Chapter 3: Medicolegal & Ethical Responsibilities

Medical ethics

Are not laws but are standards of conduct generally accepted as a moral guide for behavior.

Oath of Hippocrates:
-based on the golden rule that to be a good physician one must first be good and kind person.

The first standards of medical conduct and ethics.

The Modern Hippocratic Oath

Updated by Dr. Louis Lasagna

AMA

American Medical Association

Generally accepted practice procedures:
A physician...

1) may ethically receive payments from patients but cannot accept rebate of any kind
2) may accept small gifts (e.g., plastic anatomic models, stethoscopes, booklets) but may not ethically accept large "gifts" from manufacturers or distributors of pharmaceuticals, remedies, or equipment
3) may employ a collection agency to try to collect overdue bills but may not sell delinquent accounts to the agency

Hippocrates

(c. 460 B.C. - 733 B.C.)
-Greek physician aka the father of medicine
-developed a code, the Oath of Hippocrates

Bioethics

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One of the most common unethical acts that occur in an office is

Theft-in the form of misuse of office equipment, such as copy machine to copy your taxes, using the fax machine to send something personal, using company time to send e-mails or look at Facebook, or taking office supplies home.

Ethical conduct, a medical assistant should:

1) remember that everything seen, heard or read about a patient is confidential & should not leave the office; before patient information is released, the patient must sign an authorization form for release of info unless subpoenaed
2) apply discretion when speaking or using intercoms
3) avoid talking about anything of private nature when speaking to a physician via cellular or telephone
4) never discuss a patient's condition within hearing distance
5) sidestep discussing a patient with acquaintances or the patient's friends
6)never leave a patient's records lying exposed
7) remain loyal to your employer; do not criticize the physician to a patient
8) communicate with courtesy
9) notify the physician if patient is being treated by another physician of the same ailment
10) avoid dishonest or unethical coworkers

Medical etiquette

is the customary code of conduct, courtesy, and manners in the medical profession.

HIPAA

Health Insurance Portability & Accountability Act of 1996
1) enhance portability (transferability)
2) increase accuracy of data
3) protect private health info & the rights of patients
4) reduce fraud, abuse & waste
5) upgrade efficiency & financial management
6) expedite claim processing
7) lower admin costs & simplify implementation
8) promote medical savings accounts
9) avail better access to long-term care coverage
10) improve customer satisfaction to restore trust

Title I: Health Insurance Access, Portability, and Renewal

increase transferability of health insurance when employees change jobs. it does this by prohibiting preexisting condition exclusions, disallowing discrimination of health insurance coverage based on health status, and guaranteeing renewability for certain group health plans.

Title II: Health Care Fraud, Abuse, Prevention, and Administrative Simplification

prevents fraud and abuse in health care delivery and payment for services, establishes guidelines to simplify administrative procedures, provides national standards to protect privacy, and mandates electronic transmission of certain health information.

Title III: Medical Savings Account (MSA) Benefits

addresses the MSA, increases deductions, adds consumer protection, and addresses income tax refund payments.

Title IV: Group Health Plan Directives

details how group health plans must all for portability, access, and renewability for members.

Title V: Internal Revenue Code Amendments

explains changes in the Internal Revenue Code of 1986 so that more revenue is generated to offset costs of implementing HIPAA.

Title XI: General Provisions

focuses on Medicare-related plans and addresses the coordination of general provisions, peer review, and administration simplification.

Title XXVII: Portability Assurance

speaks to the carryover of health insurance plan from one plan to another.

Compliance to HIPAA standards affects all covered entities such as:

health care professionals, health pans, health care clearing-houses, and hospitals who either provide health care or send data that is protected under HIPAA law.

PHI

Protected Health Information
-defined as information about the patient's past, present, or future health condition that contains personal identifying data

Under HIPPA's privacy rules for PHI, patient's have the right to:

1) receive notices of privacy practices
2) access medical and financial records
3) ask for an amendment to the medical records
4) receive an accounting of disclosures made
5) request restrictions on disclosures for certain uses not for TPO (to treat the patient, to receive payment, or for normal business operations).
6) ask that all communication be confidential

HITECH

Health Information Technology for Economic and Clinical Health
-American Reinvestment & Recovery Act (ARRA), that was passed February 2009
-added new breach notification requirements for disclosure of health information

According to present HIPAA privacy rules, an individual can ask fr a covered entity to restrict are disclosures for the purpose of treatment, receiving payment, or day-to-day operations (TPO); however,

the covered entity is not required to agree to the request.

