LAWS & REGULATIONS TEST 1
Notice of Proposed Rule-making
"Notice of Proposed Rulemaking" issued by the Department of HHS, provides a process for public input into a regulating body's decision-making. A notice of proposed rule-making or NPRM is issued by law when a regulatory agency of the United States Federal Government wishes to add, remove, or change a rule (or regulation) as part of the rule-making process. NPRM procedure is required and defined by the Administrative Procedure Act. The Constitution does not require NPRM. Rather, Congress created the requirement to enlighten agencies that is, to force them to listen to comments and concerns of people who the regulation will likely affect. The FAA, FCC, NTIA, and EPA are examples of agencies subject to these procedures. The NPRM is published in the Federal Register and typically gives 60 days for public comment from any interested party, and an additional 30 days for reply comments. Original comments may still be filed in the reply comments window. While this is the normal method of agency rulemaking, emergency rulemaking is allowed to bypass the NPRM process. A notice is not required to be published in the Federal Register if all persons subject to it are named and are personally served with a copy of it.
4 Guidelines for determining disparate treatment:
4 Guidelines for determining disparate treatment: 1. The person is a member of the protected class 2. Person applied for job and was qualified 3. Person was rejected for the job 4. Position remained open to applicants with equal or fewer qualifications
ADA does not protect the following 5 situations:
ADA does not protect the following: i. Current illegal drug use ii. Psychoactive substance abuse iii. Compulsive gambling, pyromania, kleptomania iv. Gender-identity disorders that do no result from impairment or sexual disorders v. Homosexuality or bisexuality.
American Hospital Association & defining measures & definitions
American Hospital Association- maintains common definitions and statistics for national reporting
Basic premise of the EEOC laws
Basic premise of the EEOC laws a. Employment decisions----hiring, compensation & benefits, and training opportunities---should not be based on non-job-related characteristics such as age, gender, race, or disability.
Bona fide occupational qualification
Bona fide occupational qualification- a quality that employers are allowed to consider when hiring. (ie. a woman is hired for cleaning women's bathroom.)
Committee on Ways and Means (3)
Committee on Ways and Means Legislation begins its trip through the Congress in the House Ways and Means Committee, which is responsible for considering a lot of legislation. Thus, it is among the most powerful Congressional Committees. Most Committee members must serve in the House for many years before they get appointed to the Ways and Means.
Compliance program
Compliance program a. Executive office appoints a member to develop compliance program and make regular reports to the board. b. This member reports to the compliance office rather than to the units they monitor to avoid conflicts of interest.
Conference Committee Action
Conference Committee Action Conference Committee members get appointed by the Speaker of the House and the President of the Senate. Each chamber votes as a unit. Members of the majority party control each unit. Representatives of the Administration and interest groups again try to have the Conferees support or oppose aspects of the bill. The Conference Committee reports its version back to both the House and Senate, which then vote on the Committee's compromise version. If it gets adopted, the revised bill gets sent to the White House.
Construction & Renovation:
Construction & Renovation: i. May need outside contracting ii. Tradition approach= keep a architect, construction management firm, and general contractor iii. Private organization prefer the flexibility of negotiating contracts with selected vendors iv. "Turnkey construction"= single contract to deliver finished facility 1. Reduced cost 2. Flexible and speedy
Controllership Functions/ Transaction Accounting:
Controllership Functions/ Transaction Accounting: a. Transaction accounting = records and reports all transactions affecting the value of the firm and its subsidiaries. b. Two types of transactions: i. Service transactions= transactions that provide elements of care to patients ii. Resource Transactions= transactions that acquire resources like equipment, supplies, personnel c. Data captured from transactions are organized through managerial and financial accounting functions d. Service transactions: i. All routine cash acquisition recorded except gifts, loans, and sales of assets. ii. Routinely records patients information, unit supplying service, - must meet HIPPA guidelines. iii. Services transactions can be organized by patient, service, or CSS. iv. When service transaction is organized by patient name, it is a patient ledger (detailed record of individual services or supplies rendered to each patient) which is integrated into medical records for quality control e. Resource Transactions: i. Data that is captured includes ordering person/ unit, quantities, allocation, time, and prices of resources purchased
Darling vs. Charleston Community Hospital.
Darling vs. Charleston Community Hospital. Lesson learned is that an institution cannot defend itself on grounds that the medical staff is independent and self governing. Hospitals, entities and boards of directors have a duty to protect patients and a duty to identify and act on potential causes of injury from physicians and other care providers.
