HPA 332 Quiz 3

Protocols

Appropriate ways in which a leader acts.

Stark I

Enacted to deal with physician self-referrals, often referred to as the Ethics in Patient Referrals Act. Makes it illegal for a physician to make a Medicare financed referral to an organization in which he or she or a family member has a financial interest. Also prohibits billings by a laboratory for services provided pursuant to illegal referrals.

Leaders have an _____ focus

External

Managers have an _____ focus

Internal

Malfeasance

Performing an illegal act

Internal control of compliance programs are now the responsibility of

The board, management and other internal personnel

Major amendments to the FCA

(1986) Removed the clause requiring that there be a specific intent to defraud the federal government and that the government need only show that the claim submitted is false and submitted knowingly.

Theories of leadership

1.) The leader is able to both complete tasks and create working relationships 2.) Leaders can be more effective if they establish relationships with subordinates 3.) Leaders remove obstacles for employees to achieve success 4.) The leader can adapt his/her actions to an employee's needs 5.) Leadership ability is based on style as well as the circumstances in which he/she works

The Criminal Disclosure Provision

A felony for a healthcare provider or beneficiary to possess "knowledge of the occurrence of any event affecting: payment, to conceal or fail to disclose such event with an intent fraudulently to secure such benefit or payment

Patient Self-Determination

A law that requires healthcare organizations to inform patients of their rights as they pertain to their ability to determine their own health care. For instance, a patient would be informed about their right to consent, their ability to accept and refuse care, and advanced directives.

OIG published...

A list of 8 essential elements of an effective compliance program. They are part of the Federal Sentencing Guidelines. For this to be effective, all employees must be aware of the plan.

EMTALA Mandates...

A medical screening exam be given to any patient who presents to a provider of emergent or urgent care. The patient must be treated and discharged or admitted as an inpatient and transferred from the ER

Monitoring

A process that assesses the quality of internal control performances over time

Motivation

Ability to enjoy challenges and being passionate towards work.

Legal

Action is required by law, legal consequences may occur if no action is taken. Many professionals have a duty to report based on law, results from numerous areas of law such as rules of professional responsibility, legislative action, court rulings, and so on. Individuals may face criminal sanctions if they deviate from the law.

Self-Regulation

Adaptability to changes and control over impulses

End of life care issues

Advance directives, surrogate decision-makers, care in the absence of clear directives, decisions about life-sustaining treatment, balancing familial, societal, and practitioner rights and responsibilities

Low Emotional Intelligence

Aggressive, demanding, egotistical, bossy, confrontational. Easily distracted, glib, selfish, poor listener, impulsive, resistant to change, passive, un-responsive, slow, stubborn, critical, picky, fussy, hard to please, perfectionist

To the Employees

Allow free expression, ensure a safe workplace environment, follow nondiscrimination policies

Technical

Analytical, writing, knowledge of regulations

Stark II was adopted for other

Ancillary services

Emotional Intelligence

Another dimension of intelligence. Empathy, self-awareness, self-regulation, social skills.

False Imprisonment

Another form of intentional tort. Could include inappropriately restraining a patient or keeping someone in a more restrictive level of care than necessary.

The Sherman Antitrust Act

Applies to agreements that unreasonably restrain trade. These include, but are not limited to: price fixing, boycotting other organizations, dividing market territories, and using coercive tactics with the intent to harm or injure another party. Applies to virtually all businesses in the country, including health care.

Patient Responsibilities

Ask questions of their providers, provide accurate information to the provider, follow the care plan agreed upon with their provider

High Emotional Intelligence

Assertive, ambitious, driving, strong-willed, decisive, warm, enthusiastic, charming, persuasive, patient, stable, predictable, consistent, good listener, detailed, careful, meticulous, systematic, neat

Under civil law malpractice can

Be simple carelessness

Provider Rights

Be treated with fairness and dignity by their employers, be protected from sexual or other types of harassment, generally be able to excuse themselves from patient care with which they disagree

Autonomy

Capacity to think, decide and act independently, and with free will

Competencies

Certain skills, knowledge, and abilities

Under-Coding

Charging less than what should be charged for a procedure

Interpersonal Competencies

Communication, motivating, empowerment of subordinates, management of group process, conflict management and resolution, negotiation, formal presentations, social interaction

To the Profession

Comply with laws, avoid any conflicts of interest, respect confidences

Abuse

Consists of improper acts that are unintentional but inconsistent with standard practices.

Five components of internal control

Control environment, risk assessment, control activities, information and communication, and monitoring

Behavioral skills

Decisiveness, organized, work/life balance

Malpractice

Defined as negligence or carelessness of a professional person.

Coercive

Demanding and power based. Problematic employees

Intentional Tort

Depends on proving that the harm was committed deliberately. In healthcare, surgery mistakenly performed on an unconscious patient without his/her consent.

