Ethics, Boundaries, HIPAA

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Ethics, Boundaries, HIPAA Confidentiality,
and Fraud and Abuse

• Ethical Principles and Practices
• A New Employee Orientation (NEO) and
• new CPSA staff Required Training

Self-Study Module - June 2012
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Module Objectives

• Upon completion of this module, you will be able
  to
• Consider ethics in decision-making
• Understand boundaries and
• boundary violations
• Know your role and responsibilities regarding
• HIPAA and client confidentiality
• Recognize fraud and abuse and identify courses
• of action

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Module Overview

• In this module, you will learn about Ethics,
  Boundaries, HIPAA Confidentiality, and Fraud
  and Abuse. Since each of these topics includes
  important information, each is a section in this
  module.
• This module is an introduction to important
  topics that will affect your work each day
  topics which should be discussed with your
  supervisor on an on-going basis.

Lets begin with Ethics
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Ethics
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Understanding Ethics
What are Ethics?

• A set of principles of right conduct
• A theory or a system of moral values
• The rules or standards governing the conduct
• of a person or the conduct of the members of
• a profession (i.e., behavioral health)

Merriam-Webster Dictionary ethics the
discipline dealing with what is good and bad and
with moral duty and obligation
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Understanding Ethics

• Why do you need to complete training on Ethics?
• As behavioral health professionals, we must make
  every effort to always act in the best interest
  of the individuals we serve.

The concepts of Do no harm and Put the
clients best interest first form the ethical
basis of our work.
At times, you most likely will encounter ethical
situations that are challenging. If you find
yourself hesitating, doubting or questioning a
potential course of action, it may be an ethical
situation! Consulting your supervisor when
questions and issues arise can help you determine
your best response or course of action.
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Understanding Ethics
Ethical behavior is part of our professions -
and your agencys - mission and values

• Organizational missions/values and Codes of
  Conduct usually guide professional behavior
• Across agencies, ethics and values may vary
  slightly
• Not all behavioral health workers may belong to a
  professional discipline with a Code of Ethics,
  but all agencies have a Code of Ethics which
  guides staff behavior. This Code of Ethics
  usually appears in the agency Policy and
  Procedures Manual.

Be sure you know your agencys requirements and
expectations regarding your professional and
ethical behavior!
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Code of Ethics

• Most behavioral health professions (social
  workers, psychologists, certified substance abuse
  counselors, and others) have a Code of Ethics
  that defines appropriate behavior.

Though the Codes may vary for different
professional disciplines, each supports doing no
harm, and always acting in the client or
individuals best interest. Consider the code of
ethics pertaining to your area of professional
expertise, as well as your agencys code of
ethics/conduct when dealing with client contact,
services and issues.
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Ethics, Laws Morals
Ethics are distinct from, but closely tied to
laws and morals.
Laws dictate what is legal they are established
by the government to protect the citizens, and
are enforced by police and the courts.
Morals are concerned with the judgment of human
character typically, morals have to do with the
right conduct of people, and are often determined
by societal norms.
How do Ethics, Laws Morals work together?...
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Ethics, Laws Morals
Ethics are everywhere. Consider the following
topics youve likely read or heard about in the
news

• Capital Punishment
• Death with Dignity (assisted suicide)
• Right to Choose (abortion)
• Stem Cell Research

Some decisions or actions associated with these
topics may be legal, yet a person may question or
debate the ethical or moral correctness of these
issues.
We will encounter ethical situations in our work.
Lets find out our role when these occur
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Evolving Ethics
Knowing your agencys Code of Ethics is vital,
but your relationship with ethics doesnt stop
there. Its important to realize that ethics are
constantly evolving. Considering the changes in
the delivery of behavioral health services
illustrates this. In the past, individuals
receiving services were usually restrained,
committed to hospitals against their will,
forcibly medicated, and often had little or no
say in the services/treatments they were
subjected to. Today, we strive to include the
individual in decision-making and service
planning. Clinical teams include the individual
and use natural supports to ensure services are
the most appropriate and effective. The ethics
of our profession dictate this client involvement
and a focus on client rights and empowerment. It
is also important to keep in mind that culture
will have an impact on peoples/clients ethics
and their views of correct/acceptable behaviors.
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Applying Ethics
What can you do when an ethical dilemma arises?
When you find yourself in doubt, hesitating, or
questioning yourself about how to proceed - you
are probably faced with an ethical situation.
Generally, before you proceed you should

