Legal and Ethical Issues

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5

• Legal and Ethical Issues

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Learning Outcomes

• 5.1 Explain the difference between laws and
  ethics.
• 5.2 Identify the responsibilities of the patient
  and physician in a physician-patient
  contract, including the components for
  informed consent that must be understood
  by the patient.
• 5.3 Describe the four Ds of negligence required
  to prove malpractice and explain the four
  Cs of malpractice prevention.

3
Learning Outcomes

• 5.5 Briefly summarize the purpose of the
  following federal healthcare regulations
  HCQIA, Federal False Claims Act, OSHA and
  HIPAA.
• 5.6 Identify the six principles for preventing
  improper release of information from the
  medical office.
• 5.7 Explain the importance of ethics in the
  medical office.
• 5.8 Explain the differences among the practice
  management models.

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Introduction

• Medical law is important quality of patient care
• You must understand
• Medical law
• Ethics
• Health Insurance Portability and Accountability
  Act (HIPAA)

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Introduction (cont.)

• Basic knowledge of medical law and ethics
• Rights, responsibilities, and concerns
• Legal and ethical issues
• Impact of rising costs
• Protected information

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Laws and Ethics

• Law
• Rule of conduct or action
• Formally recognized as binding
• Enforced by a controlling authority.

• Ethics
• Standard of behavior
• Classification of Law
• Criminal law
• Civil law

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Laws and Ethics (cont.)

• Unintentional Torts

• Intentional Torts

• Negligence
• Malpractice

• Assault
• Battery
• Defamation
• False imprisonment
• Fraud
• Invasion of privacy

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Contracts
Elements of a Contract
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Contracts (cont.)

• Types of contracts
• Expressed contracts clearly stated
• Implied contracts conduct of the parties
  indicated acceptance
• Legal elements

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Contracts (cont.)

• Employment Contract
• Description of duties
• Plans for handling change in job
• Compensation
• Benefits
• Grievance procedures

• Reasons for termination
• Termination procedures
• Special provisions

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Apply Your Knowledge
What is the difference between law and ethics?
ANSWER A law is a rule of conduct or action and
is enacted by governments to maintain order and
public safety. Ethics is a standard of behavior
based on moral values that are influenced by
family, culture, and society.
Good Answer!
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The Physician/Patient Contract

• Reasonable limitations
• Both parties have rights and responsibilities
  related to the contract

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Physician Rights and Responsibilities

• Rights
• Set up a practice
• Select a location to practice
• Specialize
• Determine what services to provide

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Physician Rights and Responsibilities (cont.)

• Responsibilities
• Use due care, skill, judgment, and diligence
• Keep knowledge up-to-date
• Perform to the best of his or her ability
• Educate patients

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Physician Rights and Responsibilities (cont.)

• Medical Assistants and Liability
• Know scope of practice
• Understand
• Standard of care
• Duty of care

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Patient Rights and Responsibilities

• Rights

• Responsibilities

• Select a physician
• Terminate services
• Patient Care Partnership

• Follow instructions and cooperate
• Provide relevant information
• Follow physicians orders
• Pay fees

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Patient Rights and Responsibilities (cont.)

• Consent
• Implied consent actions imply permission
• Informed consent
• Must receive all information necessary to make a
  decision regarding treatment
• Doctrine of informed consent

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Patient Rights and Responsibilities (cont.)

• Those able to give consent
• Adults of sound mind
• Emancipated minors
• Mature minors

• Those who cannot give consent
• Minors
• Mentally incompetent persons
• Foreign language speakers without an interpreter

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Terminating the Physician/Patient Contract

• Reasons for terminating care
• Refusal to follow instructions
• Complaints by family member
• Personality conflicts
• Failure to pay
• Failure to keep appointments

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Terminating the Physician/Patient Contract (cont.)

• When terminating care
• Provide written notification
• Send letter by certified mail, return receipt
• Place copy of letter medical record
• Document in the patient record

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Standard of Care

• Maintain confidentiality
• Practice within scope of training and
  capabilities
• Prepare and maintain medical records
• Document accurately
• Use proper guidelines when releasing information

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Standard of Care (cont.)

• Follow legal guidelines
• Maintain and dispose of regulated substances
  appropriately
• Follow risk-management and safety procedures
• Meet criteria for professional credentialing

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Closing a Medical Practice

• Comply with and stay current on HIPAA laws
• Notify patients in writing
• Give option of choosing another physician or make
  referral
• Secure or dispose of records appropriately

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Apply Your Knowledge
Patients have rights and responsibilities
relating to health care. The rights are
determined by the Patient Care Partnership. What
are the patients responsibilities?