EXECUTIVE BRANCH PREPARATION
EXECUTIVE BRANCH PREPARATION Many recommendations for new legislation come from the President. Many people are involved in shaping these recommendations. Months of preparation may go into new proposed legislation before the President makes his recommendations to Congress. Advice and assistance also come from other government agencies, such as CMS.Once drafted, the HHS Department sends the legislation to the White House for review by the President and his advisors. The President may direct the HHS to make changes to the legislation or to remove or add some provisions. Then, the HHS makes the changes and provides the President with any additional information he requests. Next, the President sends a message to the Congress as he formally submits the proposed legislation. The President may send proposals to Congress any time. In practice, however, the President will propose only one major bill each year. He often mentions his proposals in his annual State of the Union address. In addition, the President will also discuss any proposed legislation in the Economic Report of the President, which goes to the Congress every January. Usually, the President sends proposed legislation to Congress during the first few months of the year.
Economic arrangement with insurers
Economic arrangement with insurers a. Simple contracts establish fees for various procedures b. Explicit payments for increasing profit of the institution are illegal.
Electronic data and software protection methods:
Electronic data and software protection methods: 1. Duplication 2. Separate storage site 3. Protection of site (anti-virus eg) 4. Routine backups 5. Power supplies are redundant to protect against surges 6. Central processing and archiving are safely located and physically protected 7. Passwords, security devices, & activity monitors 8. Surveillance and auditing employees 9. Personnel selection and bonding
Four-fifths Rule-
Four-fifths Rule- discrimination has occurred if the section rate for the protected rate is less than 80% of the selection rate for the majority.
HIPPA---defining measures & definitions
HIPPA- standard definitions for common patient transactions
5 HR functions in safety:
HR functions in safety: i. Monitor federal/state regulation and professional literatures on occupational safety for hazardous areas ii. Identify department/group accountable for safety and compliance on each specific risk iii. Keep records, perform risk analysis, and lead improvement efforts for general/widespread exposures iv. Maintain records for compliance and respond to visits and inquiries from official agencies v. Provide and assist with training and promotion of safe procedures
INFLUENCING CONGRESS
INFLUENCING CONGRESS: Under the Constitution, the American public has the right to a representative form of government. Members of Congress and the President must be elected to office. They must win reelection for another term to continue serving the public. The First Amendment to the Constitution grants citizens the right to "petition the government for a redress of grievances." Citizens may act on their own behalf, as individuals, or organize into groups for influencing government officials. Citizens may make their views known to those who represent them in Congress. They do this by writing letters or by visiting elected officials' offices in their district or State. They may also contribute time or money to a candidate's campaign, vote in the primaries and general elections, and join groups that share their ideas. Pressure groups that get formed to achieve a certain goal often strongly influence Members of Congress. Most, known as "special interest" groups, are concerned only with a narrow set of issues. There are also "public interest groups" that are concerned with issues that affect the public at large, not just their own members. Pressure groups use many tactics to achieve their goals. They attempt to influence the voting public through paid advertising, public speaking, and direct mail campaigns. By swaying public opinion, they hope to influence indirectly the actions of Congress or officials in the Executive Branch. These groups also attempt to influence members of Congress more directly. Also, they organize letter writing campaigns and contribute time and money to help get candidates elected. These groups also present members of Congress with proposed legislation, supply background information or statistics to support their viewpoints, and testify at Congressional hearings. Many groups have an office in Washington for these activities. "Lobbying" is the name of the practice they use to influence the course of legislation, and developed many years ago. This was because people waited in the lobbies outside the House and Senate chambers, hoping to speak with the lawmakers as they entered or left. Today, lobbying is an accepted part of the legislative process. Members of Congress often view lobbyists as useful sources of information and political support. They see the pressure groups that lobbyists represent as a valuable tool for citizens to present their views before members of Congress.
Define Joint Commissions on Accreditation of Healthcare Organizations:
Joint Commissions on Accreditation of Healthcare Organizations: a. A voluntary consortium of HCO's and profession provider organizations that ensures a minimum level of safety and quality in HCO's b. Principle vehicle to control quality of healthcare transactions in hospitals.
Legal requirements for the maintenance of patient records, including length of time that they must be retained by the organization and the release of information contained within medical records
Legal requirements for the maintenance of patient records, including length of time that they must be retained by the organization and the release of information contained within medical records There are strict guidance measures established by Medicare, JCAHO, and other accrediting bodies that address the maintenance requirements, entry requirements, co-signatures and approvals, auditing, security, protection and sharing exceptions for medical records. The record retention requirement for Medicare has recently been extended from 6 years to 10.
Legal status of a corporation when considered a "person".