• Stop take no further action step back from the
  situation
• Gather all the facts regarding the
  issue/situation
• Consider the impact (on the client, you, your
  agency) of your possible courses of
  action
• Talk with your supervisor
• Discuss with the clinical team, if indicated
• Review your agencys Code of Ethics and consider
  what
• company values and ethical
  principles are relevant

There is a mnemonic device that can help you to
remember this course of action
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Applying Ethics

• A mnemonic device that may be helpful with
  approaching ethical dilemmas

Evaluate your facts for accuracy Think about all
possible courses of action Handle your decision
as if it was going public Identify potential
consequences of your decision Consider if your
decision is setting a precedent Stop if you are
in doubt - ask for direction
Now, lets move on to a related topic
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Boundaries
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Exploring Boundaries

• What are boundaries?

Boundaries are the invisible limits between
professionals and the individuals we serve that
protect the people we serve from exploitation or
harm, and help protect us from physical,
emotional, or legal ramifications.

• Boundaries
• allow for a safe, trusting, clinically-focused
  connection and relationship to exist between
  behavioral health workers and clients
• protect the space between the professionals
  position of power and the clients vulnerability.

Establishing and maintaining clinically
appropriate boundaries is one of the most
important ethical foundations in our profession!
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Boundaries Whos Responsible?
Boundaries do not automatically occur - they must
be established and maintained.

• It is our responsibility as behavioral health
  workers to establish
  and maintain boundaries - it is not the
  responsibility of the individuals we serve to do
  either of these.
• Once we discuss and establish boundaries with
  clients, we must help maintain these boundaries
  by regularly reminding clients about them and
  reinforcing these boundaries through our words
  and actions.

Considerations for establishing boundaries
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Establishing Boundaries

• Boundaries should be discussed/established at the
  outset of the clinical partnership or
  relationship (and reinforced throughout the
  course of services)
• Talk to your client about

• roles, responsibilities and expectations - for
  you and for them
• what the clinical/professional relationship is
  and isnt - how it differs from casual or
  personal relationships
• appropriate and inappropriate behaviors and
  limits to services and your availability

Note Establishing boundaries with co-workers is
also vital. Understanding the role of
boundaries in these professional relationships
may be difficult - this may be a topic to
discuss with your supervisor.
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Boundaries Dual Relationships

• A dual relationship occurs when in addition to
  the professional relationship with the client -
  or former client - another relationship exists.
  This additional relationship may involve the
  client as a friend, partner, student, family
  member, or business partner.
• Dual relationship examples include

• Seeing the client outside the clinical
  setting/parameters - attending social events
  together, establishing a friendship, tutoring,
  dating.
• Any business arrangement - buying from or selling
  to the client any item having a client work on
  your house or car having a client babysit your
  kids getting a massage from a client.
• Gift giving or receiving doing favors for the
  client (outside of clinical actions) or having
  them do favors for you.
• If you over self-disclose, and the client is
  counseling you.

Dual relationships may be confusing, harmful, or
exploitive for the client.
They should always be avoided, with
current and former clients!
If
you have questions or concerns seek supervision!
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Crossing a Boundary Line
Most behavioral health workers do not purposely
cross boundaries or practice inappropriate
behaviors. Boundaries often get crossed
unintentionally - and the result is often seen by
a change in behaviors (yours and/or the members)
or changes in the clinical relationship
gt late to or missed appointments gt less client
openness/honesty gt reduced focus in clinical
issues gt reduced communication
gt a reduction/halt to clinical progress gt change
in attitude - yours or theirs gt discomfort -
yours or theirs