• ANSWER Patient responsibilities are
• Follow physicians instructions and cooperate
  with plan of care
• Provide relevant information to the physician
• Follow the physicians orders for treatment
• Pay the fees charged for services provided

Good Job!
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Preventing Malpractice Claims

• Lawsuits
• Add to cost of healthcare
• Take a psychological toll on all involved
• Risk management
• Identify and track
• Develop improvement plans
• Monitor
• Assess

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Medical Negligence

• Malpractice claims
• Medical negligence
• Malfeasance
• Misfeasance
• Nonfeasance

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Medical Negligence (cont.)
D
Four Ds of Negligence
Duty
Derelict
Direct Cause
Damages
Patients must be able to prove all 4 Ds in order
to move forward with a malpractice suit.
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Medical Negligence (cont.)

• Malpractice lawsuits civil law
• Tort
• Breach of contract
• Settling malpractice suits
• Trial
• Arbitration
• Subpoena

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Medical Negligence (cont.)

• Law of Agency
• Employees agents of the physician
• Respondeat superior
• Let the master answer
• Physicians are responsible for the negligence of
  employees

Employees are legally responsible for their own
actions, and they can be sued directly.
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Medical Negligence (cont.)

• Courtroom conduct
• Attend proceedings
• Be on time
• Bring required documents
• Refresh your memory

• Speak professionally
• Answer all questions
• Answer only the question asked
• Appear well groomed

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Medical Negligence (cont.)

• Professional liability coverage
• Protects against financial losses
• High cost to practice

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Reason Patients Sue

• Unrealistic expectations
• Poor rapport and poorcommunication
• Greed and our litigious society
• Poor quality of care

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Preventing Malpractice Claims (cont.)

• Statute of Limitations
• Laws that set the deadline or maximum period of
  time within which a lawsuit or claim may be filed
• Deadlines vary
• Type of case
• State vs. federal court

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Preventing Malpractice Claims (cont.)
The 4 Cs of Malpractice Prevention
C
Caring
Communication
Competence
Charting
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Preventing Malpractice Claims (cont.)

• Effective Communication
• Good listening skills
• Return calls
• Be sure informed consent forms are signed

• Avoid admitting guilt
• Use tact, good judgment, and professional ability
• Reach an understanding about fees

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Apply Your Knowledge
What are the 4 D of negligence needed to prove a
malpractice and 4Cs of malpractice prevention?
ANSWER The 4 Ds are duty, derelict, direct
cause, and damages. The 4 Cs are caring,
communication, competence, and charting.
Bravo!
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Administrative Procedures and the Law

• Risk management
• Must meet legal standards
• Insurance billing
• Patient consent forms
• Office correspondence
• Documentation
• Appointment scheduling

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Documentation

• Referrals
• Missed appointments
• Dismissals
• All other patient contact

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Documentation (cont.)

• Medical record correction
• Ownership of the patient record
• Retention and storage of the patient record

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Credentialing

• Ensures healthcare providers are qualified
• Medicare requirements
• CMS Website
• www.cms.gov/manuals/downloads.
• Provider Enrollment Chain and Ownership System
  (PECOS).
• Insurance carriers

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FDA Regulatory Function

• Drug manufacturing
• Nonprescription or OTC drugs
• Prescription drugs
• Pregnancy categories
• Controlled substances

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FDA Regulatory Function (cont.)

• Comprehensive Drug Abuse Prevention and Control
  Act
• Drug Enforcement Administration
• Doctor registration
• Ordering controlled substances

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Legal Documents and the Patient

• Advance medical directive
• Durable power of attorney
• Uniform donor card

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Apply Your Knowledge
What are the legal implications of poor
documentation?
ANSWER Poor or incomplete documentation can
contribute to the loss of medical liability
cases. It is important that documentation
demonstrate that nothing was neglected and that
care given met standards.
Good Job!
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Federal Legislation Affecting Health Care

• Health Care Quality Improvement Act (1986)
• Improve the quality of medical care
• Peer review
• Limitation of damages
• Protection to those providing information
• National Practitioner Data Bank

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Federal False Claims Act

• Qui tam
• To bring action for the king and ones self
• Control three types of illegal conduct
• False billing claims
• Kickbacks
• Self-referrals

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Occupational Safety and Health Administration
(OSHA)

• Division of the U.S. Department of Labor
• Protection of workers from exposure to health
  hazards on the job
• OSHA Blood-borne Pathogens Protection Standard
  1991

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Health Insurance Portability and Accountability
Act (HIPAA)

• Improve efficiency and effectiveness of
  health-care delivery
• Protect and enhance the rights of patients
• Improve the quality of health care

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HIPAA (cont.)