Legal status of a corporation when considered a "person". Despite not being natural persons, corporations are recognized by the law to have rights and responsibilities like actual people. Corporations can exercise human rights against real individuals and the state, [1] and they may be responsible for human rights violations. [2]Just as they are "born" into existence through its members obtaining a certificate of incorporation, they can "die" when they lose money into insolvency. Corporations can even be convicted of criminal offenses, such as fraud and manslaughter.
Legal status of the physician-patient relationship and informed consent
Legal status of the physician-patient relationship and informed consent: The physician patient relationship is based on a contract, which is a voluntary agreement between the parties. It may be in writing, but a written agreement is not required. Rather, the contract may be created by the conduct of the parties. If a person requests medical examination or treatment, and if the doctor begins to examine or treat that person, a contract has been created in the eyes of the law. The legal doctrine of informed consent is based on the principle that people have a right to make the decisions about their own medical treatment. For consent to be valid, it must be fully informed. Therefore, the patient must be advised before the treatment of the risks and benefits of the particular treatment, as well as the possible alternatives to that treatment.
Medical/legal aspects of patient care, including the release of patient information.
Medical/legal aspects of patient care: Informed consent: based on the principle that people have right to make the decisions about their own medical treatment. It is primarily a matter of state law. Consent may be implied in an emergency. Also, the provider must disclose personal interests, if any. Under most circumstances, adult patients of "sound mind" have a right to refuse treatment and to have the right to a natural death. Cobra Antidumping Law(also known as EMTALA, see above). Under the ADA, providers cannot refuse to treat HIVpositive patients on the grounds of their diagnosis.The AMA takes the position that for a physician to participate in assisted suicide would be unethical. It's a crime in almost every state. Oregon has Death with Dignity Act.
Notice of Proposed Rule-making Contents
Notice of Proposed Rule-making Each notice, whether published in the Federal Register or personally served, includes: 1. A statement of the time, place, and nature of the proposed rulemaking proceeding; 2. A reference to the authority under which it is issued; 3. A description of the subjects and issues involved or the substance and terms of the proposed regulation; 4. A statement of the time within which written comments must be submitted; and 5. A statement of how and to what extent interested persons may participate in the proceeding.
What 2 things led to creation of Patient Consent?
Patient Consent, founded on Case Law and CMS requirement for participation in the Medicare program.
HIPPA & PSRO
Regulatory Approaches a. PSRO (professional standards review organizations)= local physician controlled groups responsible for utilization review monitoring both the quality and the appropriateness of hospital care under Medicare program. b. HIPPA= restricted the ability of insurance companies and employers to intervene in the care process and provided judicial relief.
Requirements of the ADA as it relates to healthcare organizations.
Requirements of the ADA as it relates to healthcare organizations: Providers cannot refuse treatment based on disability. The ADA also requires addressing architectural barriers, auxiliary aids and services (such as sign language or electronic devices). Title III of the ADA of 1990 extended the reach beyond federally funded services into the private offices of physicians, dentists, and other practicioners. However, most courts hold that the ADA does not prevent health insurance companies from discriminating on the basis of disability in structuring their benefits for particular diseases such as AIDS.
What are 4 conditions that Right to refuse treatment can be counteracted?
Right to refuse treatment, the U.S. Constitution (protected liberty interest). Can be counteracted by : • Protection of Third Parties • Prevention of suicide • Preservation of ethical standards of the medical profession • Preservation of human life
Senate Committees
Senate Finance Committee is responsible for all Senate legislation dealing with tax matters. This Committee begins its formal work on the legislation after the House has passed its version of the bill. It holds hearings to consider the bill passed by the House. Witnesses appear at the Committee to direct their testimony to the House version of the bill.After the hearings are finished, the Committee marks up the House bill. When the Committee completes its markup, the bill is usually very different from the one passed by the House. It then gets reported to the full Senate for floor action. A report gets filed along with the bill. The report explains in detail the amendments made by the Finance Committee. The entire Senate debates the bill as reported by the Committee. During the debate, the Senators may further amend the bill before they bring it to a vote. Legislation does not get considered again if the Senate fails to pass the bill. If the Senate passes the House version of the bill, without amendments, it gets sent directly to the President. Further Congressional action required because there are now two versions of the bill-- the bill passed by the House and the House bill as amended and passed by the Senate.The bill with the Senate amendments gets returned to the House of Representatives. House may adop a motion to disagree with the Senate amendments. Conference Committee adjusts the differences between the two versions of the bill.
Process of how bill becomes a law (5)
The Congress takes steps known as the legislative process to pass a Federal law. This process begins when a Senator or Representative prepares a proposed law, called a "bill." It ends when Congress approves the bill and sends it to the President. When the President signs the bill, it then becomes law.Presidents can, and frequently do, recommend changes to current laws, but only Congress can make the changes.