• If you believe a boundary (yours or theirs) has
  been crossed
• discuss your concerns with the client (unless
  doing so would cause additional problems)
• discuss the situation with your supervisor right
  away

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Boundaries and Work Roles
Establishing and maintaining boundaries in
behavioral health used to be much simpler.
Oftentimes, the client worked with one, or maybe
two behavioral health staff when planning and
receiving services, and there were clear
lines/boundaries between these well-defined roles.
In todays behavioral health, in promoting the
recovery model, clients find they often have
several individuals and entities that make up
their clinical team and provide services. Many
roles/positions, including Support Specialists,
may interact with clients in various settings -
some of these non-therapeutic. All behavioral
health staff, regardless of position or role,
must be constantly aware of boundaries, always
maintaining appropriate, ethical behavior and
boundaries, even in casual settings.
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Results of Crossing the Line

• FOR YOU / YOUR AGENCY
• you or your agency could be sued
• you may lose your job
• loss of your professional license / your agency
  could be sanctioned you may ruin your/your
  agencys professional image and reputation

• FOR THE INDIVIDUAL SERVED
• damage to their physical, emotional, or mental
  well-being
• leaving services or the discontinuation of
  services
• client may not want to access behavioral health
  services in the future

Lets look at a couple of scenarios about ethics
and boundaries
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Scenario 1
In a casual conversation at work, one of your
colleagues tells you that she ran into the father
of a former child client. Although the child is
no longer a client with your agency, she is still
receiving services from another system provider.
Your colleague goes on to tell you that she had
always thought the father was attractive and as
the two of them were talking recently she decided
to ask him out for coffee. Your friend tells you
she has a date with him this weekend.
What ethical topic does this involve? What
do you do?
Click on this box for answers
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Scenario 1 - Discussion
What Ethical topic does this address?
The issue deals with Boundaries and Dual
Relationships.
What do you do?
The legal issue - There could be a stipulation
against relationships with former clients in your
agencys code of conduct. There may also be a
statute of limitations (how long a client must be
gone from the agency before establishing a
relationship). If none of these apply then there
is no legal issue. The ethical and moral issue
- The relationship with the daughter was
established within a power-differential dynamic,
so it is not advisable and probably not ethical
for your co-worker to pursue a relationship with
the father. You should advise your co-worker
of these ethical issues discuss this situation
with your supervisor.
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Scenario 2
When you first meet Cordell, you think he seems
familiar, but its not until later that you
realize you are providing services to your
neighbors 17 year-old son. You typically have
dinner with his mother once a month at a home
owners association picnic. You sometimes talk
about your work at these picnics, but you dont
ever use names do you continue working with
Cordell? What ethical topic does this
involve? What do you do?
Click on this box for answers
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Scenario 2 - Discussion
What Ethical topic does this address?
The issue deals with Boundaries and Dual
Relationships.
What do you do?
The legal issue - There are no legal issues
involved. The ethical and moral issue - This is
a classic example of a dual relationship (since
the client is the son of a friend you have
regular contact with). You should discuss the
situation with your supervisor and explain to
Cordell that you must transfer his case to
another behavioral health worker.
Next, well examine confidentiality and privacy
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HIPAA, Privacy and Confidentiality
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Understanding Confidentiality

• Confidentiality is our professional
  responsibility to protect the privacy and
  personal information of the individuals we serve.
• Maintaining confidentiality is part of being
  ethical and setting good boundaries.
• Laws, including HIPAA (Health Insurance
  Portability and Accountability Act), protect
  privacy and highlight the legal importance of
  confidentiality.

