare and Medicaid insure what percentage of Americans?
25%
Medicare roughly covers 1 in what Americans?
1 in 7
When are Americans eligible for benefits under Social Security?
Automatically when they turn 65.
Where does Medicare set its price through?
Diagnostic Related Groups
What is Medicaid defined as?
A welfare program for the poor that is federally mandated to be administered by states.
What is Medicaid based on?
A service fee where physicians may opt in.
What percent of Medicare rates is paid for by Medicaid?
64%
Congress created what to combat the problem of uninsured children?
State Children’s Health Insurance Program (SCHIP)
What did the Omnibus Budget Reconciliation Act of 1990 do?
Pharmaceutical companies now state Medicaid beneficiaries rebates for drugs.
Whether an entity is non-profit is a matter of what?
State Law
The issue regarding tax exemption is a matter of what?
State and Federal Law
What must one do when creating a nonprofit?
They must file articles of incorporation with the Secretary of State.
What needs to be filed to receive federal tax exemption?
File a 1023 with the IRS and indicate the purpose.
What can a charitable organization pay taxes on?
Unrelated Business Income (UBI)
How many different types of tax exemptions are there?
20
What is significant about a 501(c)(3)?
They are the type of organization for which contributions are deductible to donors under Internal Revenue Code 170.
What did the court decide in the case of Utah County v. Inter Mountain Healthcare Inc.?
In this case, the court held that the hospital may be considered non-profit and still not be entitled to tax exemption. The court said that they did not meet the 6 criteria to qualify.
Community benefits test with what 2 provisions?
1.) Further the purpose of a government institution, or
2.) Provide a service that would not be done if the entity was not doing it with tax exemptions.
What are the purposes health information contained in the health record serves many clinical and non-clinical purposes?
1.) Supporting direct patient care.
2.) Quality improvement.
3.) Public health monitoring.
4.) Billing and reimbursement.
To be admissible, evidence must be what?
Pertinent and proper that is competent and relevant.
What is hearsay?
Out-of-court statements offered to prove the truth of the matter asserted.
Why are healthcare records considered hearsay?
Because the healthcare provider making the statement or entries into the record does not do so in court under oath. This is true unless they fall under an exception to the rule, such as the business record exception.
In response to the legal process, the rules of ownership of health information is what?
a.) The record must remain in the provider’s control and safekeeping.
b.) May be removed only in accordance with proper legal processes.
What are the legal processes the ownership of health information may be removed by?
1.) Subpoenas
2.) Court Orders
3.) Warrants
4.) Discovery Requests
What should a litigation response team consist of?
1.) The healthcare provider’s legal counsel.
2.) Senior management of the healthcare organization.
3.) Health information management professionals.
4.) Information technology professionals.
The health information professional should also determine whether the information requested involves what?
1.) Treatment for substance abuse.
2.) Mental health.
3.) Genetic testing information
4.) AIDS.
What may one do if they find a subpoena to be burdensome, unreasonable, oppressive, or has the involvement of privileged documents?
One may consult legal counsel to consider filing a motion to quash, which challenges the validity of a subpoena duces tecum.
What is ethics?
Ethics is the formal study of the moral choices that conform to standards of conduct.
The concepts of ethics, morality, and law are based on what values?
1.) Social Norms
2.) Religion
3.) Family Orientation
What concept is involved in informed consent?
Autonomy
What is the ethical concept of beneficence?
Beneficence involves the qualities of kindness, mercy, and charity. It refers to the obligation to do good in all circumstances.
What is the ethical concept of non-maleficence?
Non-maleficence refers to the prohibition against doing harm. A prime example of this concept is the Hippocratic Oath taken by doctors.
What is the ethical concept of fidelity?
Fidelity means faithfulness and devotion to one’s obligations or duty.
What is the ethical concept of justice?
Justice refers to the obligation to be fair to all people.
What is the ethical concept of rights?
Rights refer to a just claim or entitlement, such as patient rights, confidentiality, and privacy. Patient rights recognize that the patient is entitled to determine for himself the extent to which he will receive or forego care and treatment.
What is the ethical concept of veracity?
Veracity refers to habitual truthfulness and honesty. In healthcare, veracity involves the special relationship between the patient and the healthcare provider. It requires the healthcare provider to disclose factual information to the patient so that they can exercise autonomy and determine the course of their care.
What does veracity also play a role in?
Medical Research
What does the Patient Self Determination Act do?
This law is an effort to move ethical concepts to a legal basis.
What does the Privacy Rule entail?
1.) The right to be informed about the uses and disclosures of this information.
2.) The right to restrict the uses or disclosures of this information.
3.) The right to amend this information.
4.) The right to inspect and copy this information.
Ethics is a central art to what?
The health information management profession.
What are some ethical theories and challenges?
1.) One person may rely on a particular ethical concept or theory; another person may rely on religious beliefs.
2.) Others may rely on personal experiences or may look to a professional code of ethics for guidance.
What is the Code of Ethics of the American Health Information Management Association (AHIMA)?
It guides the health information professional. In his obligations to himself, the patient, other members of the healthcare team, his employer, their peers, their professional associations, and the public.
What is the most effective way to communicate a code of ethics?
Education
Codes of ethics are more effective when they are what?
Enforced
What is a way that a code of ethics can be created?
Through a committee.
What are the main issues in bioethics?
1.) The removal of life support systems.
2.) The treatment of seriously ill newborns.
3.) Procedures about procurement of organs.
What are some other issues in bioethics?
1.) Family Planning
2.) Sterilization
3.) Prenatal Screening
4.) Genetic Screening
5.) Eugenics
6.) Organ Transplantation
What are transplants where one uses their own body parts called?
Autografts
What are transplants where one uses a donor’s body parts called?
Allografts/Homografts
Transplants involving animal tissue, cells, or organs into human bodies are called what?
Xenografts/Heterografts
What are the issues involving genetic science?
The involvement of the Human Genome Project to map the human DNA. This is also used to administer gene therapy and stem cell research.
The ethical issues related to death and dying are related to what?
Advanced Directives, which are written instructions that describe the kind of healthcare the patient wishes to have or not if they become incapacitated.
What are the two types of advanced directives in healthcare?
1.) Living Will; is a written document, executed while a patient is competent, that provides direction about the medical care the patient should receive if they are incapacitated or unable to make personal decisions.
2.) A Durable Power of Attorney for Healthcare; this document allows a competent individual to exercise health-related decisions on her behalf if she becomes incapacitated or unable to make decisions.
What is passive euthanasia?
Also called negative euthanasia, is recognized in the healthcare setting with the use of Do Not Resuscitate (DNR) or “no-code” orders.
What is active euthanasia?
Also called positive euthanasia, involves actions that speed the process of dying. In the healthcare setting, active euthanasia involves a situation where the provider prescribes, supplies, or administers an agent that results in death.
What is withholding treatment?
Withholding treatment involves the decision of the patient, her family, or her legal guardian to refrain from giving permission for treatment or care.
What is withdrawing treatment?
Withdrawing the treatment involves the decision of the patient, her family, or legal guardians to discontinue activities or remove forms of patient care.