Trends in the concept of privilege:
Trends in the concept of privilege: a. Concept of priveledging were expanded to include due process, equal opportunity, cost control and avoidance of restraint of trade b. Prospective per case payment required hospital deliver care at fixed price (control of cost) c. Priveleging process cannot be used to exclude competing physicians (restriction of trade)
What constitutes a violation of antitrust laws for healthcare organizations?
What constitutes a violation of antitrust laws for healthcare organizations? Cannot price fix, overtly or by accident; cannot boycott (State of Michigan Medical Society members unlawfully agreeing to not accept Medicaid until rates increased), competitors cannot allocate particular products and services or particular territories to each of the competing sellers (I'll do MRI, you do lithotripsy).
What constitutes sexual harassment and the legal requirements for investigating it?
What constitutes sexual harassment and the legal requirements for investigating it. Sexual harassment is a form of sex discrimination that violates Title VII of the Civil Rights Act of 1964. Title VII applies to employers with 15 or more employees, including state and local governments. It also applies to employment agencies and to labor organizations, as well as to the federal government. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when this conduct explicitly or implicitly affects an individual's employment, unreasonably interferes with an individual's work performance, or creates an intimidating, hostile, or offensive work environment. When investigating allegations of sexual harassment, EEOC looks at the whole record: the circumstances, such as the nature of the sexual advances, and the context in which the alleged incidents occurred. A determination on the allegations is made from the facts on a case by case basis. Prevention is the best tool to eliminate sexual harassment in the workplace. Employers are encouraged to take steps necessary to prevent sexual harassment from occurring. They should clearly communicate to employees that sexual harassment will not be tolerated. They can do so by providing sexual harassment training to their employees and by establishing an effective complaint or grievance process and taking immediate and appropriate action when an employee complains. It is also unlawful to retaliate against an individual for opposing employment practices that discriminate based on sex or for filing a discrimination charge, testifying, or participating in any way in an investigation, proceeding, or litigation under Title VII.
What legal factors are important in securing informed patient consent?
What legal factors are important in securing informed patient consent? Our legal and ethical concepts of informed consent have traditionally been limited to a requirement to disclose the risks of, the benefits of, and the alternatives to the proposed treatment. Now that we have moved to a system of managed care, we may want to expand the concept of informed consent to require disclosure of a physician's financial interests.
Which activities tax-exempt organizations cannot legally engage in?
Which activities tax-exempt organizations cannot legally engage in? The Operational Test requires that: (1) the organization engage primarily in activities that further one or more recognized exempt purposes, (2) such activities serve a public rather than a private purpose, (3) no part of the net earnings of the organization may inure to the benefit of any private shareholder or individual, and (4) the organization may not engage in political activity, and no more than an insubstantial part of its activities may be to influence legislation
Financial Accounting Standards Board---defining measures & definitions
d. Financial Accounting Standards Board-- ensures accurate definitions of audited accounts
TRUE/ FALSE: Stark regulation does indicate that physician may refer to hospital in which they have ownership or investment interest, but only for services provided by the hospital
TRUE Stark regulation does indicate that physician may refer to hospital in which they have ownership or investment interest, but only for services provided by the hospital
DO Intra-group referrals in a physician group do not violate Stark Law?
TRUE Intra-group referrals in a physician group do not violate Stark Law
"Qui Tam" Lawsuit (7)
"Qui Tam" Lawsuit a. He who brings action for the king and himself b. Private citizens are allowed to sue on their own behalf and the behalf of the government to recover damages c. To file suit, the plaintiff must meet certain conditions: i. Must be the first to file ii. Must not already be government proceeding relating to same facts iii. Suit must not be based on matters that have been publically disclosed. Government is not required to show actual damages to prove FCA violation. 6. FCA case can be based solely on violation of anti-kickback or self-referral laws but still not ultimate resolution. 7. Plaintiff can proceed to assist the government or pursue the case individually, often with financial advantage. a. Government provides protection against employment-related retaliation b. Government must prove beyond a reasonable doubt that the defendant knew the claim was false So under the FCA, the government would not have to prove that the defendant made a false statement or representation knowingly and willfully, as required under the criminal statute. However, it is not enough for the government to merely prove that the claim was submitted by mistake, even if the mistake was caused by negligence or carelessness. The False Claims Act allows private citizens to sue on the own behalf and for the government to recover damages and penalties. This type of lawsuit is known as "Qui tam". In order to file a Qui Tam Suit, the plaintiff must be the first to file, there must not already be any government processing relating to the same facts, and the suit must not be based on matters that have been publicly disclosed. It is NOT A REQUIREMENT THAT THE PERSON HAVE FIRST HAND KNOWLEDGE OF THE VIOLATION. Also, note that the FCA does not deal with inducing or rewarding referrals. That's the Federal Antikickback statute!