In our profession, we often need to share
information with others about the individuals we
serve. In order to do so legally and ethically,
an Authorization of Release of Information form
must be signed by the client, and maintained in
their clinical record.
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Limits of Confidentiality
Keeping client confidentiality does have limits
(sometimes called exceptions) that often center
around safety issues. The following situations
would allow us/mandate us to break
confidentiality

• Client is a danger to themselves
• Client is a danger to others (in this case we are
  also obligated to warn that person or persons
  about this danger - called Duty to Warn)
• Abuse, neglect or exploitation of children or
  dependent adults - you are a mandated reporter
  of these situations
• A client-signed Release of Information
• Certain medical emergencies or legal proceedings

Get direction from your supervisor before
breaking client confidentiality!
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HIPAA

• The Health Insurance Portability and
  Accountability Act of 1996 is a federal law
  that protects personal protected health
  information (PHI) held by covered entities (i.e.
  your agency).
• Gives patients the right to examine their
  information and clinical/health records.
• The Privacy Rule regulates how covered entities
  use and disclose individually identifiable health
  information (PHI).
• The Security Rule establishes a national set of
  security standards for protecting certain health
  information that is held or transferred in
  electronic form.

A little more on PHI
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Protected Health Information (PHI)
PHI Individually identifiable health information
that is transmitted or maintained in any form or
medium by a health care / mental health care
entity.

• Examples of PHI
• client name, DOB, address, SSN, photo, etc.
• a list of medications taken by a specified
  individual
• a list of names of individuals diagnosed with
  ADHD in the past year by a specific provider
• use of real service documentation (even with name
  deleted) in training that includes specific
  details about an individual where he/she could be
  identified due to her unique challenges and
  situation

PHI must be protected - not shared - at all times
(unless a safety issue is present or authorized
by client to share)
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Disclosure Confidentiality
Disclosure is the release, transfer or provision
of access to PHI to parties outside the entity
holding the information.
The Minimum Necessary Standard directs that we
disclose (with client permission/authorization)
only the minimum information necessary to
accomplish an intended communication of
information.

• When disclosing information, ask yourself
• Does this person need to know what I am telling
  him/her?
• Is there an appropriate Release of Information
  form in the chart/file regarding release of this
  information to this recipient?

Disclosure must only occur when the recipient has
some direct bearing on the individual case. For
instance, disclosure to the individuals
Vocational Rehabilitation Counselor may be
appropriate disclosure to a Case Aide not
involved may not be.
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More on Confidentiality

• Persons with substance use and/or HIV positive
  status are protected by additional laws and
  documentation guidelines

Information on substance use and HIV status is
highly confidential due to its nature. This
information can only be released with specific
written authorization from the individual
identifying these two areas.
Consult your supervisor before releasing any
information regarding substance use or HIV / AIDS
status.
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Maintaining Confidentiality
Specific practices ensure confidentiality is
maintained in all communication forms. These
include the following recommendations
and requirements

• Electronic Communication
• Encrypt confidential emails, especially those
  containing any client PHI - find out how this is
  done at your agency!
• Use password protection on your computer - do not
  share your password!
• Dont store PHI on shared drives, removable
  drives or portable devices which can be stolen or
  misplaced.
• Lock your computer/workstation when not in use -
  even if you step away from your computer only for
  a minute!
• Find out your agencys email and faxing security
  rules and regulations.

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Maintaining Confidentiality (cont.)

• Verbal Communication
• Dont listen to messages or make phone calls on
  speaker phone if others may hear - always be
  aware of your immediate surroundings when talking
  about clients, on the phone or otherwise.
• Avoid talking about individual client issues or
  sensitive matters on cell phones or in public
  places - even if you dont use the clients name,
  you may still talk about issues/situations that
  make them identifiable.
• When answering calls from outside your agency,
  and you dont know the caller, do not divulge
  whether a person is a client at your agency.
• Always be aware that whenever you speak in your
  office, your building or out
  in public, what you say may be overheard.
• Be cautious when sharing information over the
  phone - make
  sure you know the identity of the person you
  are speaking with
  and make sure an appropriate Release of
  Information is in the
  file/clinical record.

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Maintaining Confidentiality (cont.)

• Written Communication
• Secure records in secure/locked cabinets or
  rooms.
• Be cautious when using or transporting files
  turn files/client information over on your desk
  if someone approaches lock files in your desk if
  stepping away from your desk, even momentarily.
• Written materials/records should never be taken
  out of the building unless under special
  circumstances - check your agency policy.
• Dont leave documents on fax machines, copiers,
  or in any public spaces - retrieve items
  immediately.
• Shred or properly dispose of unnecessary
  documents - this
  includes all written information
  (post-it notes, messages,
  fax cover sheets, etc.).