Anti-Kickback Act

Designed to prevent the offer or payment of bribes or other remuneration as an inducement to refer Medicare patients for treatment or services.

Great Man Theory

Developed out of the idea that certain traits determined good leadership. The traits that were recognized as necessary for effective leaders were ones that were already inherent in that person. (1920s and 1930s).

Justice

Distributive (access to same); respect for the law; rights; and retributive (fit punishment to the crime)

Non-maleficence

Do no harm

Kefauver-Harris

Drug safety through FDA empowerment, 1962

Tort Law

Duties are determined by law. Parties are generally unknown. Individuals do not consent. Legal action is available. Damages are awarded and are the only remedy. Damages are normally decided by a judge or jury that makes a decision based on the evidence.

Contact Law

Duties are determined by the parties who are privy to the contract. Parties are known as those that have been contracted with. Consented to. No legal action for the contract itself, only for the particular breach that occurred. Damages are normally determined by the writing contained in the contract; the intent of the contracting parties will determine the legal remedy.

Negligence must have the following elements

Duty toward the harmed party, breach of duty, injury or damages, causation

EMTALA (The Emergency Medical Treatment and Active Labor Act)

Enacted in 1986 to prevent patient dumping. Used to prevent an emergency room from refusing treatment or transferring a patient to another facility because of their inability to pay for treatment.

The Emergency Medical Treatment and Active Labor Act (EMTALA)

Enacted in 1986 to prevent patient dumping. Used to prevent emergency rooms from refusing treatment or transferring a patient to another facility because of a patient's inability to pay for treatment. Mandates that an appropriate medical screening exam be given to any patient who presents to any department that is established as a provider of emergent or urgent care. Also restricts the emergency room staff from discussing financial or insurance information until after the MSE has been performed.

Stark II

Expanded Stark I laws. Prohibits physicians from referring patients to providers with which the physician has a financial relationship. Any amounts billed illegally must be refunded. Applies to Medicare services as well as Medicaid. Knowingly billing or failing to make a refund is subject to a civil fine of $15,000 per item billed.

Safe Harbor was not

Expanded to include facilities that are not traditionally considered "surgical" facilities, such as lithotripsy centers, end stage renal disease facilities, comprehensive outpatient rehab, radiation oncology, cardiac catheterization, and optical dispensing facilities, despite support for inclusion

Tax Relief and Health Care Act of 2006

Expanding the Medicare Recovery Audit Contractor program to all 50 states and making it permanent

Types of Intentional Torts

False imprisonment, defamation of character, invasion of privacy

False Claims Act (FCA)

Federal government's primary civil remedy for fraudulent claims. Providers who make improper claims are fined $5500-$11,000 per claim. The Act is also applied to improper billing, claims for services not rendered, unnecessary services, misrepresenting credentials, and substandard quality of care.

Coaching

Focus on personal development, top level. Recommended for the very top personnel in an organization. Leader focuses on the personal development of his or her followers rather than the work tasks. Should be reserved for followers the leader can trust and those who have proven their competence.

President's Health Care Fraud Prevention and Enforcement Action Team or HEAT

Geared toward stopping fraud and abuse of Medicare and Medicaid claims. However, this act is different in the sense that the President is also using it as an enforcement tool against agencies directed to stop such fraud and abuse, but this law gives muscle to agencies and assists CMS with enforcement against those individuals or organizations that are violating the law and attempting to defraud the system.

Legislature

Government body that makes rules and laws that society abides by.

Types of POA

Health care, financial, medical, durable

To report violations of the code

Healthcare executive-supplier interactions, decisions near the end of life, impaired healthcare executives

What happens when you violate anti-kickback laws?

Imposes criminal liability for the knowing and willful payment, in return for referring an individual to a person, items, or services reimbursable by the federal health care program. Activities outside of these safe harbors are not necessarily illegal, but it is often unclear at what point conduct crosses the line between a legitimate practice and a violation of the anti-kickback act. Formerly known as the Medicare and Medicaid Anti-Kickback Act

Violations of Stark Laws

Include paying a physician for a referral and a hospital offering a rental space to a physician below fair market price.

Fraud

Intentional act of deception

Recovery Audit Contractors (RACs)

Introduced by CMS in response to the continuing fraud and abuse problem faced by both programs. Examiners work on a contingency basis, meaning that they only get paid when they find a mistake. Goal is to use computer systems to find data that will lead to discrepancies so that information can be obtained that will lead to monetary recovery.