"Responsible Official" Doctrine:
"Responsible Official" Doctrine: a. Officials and managers may be held personally accountable if they deliberately or recklessly disregarded the possibility of criminal conduct occurring
"Stark" Self-Referral Laws:
"Stark" Self-Referral Laws: 1. Imposes obligation on each entity that provides designated health services to report the names and identification numbers of all physicians who have a compensation arrangement or ownership or investment interest in entity to Secretary of Health and Human Service. 2. No proof of intent needed a. Key difference from anti-kickback law, which does require proof
Equal Pay Act:/(Current Trends):
. Equal Pay Act:/(Current Trends): a. Improvement in women's wages relative to men's wages are leveling off. b. Gender gap in wages will not end until 2038. c. Women are less likely to get additional compensation (stock options, performance bonus, stock options, and profit sharing) d. Comparable Worth- calls for equal or comparable pay for jobs that require comparable skills, effort, and responsibility. In healthcare, comparing nurses won't show inequality but comparing nursing with other jobs would show unfairnes.
Define Statistical Discrimination
.Statistical Discrimination- occurs when the employer makes a calculated decision about a particular person based on the empolyer's perception about the larger group to which the individual belongs.
10 key Benefits of an effective CCP:
10 key Benefits of an effective CCP: a. Improves the accuracy of claims and benefits, which reduces loss to the government and minimizes hospital penalties. b. Identifies weaknesses in internal system and management c. Improves quality of patient care d. Develops a process that allows employees to report e. Demonstrates the hospital commitment to responsible corporate conduct f. Identify and prevent criminal and unethical behaviour g. Provide accurate view of employee and contractor behavior in fraud and abuse h. Creates centralized information source for healthcare statues and regulation i. Develop investigation process for alleged misconduct j. Initiation of corrective action
11 Safe harbor activities for Anti-kick back law:
11 Safe harbor activities for Anti-kick back law: a. Categories of activities in which providers may engage without being subject to prosecution b. Examples: i. Investment in publicly traded entities ii. Fair market value leases for rental of space or equipment iii. Purchase of physician practice iv. Payment to referral services for patients so long as the payment is not related to the number of referrals made v. Properly disclosed warranties vi. Properly disclosed discounts that are contemporaneous with original sale vii. Bonea fide employment relationships viii. Discounts available to group purchasing organization ix. Waivers of coinsurance and deductible for indigent patients x. Price reductions offered by providers to health plans xi. Marketing incentives offered to enrollee by health plans
13th amendment
13th amendment- earliest form of workplace regulation- outlawed slavery.
3 Disadvantages of Corporate Compliance Program
3 Disadvantages of CCP: a. Expensive i. Cost of attorneys, consultants, ongoing implementation efforts ii. Staff time for implementation b. Potential for uncovering past fraud activities c. CCP will viewed as the organizations self-established "standard of care" i. Failure to follow CCP- Negligence evidence
3 Situations where waiving coinsurance or deductible amount is illegal:
3 Situations where waiving coinsurance or deductible amount is illegal: a. Waiver is offered as part of advertisement of solictition b. The individual is not in financial need c. Does not make a reasonable effort to collect coinsurance or deductible after failing to collect it.
4 Strategies that organizations can use to prevent and identify discrimination in the workplace.
4 strategies organizations use to prevent workplace discrimination. A. Employee Training on Proper Conduct 1. Training employees in appropriate conduct and supervising the conduct is of importance. 2. Employer should assume the burden on employee education to promote organizational compatibility and to avoid future litigation. B. Interview Questions= a. Sensitivity to legal doctrines and workplace regulations, as well as to cultural differences, when framing interview questions is a must for managers. C. Defenses against Discrimination = 1. Educate employees of what behavior is expected and accepted by the organization at the onset of employment. 2. Create a manual of standard policies. D. Termination at Will= a. State and federal laws supersede any private policies set by an organization. b. Termination at Will does not permit an employer to terminate an employee on non-work performance grounds--that is, an employee has the right to contest a termination, even if a termination at will policy exists, if the employee believes that he was fired for discriminatory reasons.