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Impact of Violations

• HIPAA violations can be civil (unknowingly/uninten
  tional violation) and criminal (knowingly/intentio
  nal violation) in nature - both could result in
  substantial fines and/or prison terms.
• Privacy violations can lead to damaging a
  members reputation, cause stigma around a
  particular issue and lead the member to lose
  trust in you, your agency and the Behavioral
  Health System.
• Violations of confidentiality can also cause
  damage to the members emotional and/or physical
  well-being which may delay their recovery
  process.

Lets consider a couple more scenarios
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Scenario 3
You are attending an interagency training meeting
with several people from partner agencies. One
of the staff at your agency is in charge of a
training session during the meeting. She is
passing out a detailed service plan that she says
she created to use for this training. She begins
to go through the service plan discussing the
medications which the client is taking. As she
continues to talk you recognize that this is an
actual client that you used to see when you
worked at another agency. A couple of staff
members from that agency are also in the
meeting. What ethical topic does this
involve? What do you do?
Click on this box for answers
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Scenario 3 - Discussion
What Ethical topic does this address?
The issue deals with Confidentiality -
specifically HIPAA and PHI
What do you do?
The legal issue - There is an issue with
breaking HIPAA laws regarding Protected Health
Information. The ethical and moral issue -
Along with being a legal issue, it is ethically
inappropriate to breach client confidentiality
and privacy by disclosing PHI, even when not
divulging the clients name. You should take
the training person aside and explain to her how
she has just violated HIPAA laws - even though it
was unintentional. Review this situation with
your supervisor.
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Scenario 4
You work at an agency that provides therapy. You
and another employee are in the company break
room when you overhear two therapists discussing
a clients marital issues. Your co-worker tells
you that from what she is hearing she knows who
the client is and that she plays softball with
the clients partner. What ethical
topic does this involve? What do you
do?
Click on this box for answers
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Scenario 4 - Discussion
What Ethical topic does this address?
The issue deals with Confidentiality
What do you do?
The legal issue - There is not a legal issue
involved in this scenario. The ethical and moral
issue - The therapists are breaching
confidentiality. You should approach the
therapists and let them know you can identify the
client they are referring to - they are breaking
confidentiality. You should discuss this event
with your supervisor.
On to our last topic, Fraud and Abuse
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Fraud and Abuse
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Fraud and Abuse Introduction
Monitoring and minimizing fraud and abuse is a
vital component of being ethical in this
profession

• Fraud and abuse can adversely affect the ability
  of an organization to effectively provide
  services.
• Fraud and abuse can result in an organization
  being sanctioned and fined into the tens or
  hundreds of thousands of dollars.

As an employee of an entity receiving public
funds (government money) you are mandated to
report fraud or abuse - whether it is known, or
even suspected.
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Fraud and Abuse Definitions

• What is fraud?
• Fraud is an act of intentional
• deception or misrepresentation
• made by a person with knowledge
• that the deception could result in some
• unauthorized benefit to himself/herself or some
• other person.

This includes any act that constitutes Fraud
under applicable Federal or State law.
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Applicable Laws Regulations

• 31 USC 3729- 3733 False Claims Act
• A.R.S. 13-2311 Fraudulent Schemes and Practices
• A.R.S. 36-2918 Medicaid False Statements
• A.R.S. 36-2918.01 Duty to Report Fraud and Abuse
• A.A.C. R9-22-101 Civil Monetary Penalties
  Assessments

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Fraud and Abuse Definitions

• What is abuse?
• Abuse includes (sometimes unintentional)
  activities
• that are inconsistent with standard fiscal
  business
• or medical practices that result in unnecessary
• costs to AHCCCS, ADHS/DBHS and/or your agency.
• Note Individuals receiving services can also
  commit acts of abuse (for example, loaning or
  selling an AHCCCS identification card).