HITECH Act
A covered entity must grant a request for a restriction if:

1) the disclosure is to a health plan for purposes of either payment or health care operations, and
2) the personal health information pertains to a service for which the patient paid in full, out of pocket

HITECH applies universally--

for all health care plans (i.e., Medicare, Medicaid, TRICARE, state commercial insurance plans, and the Employee Retirement Income Security Act). the medical record must be flagged so that records are not disclosed should a record request be received.

Compliance plan

is a written document that includes office policies and procedures, rules to follow, and practice standards that are monitored through internal auditing.
it is an ever-changing program that recognizes challenges, address problem areas, and identifies risk to the medical practice.
it ensures compliance with HIPAA law, federal, state, and local laws that affect the medical practice.

Compliance officer

who may also be the security & privacy officer, needs to be named as the professional who conducts ongoing educational training sessions, identifies offenses, responds appropriately, and develops corrective action.

HIPAA violations:

Privacy Practices
-not given to every patient upon registration
Protected Health Information
-discarded in regular trash
-left unattended on computer screen
-transported in an unsecured fashion
-discussed openly with no regard to privacy
Medication
-stored in unsecured place
-charts left open and unattended
-printouts in regular trash
Patient diagnosis
-recorded on sign-in sheet
-referred to openly
Identification badges
-not worn by employees
-contain incorrect job title

Security rule

interacts with the privacy rule as well as covering physical and technical safeguards; policies, procedures, and documentation requirements; risk analysis and risk management; and administrative safeguards to secure electronic protected health information.

Confidentiality

keep information about patients confidential, refrain from talking about patients and their problems where outsiders ma overhear, a medical record contains privileged information; therefore, it must not be mislaid so other individuals can see it or leaf through it.

Consent form

use and disclosure of protected health information for treatment, payment, and health care operations (TPO)

Authorization form

for use and disclosure of protected health information for specific purposes, other than TPO

Restricted Record Access

if patient has HIV or AIDS, information cannot be disclosed unless patient signs authorization form

Patients Receiving Records

if patients request to access, read, or copy their medical records the request must be honored, generally within 30 days

Medical Litigation (lawsuit)

the patient waives the right to confidentiality and the physician's lawyer has access to the patient's medical record, the attorney would then limit authorizations to disclose medical info

Medicare, Medicaid, and TRICARE Records

guarantees those receiving benefits to have access to their records

Employers Receiving Records

special attention is required when info is to be released to an employer even with the patient's signed authorization. the exception is in workers' comp cases.

Publications Release

if patient's medical record or photograph is requested, the authorization form must contain wording that indicates the info or photography is to be used in this manner

Psychiatric Records

physician should always consult with patient before releasing info even if there is a signed authorization form

Minimum necessary standard

in which you make a reasonable effort to limit the info to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.

Quackery

individuals who falsely represented having medical skills and offered cures of diseases by selling appliances and medicinal elixirs.

Physician Licensure

renewed annually, or every 2 years by payment of a licensing fee and acquiring the required continuing education units

Scope of Practice

is the range of education, training, ability, and skills a health care professional is expected to have and operate within according to the law ans within the standard care, that is, what an individual is expected to do or not to do in a given situation.

Medical Malpractice aka "bad medical practice" or referred to as medical professional liability

a doctor's failure to exercise the degree of care and skill that a physician or surgeon of the same medical specialty would use under similar circumstances.

2 types of medical liability insurance

1) claims incurred, or occurrence, insurance; the insured is covered for any claims arising from an incident that occurred or is alleged to have occurred during the policy period regardless of when the claim is made
2) claims-made insurance; the insured is covered for any claim made rather than any injury occurring while the policy is in force

Respondeat Superior aka "Let the master answer

also known as vicarious liability, applies to the relationship between the physician and the medical assistant. in other words, physicians are legally responsible for their own conduct and for any actions that a medical assistant might take while in their employ.

Medical assistants want to purchase individual protection:

they can would purchased medical professional liability insurance

Criminal Laws

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Civil Law

is the statute that enforces private rights and liabilities involving relations between individuals, corporations, government entities, and other organizations

Administrative Law

governs the activities of government agencies such as the IRS, medicare and medicaid.