5 Exceptions to the Anti-kick back's remuneration to induce referrals:
5 Exceptions to the Anti-kick back's remuneration to induce referrals: a. Properly disclosed discounts that are reflected to the cost reports b. Amounts paid by employer to employee to provide healthcare services c. Certain amounts paid by vendor to agents of group purchasing entity d. Waivers of coinsurance of Public Health service beneficiaries e. Remuneration through risk-sharing arrangement (eg. Capitation)
5 Key features of the Americans with Disability Act:
5 Key features of the Americans with Disability Act: 1. This Act provides protection to individuals with disabilities who are employed or potentially employable with disabilities in work settings such as private sector or state/local government agency that employs 15 or more employees a. Defines Disability as (a) physical or mental impairment that limits one or more of the major life functions. 2. Protects also those with a history of disability such as cancer, heart disease, or mental disorder. 3. Protects prospective employee's from being denied employment because the employer feels that the prospective employee's physical appearance would elicit a negative reaction from coworker 4. Protects severely obese person (whose weight is excess of the 100% of norm for their particular weight and height) 5. Defines "qualified individual with a disability" as individual with disability, who, with or without reasonable accommodation, can perform the essential functions of the employment position.
5 major EEOC laws:
5 major EEOC laws: a. Fair labor Standards Act= governs minimum wage, overtime pay, child labor, and equal pay. b. Equal Pay Act= requires equal pay for all men and women who perform equal jobs. c. Title VII of the Civil Rights Act of 1964- prohibits discrimination in a variety of areas including age, race, color, religion, sex, or national origin. d. Age Discrimination in Employment Act= prohibits discrimination in employment against individuals 40 years and older. e. Americans with disability Act= prohibit discrimination against people with disabilities.
7 key criteria for effective CCP:
7 key criteria for effective CCP: a. Compliance standards i. Outlines the legal requirements in all areas of the organization and business operations. ii. Distributed to all employees iii. Includes antitrust, Medicare/Medicaid fraud and abuse, occupational safely, patient protection and taxation. b. Must be overseen by top management i. Usually individual reports to CEO and board c. Must have a policy requiring criminal background checks on newly hired people d. Must educate all employees and agents about CCP requirement and continually publicize topics in employee newsletters e. Must establish reasonable methods to achieve compliance i. Ongoing monitoring activities, periodic audits of operational departments and encouragement of employees to report suspicious activities f. Consistent Discipline, including termination of employees, for violations of standards of conducts or failure to report violations g. Appropriate and consistent responses to violations detected, including corrective action to prevent recurrence.
8 Exceptions for financial relationships that trigger Stark Law:
8 Exceptions for financial relationships that trigger Stark Law: a. Owning stock/ bonds in company or mutual fund b. Owning or investing in rural providers or hospitals in Puerto Rico c. Reasonable rent for office space or equipment d. Amounts paid for employment e. Compensation under legitimate physician incentive plan (eg. Capitation, bonus in managed care, withholds) f. Reasonable payments to induce relocation of a physician to another hospital g. Isolated transaction for One time sale of property or practice i. aka installment payments are prohibited in the sale or physician practice h. Payments by a physician for clinical laboratory services or other services.
8 types of Medicare & Medicaid Fraud:
8 types of Medicare & Medicaid Fraud: 1. Filing claims for services not rendered or not necessary 2. Misrepresenting time, location, frequency, duration, or provider of service 3. Upcoding= Aligning higher payment then procedure or diagnosis warrants 4 Unbundling=Practice of billing as separate item services 5. Violation of "3-day rule a. Rule stating that outpatient diagnostic procedures performed on any of the three days prior to hospitalization are deemed to be part of the Medicare DRG payment and are not to be billed separately. 6. Payment of "kickbacks" to induce referrals or the purchase of goods and services 7. Billing of services said to have been "incident to" a physician's services but that in fact were not provided under the physician's direct supervision 8. Self-referral
A sound plan for a project renovation has the following:
A sound plan for a project renovation has the following: i. Review of space & equipment ii. Identification of special needs iii. Trial of alternative layouts, designs, and equipment configurations iv. Development of written plan and specifications v. Review of code requirements and plans for compliance vi. Approval of plan and specifications by the operating unit vii. Development of timetable and PERT chart identifying critical elements of construction viii. Contracting or formal designation of work crew and accountability ix. Ongoing review of work against specifications and timetable x. Final review, acceptance, and approval of occupancy.
What 4 organizations dictate the specifications for new construction?
All parts of the HCO is subject to safety & convenience regulations that dictate specifications for new construction i. Federal Standards for handicap ii. Life Safety Code/ National Fire Protection Association iii. Medicare iv. JAHCO
Employers & Undue hardship
An employer does not have to provide a reasonable accommodation that would cause an "undue hardship" to the employer. i. Generalized conclusions will not suffice to support a claim of undue hardship. ii. Undue hardship based on an individualized assessment of current circumstances that show that a specific reasonable accommodation would cause significant difficulty or expense. A determination of undue hardship should be based on several 5 factors, including: 1. Nature and cost of the accommodation needed; 2. . Overall financial resources of the facility making the reasonable accommodation; the number of persons employed at this facility; the effect on expenses and resources of the facility; 3. Overall financial resources, size, number of employees, and type and location of facilities of the employer (if the facility involved in the reasonable accommodation is part of a larger entity); v4. Type of operation of the employer, including the structure and functions of the workforce, the geographic separateness, and the administrative or fiscal relationship of the facility involved in making the accommodation to the employer; 5.i. Impact of the accommodation on the operation of the facility.