• Title I Health Care Portability
• Title II Prevention of Health Care Fraud and
  Abuse, Administrative Simplification and Medical
  Liability Reform
• The HIPAA Privacy Rule
• HIPAA Security Rule.

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HIPAA (cont.)

• HIPAA Privacy Rule - PHI
• Use
• Disclosure
• Managing and storing of patient information
• Notice of Privacy Practices (NPP)
• Sharing (TPO)

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HIPAA (cont.)

• HIPAA Security Rule
• A security officer
• Security awareness training
• Audit controls
• Limit physical access
• Conduct risk analyses
• Establish policies and procedures

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HIPAA (cont.)

• HIPAA Security Rule
• Chart security
• Reception area security
• Patient care area security
• Fax security
• Copier and printer security

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HIPAA (cont.)

• HIPAA Security Rule
• Violations and penalties
• Administrative simplification
• Standardizing patient information
• Standardized codes and formats electronic
  transaction records

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Apply Your Knowledge
Good Answers!
1. What do OSHA regulations describe?
ANSWER OSHA regulations describe precautions
that must be taken to protect workers from
exposure to health hazards on the job.
2. While you are documenting on the computer, you
are called to a patient room for an emergency.
What should you do before leaving the computer?
ANSWER You should close the patient record and
log off the computer to protect the
confidentiality of patient information.
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Confidentiality Issues and MandatoryDisclosure

• When in doubt, do not release information.
• It is the patients right to keep patient
  information confidential.
• Use the same degree of confidentiality for all
  patients.

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Confidentiality Issues and MandatoryDisclosure
(cont.)

1. Be aware of all applicable laws and of the
   regulations.
2. If it is necessary to break confidentiality
   discuss situation with the patient.
3. Obtain written approval from the patient before
   releasing information.

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Apply Your Knowledge
A police officer enters the physicians office
where you work and requests information about a
patient. May you release this information? What
should you do?
ANSWER No, you should not be the person to
release this information. You should refer the
officer to the patients physician, who will make
the judgment based on the urgency of the
situation and any danger that might be posed to
the patient or others.
YES!
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Ethics

• Principles of right and wrong vs. requirements of
  law
• Bioethics social issues
• Issues that arise due to medical advances
• Hippocratic Oath
• AMA Code of Medical Ethics Current Opinions
  with Annotations

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Apply Your Knowledge
Mr. Jones would like to try a new treatment for
his Parkinsonism, but his physician refuses to
discuss a new treatment with Mr. Jones because he
morally disagrees with this type of treatment.
This is an example of what type of issue, and
what should the physician do?
ANSWER This is an example of a bioethical issue.
The physician should refer the patient to
another physician who specializes in this
treatment.
Good Answer!
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Legal Medical Practice Models

• Five types of practice models
• Sole proprietorship
• Partnership
• Group practice
• Professional Corporation
• Clinics

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Apply Your Knowledge
What is the difference between a group practice
and a professional corporation?
ANSWER A group practice is three or more
physicians who share the practice income,
expenses, and facilities. In a professional
corporation the physicians are shareholders and
employees of the corporation.
Right!
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In Summary

• 5.1 A law is a rule of conduct or action. Ethics
  are standards of behavior or concepts of right
  or wrong.
• 5.2 Physician and patient rights and
  responsibilities.
• 5.3 The four Ds of malpractice and the four Cs
  of malpractice prevention.
• .

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In Summary (cont.)

• 5.4 Credentialing is the approval process a
  healthcare provider must go through to be
  allowed to bill Medicare and other insurance
  carriers for providing medical services to
  patients under their insurance plans.
• 5.5 Federal healthcare regulations HCQIA,
  Federal False Claims Act, OSHA, and HIPAA.

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In Summary (cont.)

• 5.6 The six rules for preventing improper
  release.
• 5.7 Ethics reflect the general principles of
  right and wrong. A professional,
  particularly a medical professional, is
  expected to follow especially high
  ethical standards.
• 5.8 There are five basic types of practice
  management models.

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End of Chapter 5
Let no one come to you without leaving better
and happier. Mother Theresa