Contract Law

addresses legally-binding contracts

Physician-Patient Contract

1) expressed contract: direct verbal or written statement
2) implied contract: not expressed by direct words but gathered by implication

Third Party Contracts

someone else implying they will pay for the medical bill (but may not)

Contracts and Emergency Care

medical assistant should do only the absolute essential if a physician is not present and contact 911

Good Samaritan Law

designed to encourage physicians to provide care in circumstances where they have no legal obligation to do so, without fear of being sued should things not turn out well

Contracts with Minor

minors need parental authorization unless of emergency care

Emancipated minors

children of any age who fall outside the jurisdiction and custody of their parents or guardians
-living apart from parents & guardians managing their own financial affairs
-married or divorced at any age
-on active duty
-college student living away from home
-a parent

Terminating a Contract

terminate a contract legally
1) send an "at risk" letter to warn patient

Reasons for terminating a contract

patient continues to disregard a recommended plan or if the patient is not to be seen again, appropriate letter written to document the action

Abandonment

terminates supervision without notifying patient in writing

Confirmation of Discharge

if a patient discharges a physician by telephone or discharges him- or herself from a hospital setting, the physician send a letter.

Tort Law

action brought when one person believes that another person conducted wrongful act and caused harm, and compensation for the damage or injury is being sought by the party bringing action

Intentional Tort

-assault & battery
-invasion of privacy & breach of confidential communication
-defamation of character, libel, and slander
-false imprisonment or personal restraint of the patient
-intentional infliction of emotional distress
-fraud or deceit

Negligent Torts: failure to exercise reasonable care or careless conduct outside the accepted standard of care

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Malfeasance

unlawful or improper treatment of the patient

Misfeasance

lawful treatment that has been done in the wrong way

Nonfeasance

failure to act when the physician has a duty to do so

Malpractice

carelessness or negligence of a professional person

Criminal negligence

reckless disregard for the safety of another; being indifferent to an injury that could occur

Contributory (comparative) negligence

patients act in such a manner as to contribute to their own injury, disability, or disfigurement

Assumption of risk

refers to a patient voluntarily participating in an activity with the knowledge that the activity entails some level of risk for which the patient signed a document giving informed consent

Statute of Limitations

applies when the time limit for legal action on medical negligence has been exceeded

Risk management

involves identifying problem practices or behaviors, then taking action to control or eliminate them.

Fidelity bond

is insurance against embezzlement

Bonding an employee

an insurance or bonding company guarantees payment of a specified amount to the physician in the event of financial loss caused by an employee or by some contingency over which employee handling money has no control

3 effective bonding methods:

1) position-schedule bonding aka name schedule or umbrella bond: offers coverage for a specific job rather than a named individual
2) blanket-position bonding: coverage for all employees
3) personal bonding: coverage for those who handle large amounts of money; a thorough background investigation is required

Patient Care Partnership

what to expect during a hospital stay, how to prepare when going home, what info will be needed from the patient, rights and responsibilities regarding privacy, medical bills, and insurance claims

Demurrer

opposing side may file a motion to have the case dismissed if there are not sufficient grounds for actions

Screening panel

physician review panel, that hears cases outside the courtroom in the hope of solving them without the expense, publicity, and difficulty of court proceedings.

Arbitration

this process is used when a patient and physician have agreed before treatment that both will waive right to a court trial in case of a dispute
-resolve before an impartial panel or grievance committee

No Fault Insurance

injured person is compensated without regard to fault

Informed consent

patient accept the risks and signs a consent form acknowledging the assumed risks, which include the chances of success or failure of the treatment

It is essential that medical records..

be accurate, complete, up to date, and readable reflecting the history, physical examination, assessment, and treatment plan, this doc is necessary to provide the best medical care, justify services billed to the insurance company and defend a physician in the event of a lawsuit.

Subpoena

literally means "under penalty," and it is an order by the court for witness to appear at a designated place to give testimony

Expert testimony

considered an authority on the subject matter and provide a statement that is scientific, technical, or professional in nature

Percipient witness

who merely describes what he or she did, said, and observed about a given set of circumstances.

Subpoena duces tecum

under penalty you shall bring with you...

PSDA- 1991

Patient Self Determination Act aka Danforth Bill or Medical Miranda Rights for Patients Act
-requires hospitals, hospices, physicians' offices, skilled nursing facilities, and home health providers to ask each patient whether he or she has drawn up an advance directive

Advance Directive

living will or health care power of attorney

Living will

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Health Care Power of Attorney

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Medical Directive

Ezekiel & Linda Emanuel, developed the detailed document:
-it allows patients to specify what they would and would not want done in four specific dire situations by answering 48 questions

Values History Form

another advance directive developed to try to uncover a patient's valve system and to guide a physician's decisions about treatment

Health Care Proxy

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Do Not Resuscitate Form

do not resuscitate

Uniform Anatomical Gift Act: Uniform State Laws in July 1968

competent adult to make disposition of all or part of his or her body for transplant or research purposes.