Anti-kickback Law
Anti-kickback 1. Prohibits any person to solicit, receive, offer, or pay any form of remuneration in return for referrals. 2. Violations can lead to exclusion from Medicare or Medicaid programs
Anti-kickback law & payment
Anti-kickback law prohibits payment of remuneration to induce or in return for "purchasing, leasing, or ordering any good, facility, or service": a. Example illegal for patient transportation company to provide compensation to hospital employee who arranged the patient transportation b. Hospital provides free airfare to and from to induce patients to choose their hospital
Benefits administration
Benefits administration: a. Social programs are supported by payroll taxes, deductions, and entitlements b. Market forces, direct legal obligation, and tax incentives impact these social programs c. 4 types of employee benefits: 1. Payroll and deductions 2. Vacations, holidays, and sick leave,Jury duty, military leave, educational leave FMLA Part-time position have reduced benefits Non-worked hours are a cost to HCO 3. Voluntary insurance program Health insurance is an entitlement to full-time workers Retirement, travel, and accident insurance 4. Mandatory Insurance Employers are obligated to provide worker's compensation (healthcare cost + lost wages) Employers obligated to give unemployment insurances for involuntary termination. 5. Other prerequisites: Educational programs, professional dues, journal costs, club memberships,, expense accounts Employee participation increases the executive's ability to understand the community desires and identify influential citizens. Retirement benefits (used to defer income from tax) Termination settlements (defray the risk of leadership positions)
Certificate of Need Laws
Certificate of Need Laws (state specific) prohibit the development of new healthcare facilities and services unless the provider can demonstrated to the satisfaction of state officials that the proposed facilities and services are needed. Encouraged by the National Health Planning and Resources Development Act of 1974, but this was repealed in 1986.
Collective Bargaining Agreements
Collective Bargaining Agreements a. Federal legislation supports unions; states vary b. 20% hospitals unionized in 1980's (due to federal funding) c. Decline in unionization in all industries by 2000 d. Unskilled workers, building trades, and nurses most likely to be unionized
Two methods of healthcare cost control (Competitive movements) (3)
Competitive movements a. Social Security Trust Fund for Medicare- limit payment to hospital via the prospective payment system. It was a payment program not rate regulation. b. Prospective payment differed from capitation in that price was based on categories of illnesses (DRG) c. RBRVS (resource based relative value scale)- limit physician fee.
Define Corporate Compliance Program
Corporate Compliance Program 1. Tool used to protect organization and its board from fraud/abuse of corporate policy and provision of quality patient care
Role of CCP in billing department?
Corporate Compliance Program (CCP) Play critical role in reimbursement and payment areas, where claims & billing operation can be a source of fraud and abuse and are focus of government scrutiny. i. Healthcare fraud & abuse = 10% of U.S. annual healthcare expenditure (most fertile area of illegal activity in healthcare)
Cost Control (3)
Cost Control a. The decision for cost control was delegated to providers but is now being returned to marketplace. b. Price of healthcare in the community is set by the market not by the individual healthcare organizaitons. c. Buyers (employers funding insurance) and governments support economy over service; regulation and competition are two approaches used to lower healthcare costs.
Customer Partners: Buyers
Customer Partners: Buyers a. Most insurance is provided by employment b. Federal, state, and local governmen buy as employers and also purchase insurance for special groups
Customer Partners: Payment Partners (4)
Customer Partners: Payment Partners: a. Patients rely on variety of insurance mechanisms to pay for care. b. Insurance intermediaries= managed care and traditional insurance, Medicare and Medicaid c. Medicare and Medicaid are indirect exchange partners d. Medicare deals with HCO via its intermediary (Blue Cross Blue Shield)
Customer Partners: Regulatory Agencies
Customer Partners: Regulatory Agencies a. Most insurer mandate two outside audits i. Either by JAHCO or American Osteopathic Association ii. Public Accounting firms of HCO b. NCQA (national commission on quality assurance) accreditation of HMO c. Peer review organizations= external audits for quality of care and use of insurance benefits by individual physicians and patients of Medicare.