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Fraud and Abuse - Penalties

• Regardless of whether an action is intentional or
  unintentional fraud or abuse, there are legal
  consequences - often involving fines, sanctions,
  restitution and possible incarceration

If convicted of fraud, a person is usually
charged with a criminal offense. If convicted of
abuse, a person is usually charged with a civil
offense.
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Types of Fraud and Abuse

• Financial misconduct
• Fraudulent reporting of services
• Billing for services not rendered
• Billing for unnecessary services
• Billing for a higher level of service than was
  performed
• Misrepresentation of credentials
• Falsification of records

Waste and wasteful practices are now being looked
at as forms of abuse.
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Examples of Fraud and Abuse

• Examples
• A staff member reports visiting a members house
  for one hour, but was only there for 30 minutes
• A staff member encounters for therapy, but
  doesnt meet the billing qualifications
• A staff member writes inaccurate information in
  the chart
• A staff member submits encounters/claims for
  services that are not a medical necessity
• Personal purchases on the company credit card
• Theft of inventory items
• Theft of cash from deposits
• Falsifying time card with time not worked
• Using company vehicle for personal use
• Using company phone for personal long-distance
  calls

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F A Your Responsibility

• If you know of or suspect fraud or abuse, it is
  your responsibility to contact
• your supervisor
• OR your supervisors supervisor
• OR your agency Compliance Officer
• OR Human Resources at your agency

If outside or additional assistance is needed,
contact CPSA Fraud and Abuse Hotline
520-318-6964 ADHS/DBHS Compliance Officer
866-569-4927 AHCCCS Office of Program Integrity
602-417-4045 Calls can be made anonymously
Lets look at a couple final scenarios
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Scenario 5
As a new employee, you are assigned to shadow
Vera, a highly respected clinician at your
agency. Vera tells you about how important
billing units and correct billing codes are, and
you observe her documentation. You notice a
pattern that she documents sessions for at least
1 hour, and sometimes even longer, when she
rarely spends even half that time in the session.
Is Vera committing fraud or abuse?
What, if anything, should you do?
Click on this box for answers
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Scenario 5 - Discussion
Is Vera committing fraud or abuse?
Vera is committing Fraud, as she continually
reports inflated session times - this is
intentional.
What, if anything, should you do?
You might question Vera, to be sure that you
understand what you believe to be proper billing
procedures. It would be appropriate to
immediately discuss the situation with your
supervisor.
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Scenario 6
You are a BHPP. You are completing assessments
for your agency. Your supervisor has told you
not to sign the assessment document and intake
forms after youve completed them but to hand
them off to your colleague, a BHP who will sign
them, as if she had completed the
assessments. Is this Fraud or
Abuse? What, if anything,
should you do?
Click on this box for answers
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Scenario 6 - Discussion
Is this Fraud or Abuse?
This is Fraud. The person who completes the
assessment must be the person whos signature
signifies this act. A BHP will sign off on the
assessment showing that he/she reviewed the
document that the behavioral health technician
completed and signed. A BHPP is not qualified to
provide this service.
What, if anything, should you do?
You should immediately discuss this practice with
your supervisors supervisor, or with Human
Resources.
That about wraps up the topics for this module
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Additional Information

• Can be found in the Provider Manual
• Section 4.1 Disclosure of Behavioral Health
  Information http//204.17.36.18/docs/4.1(12-1-10)
  .pdf
• Section 7.1 Fraud and Program Abuse Reporting
  http//204.17.36.18/docs/7.1(12-1-10).pdf

Remember to learn about your agencys
expectations, requirements and procedures
regarding ethical behavior/decisions,
confidentiality and disclosure, and fraud and
abuse. You play a vital role in ensuring
services are delivered in an ethical,
confidential and fiscally sound manner.
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In Conclusion

• We are here to serve members and their families.
• Remember key ethical standards and seek input
  when making ethical decisions.
• Observe client confidentiality and HIPAA rules at
  all times.
• Respecting and protecting members privacy is
  essential.
• Report fraud and abuse - observed or suspected.

Please complete your Post-Test / Final Exam at
this time