Managerial Ethics

Involves business practices and doing things for the right reasons

Functional and Technical Competencies

Knowledge of business/business acumen, strategic vision, decision making and decision quality, managerial ethics and values, problem solving, change management/dealing with ambiguity, systems thinking, governance

Stark I was created for

Laboratory services

Key Healthcare Leadership Barriers and Challenges

Laws and regulations (barriers) Physicians (Challenge) New Technology (Barrier) Culture of Safety (Challenge) Resource Limitation (Barrier) Economy (Challenge)

Stark Laws

Laws developed to prohibit physicians from referring their patients to providers in which they have a financial interest.

A living will does not

Let you select someone to make decisions for you

Managed care imposes

Limits on patients and providers

Types of Advance Directives

Living will, durable power of attorney for health care, do not resuscitate order

Types of negligent acts

Misfeasance, malfeasance, and nonfeasance

Beneficence

Moral importance of doing good to others

Enforcement Procedures

Must enforce standards through out disciplinary guidelines.

Procedures for effective internal monitoring and auditing

Must have a monitoring and auditing program, must monitor and audit contractors, must allow CMS to audit financial records, must allow the federal government to perform onsite audit, contractors must allow CMS access to their records

Fraud and abuse plan must be in place

Must have a plan in place to detect and prevent fraud and abuse.

Training and Education

Must have a training and education program in place

Ethical

No legal requirements to act, but professional organizations may require it. Censure by the governing body may occur if unethical behavior occurs. Oftentimes helps to define the duty of care owed to a patient by a professional caregiver. Standards are defined by governing bodies that license professionals. Violation of standards may result in loss of license or professional privileges.

Organizational Competencies

Organizational design, team building, priority setting, political savvy, managing and measuring performance, developing others, human resources, community and external resources, managing culture/diversity.

Examples of violating stark laws include

Paying a physician for a referral, a hospital offering rental space for a physician below fair market value, a physician who receives benefits not given to other doctors or staff

Fiduciary Duty

People or organizations have an obligation to those who have placed their trust in them.

Authentic Leadership

People will want to naturally associate with someone who is following their internal compass of true purpose. Have attributes such as confidence, hope, optimism, resilience, high levels of integrity, and positive values.

Misfeasance

Performing the correct action incorrectly

Formulary

Physician is expected to use only approved medications.

Coercive Leadership Style

Power is used inappropriately to get a desired response from a follower. Probably should not be used unless the leader is dealing with a very problematic subordinate or is in an emergency situation and needs immediate action. In healthcare settings over longer periods of time, three other leadership styles could be used more effectively: participative, pacesetting, and coaching.

Purpose of Safe Harbor Laws

Prevent conflicts of interest in patient referrals

To the patients or others served

Prevent discrimination, safegaurd patient confidentiality, have process to evaluate quality of care

Safe Harbor/Anti-Kickback Regulations

Prevent payment of bribes or other remuneration as an inducement to refer Medicare patients for treatment or services. Developed by CMS

Ethics

Principles determining behavior and conduct appropriate to a certain setting.

Key Leadership Protocols

Professionalism, reciprocal trust and respect, confident, optimistic, and passionate, being visible, open communicator, risk taker/entrepreneur, admitting fault

Clayton Act

Prohibits mergers and acquisitions that may lessen competition. Only imposes civil penalties

Federal Trade Commission Act

Prohibits unfair methods of competition. This may include techniques such as larger businesses using their size to gain lower prices from suppliers and suppliers giving discounts to larger companies without providing the same for smaller ones.

To the organization

Proper resource allocation, improve standards of management, prevent fraud and abuse within

Criminal-Disclosure Provision of the Social Security Act

Provider must disclose overpayments so that the government can initiate collection efforts. Imposes penalties for failure to disclose such payment information. Disclosure may provide a defense if the government attempts to collect. Provider liability includes felony offense, up to $25,000 fine, and up to 25 years in prison.

Common forms of fraud and abuse

Providers billing for services that were not provided or did not meet medical necessity criteria, submitting duplicate bills, upcoding services to receive higher reimbursement, and receiving kickbacks for referrals

Beginning of life care issues

Provision and funding of contraception, provision and funding of abortion, court cases and state laws, balancing parental, societal, and practitioner rights and responsibilities

Up-Coding

Purposefully charging more than what is allowable or what procedures were performed

Style Approach to Leadership

Rather than looking at only the characteristics of the leader, researchers started to recognize the importance of 2 types of behaviors in successful leadership: completing tasks and creating good relationships. This theory states that leaders have differing degrees of concern over each of these behaviors, and the best leaders would be fully attentive to both. (40s/50s)

Under criminal law, malpractice can is

Reckless disregard for the safety of another.

Baldridge National Quality Program

Recognizes the need for senior leaders to create a sustainable environment for their organizations through the continual development of future leaders by enhancing their personal leadership skills.

Statutes

Refers to an act by a legislative body such as a law. The form in which the law is expressed.

According to the American Institute of Certified Public Accountants (AICPA) assures

Reliability of financial reporting, effectiveness and efficiency of operations, compliance with applicable laws and regulations

Do Not Resuscitate Order

Request to not have CPR if your heart stops or if you stop breathing. Can be verbal or part of the living will. Hospital staff will perform CPR on all patients without a DNR. Accepted in all hospitals in all states.

Executive Order

Requirement that the president makes of individuals or organizations under the jurisdiction of the executive branch of government. Respected much like a law.

Emergency Medical Transfer and Active Labor Act (EMTALA)

Requires all Medicare and Medicaid hospitals with an emergency department to provide appropriate medical screening to all seeking care. Often referred to as the anti-dumping law because it prohibits hospitals from transferring an emergency patient to another hospital because of an inability to pay.

Key ethical principles for healthcare research

Respect for persons, beneficence, nonmaleficence, and justice.

Self Development and Self-Understanding Competencies

Self-awareness and self-confidence, self-regulation and personal responsibility, honesty and integrity, lifelong learning, motivation/drive to achieve, empathy and compassion, flexibility, perseverance, work/life balance.

Patient Rights

Self-determination, expect confidentiality of information, informed consent or competent surrogate, right to refuse care, emergency treatment, even without ability to pay

Situational Approach to Leadership

Set of theories focused on the leader changing his or her behavior in certain situations in order to meet the needs of subordinates. This would imply a very fluid leadership process whereby one can adapt one's actions to employee's needs at any given time. (1960s)

Control Environment

Sets the tone of an organization. It's the foundation for all other components of internal control, providing the discipline and structure.

Pacesetting

Setting high performance standards, highly competent. Very effective when the employees are self-motivated and highly competent -- research scientists or intensive care nurses.

Leadership responsibilities

Setting mission, motivating stakeholders, spokesperson, future strategies, transformation

3 laws that form the basis of antitrust law

Sherman antitrust act, clayton act, federal trade commission act.

Empathy

Social awareness skill, putting yourself in another's shoes

Participative

Soliciting input, most followers

Competent

Speaks to an individual's ability to make decisions or perform tasks. Also means that a professional has the skills to perform a task.

Effective lines of communication throughout the organization

Sponsor must have: a.) Organized lines of communication to effectively provide information as it pertains to compliance issues b.) Mechanisms are in place for capturing concerns and risks.

Designation of a compliance officer

Sponsor must have: a.) compliance officer in place b.) compliance committee in place c.) Established protocol for overview d.) Compliance officer if responsible for fraud and abuse program.

Management Responsibilities

Staffing, resources, service, regulations, counseling

Operation Restore Trust (ORT)

Started in 1995 to counter charges about healthcare fraud and abuse. Initially involved the five states with the heaviest volume of Medicare beneficiaries. In 1997, expanded to include 12 more states and now includes all 50 states. Program investigates and applies penalties for fraud and also provides advisories to prevent violations. Uses statistical data to select claims for audits and investigations.

Health Care Power of Attorney

States whom you have chose to make health care decisions for you if you can't. Becomes active if you become unconscious or unable to make decisions.

Laws are created via

Statutes, Administrative agencies, Executive orders

Helsinki declaration

Subject has a higher priority than society, 1964

Social Skills

Supportive communication skills, abilities to influence and inspire.

Risk Assessment

The entity's identification and analysis of relevant risks to achievement of its objectives, forming a basis for determining how the risks should be managed

Information and Communication

The identification, capture, and exchange information in a form and time frame that enable people to carry out their responsibilities

Procedures for corrective action

The organization must ensure prompt response to violations and appropriate corrective action is taken

Control Activities

The policies and procedures to help ensure that management directives are carried out.

Binding Policy

The policy is final and must be followed when it applies.

Written policies, procedures, and standards of conduct

These must speak to the organization's commitment to comply with all applicable federal and state standards.

Physicians are a challenge because

They are not always easily controlled by the medical organizations where they work (hospital, insurance companies, LTC facilities). Has substantial input over the volume of patients that a healthcare facility receives.

Path-Goal Theory of Leadership

This theory still placed its attention on the leader's style and the work situation (subordinate characteristics and work task structure) but also recognized the importance of setting goals for employees. The leader was expected to remove any obstacles in order to provide the support necessary for them to achieve those goals.

Defamation of character

Type of intentional tort. Can be slander or libel -- oral or written false representations of a person's character that will hold that person up to shame or ridicule.

Contingency Theory of Leadership

Under this theory, the focus was on both the leader's style as well as the situation in which the leader worked, thus building upon the two earlier theories. (Early 1970s)

To the community and society

Work to meet the needs of the community, provide appropriate access to services, advocate for healthy society.

Living Will

Written legal document that describes the kind of medical care treatments you would want if you were seriously or terminally ill. Guidelines vary by state

Nuremberg Code

voluntary and informed consent, 1947 (post Nuremburg trials)