Debt and Equity Capitalization:
Debt and Equity Capitalization: a. Finance develops the long-range financial plan to implement the strategic plan and recommends the best solution to the governing board. b. Finance monitors financial markets for opportunities to restructure the financing and manages endowments of non-profit HCO c. Non-profit HCO: i. Equity can only increase from donations and retained earning from operations and on investments. ii. Long-terms tax-exempt bonds will remain important form of capital finance since donation limited. iii. Well-managed HCO deliberately mange their debts and investments to attract funds at advantageous rates.- aka effective use of debt, maintenance of cash reserves, and profitable operations
Defining terminology and measures
Defining terminology and measures a. Well-managed Information system ensures the integrity, quality, and security of data by deliberate programs that control data, data capture routines, and access to recorded data. b. Any term that is quantitative system must have precise definition (eg. Admission, patient day, unit price) c. Healthcare organizations are concerned about problem of accurate definitions (eg. Is a stay less than 24 hours considered one day? Is a charge what is billed or what is collected?) First step for ensuring data quality is to compile these definitions and abide by them i. Committee on measurement and definitions can ensure that all relevant national sources have been adopted, investigate potential conflicts and ambiguities, and define additional measures the institution needs Definitions are embedded in business contracts and government regulations.
Difference between Disparate Impact and Disparate Treatment:
Difference between Disparate Impact and Disparate Treatment: i. Motive is irrelevant in disparate impact cases ii. Disparate treatment cases= the intent to discriminate must be proven. iii. In disparate impact case, the plaintiff must make the case that a particular employment practice disproportionately affects a particular group, and whether the employer intended to discriminate is irrelevant.
Discuss the concept of employment at will and the ways in which this concept has been eroded.
Discuss the concept of employment at will and the ways in which this concept has been eroded. a. Employment at Will i. Assumes that both employee and employer have the right to sever the work relationship at any time without notice for any reason, no reason, or even bad or immoral reason. ii. This concept of employment at will has been eroded by a many laws and regulations.
Define Disparate Impact
Disparate Impact refers to significant under-representation of members o the protected class as a result of the organization's employment policies and procedures
Define Disparate Treatment
Disparate Treatment is when employees in the same organization are treated differently because of their race, color, religion, sex, national origin, age, or disability.
Economic, legal, and social considerations
Economic, legal, and social considerations a. Employment compensation, including benefits is an exchange transaction governed by marketplace b. HCO depart from market price for labor because lower price may not attract qualified staff and higher price may waste funds c. HR plays a role in keeping contact with appropriate markets for wage and salary prices d. Well-run HCO are limited in their role in addressing social problems like unemployment due to: i. Requirement to comply with laws and regulations (eg. Fair labor act, OSHA/working conditions, and equal opportunity) ii. Comply with market trends (must pay fair wages to get qualified staff) iii. Advocate as an organization for more significant redress on social problems iv. Indirect methods of increasing employment is though hiring disadvantaged groups v. Can increase jobs by locating facility in inner-city areas vi. Can provide scholarships for disadvantaged personal seeking education in health professions vii. Promote the use of local contractor who employ from disadvantaged groups
Effective Grievance management:
Effective Grievance management: a. Requires sound employment policies, effective education for workers/supervisors, and system that emphasize rewards over sanctions b. Should stimulate the following 6 reactions: i. Documentation of issues, location, and position of two parties to provide guides to preventative or corrective action ii. Implementation of changes designed to prevent recurrences iii. Settlement without formal review, either by mutual agreement or by concession on the part of the organization iv. Informal negotiations (allows flexibility and innovation for satisfactory solution) v. Credible, unbiased, informal review to identify constructive solutions. vi. Counseling for the supervisor aimed at improvement in seeking human relations.
Emergency Medical Treatment and Labor Act (EMTALA),
Emergency Medical Treatment and Labor Act (EMTALA), prohibits hospitals in most circumstances from failing to provide care and requires them to stabilize patients in emergencies and labor.
Ethics in Patient Referral Act
Ethics in Patient Referral Act (part of SS Act), commonly referred to as the "Stark law", applied originally to laboratory services (1989). In 1993, it was expanded to cover many types of "designated health services", and this is referred to as "Stark II". Final regulations came out of CMS in 2001. Under the federal law, physicians are not actually prohibited from owning an interest in a healthcare facility. However, if a physician or immediate family member has an ownership interest or compensation arrangement with an entity, the physician may not refer a patient to the entity, and the entity may not bill the government program that were rendered as a result of the referral. Under these circumstances, many HCO's do not want -or will not permit—referring physicians to have ownership interests or compensation arrangements, because they do not want to lose the opportunity to bill for their referrals. The Stark Law is intended to protect against unnecessary care and overuse of services driven by private financial gain rather than by medical need.
Fair Labor Standard Act and Child Workers
Fair Labor Standard Act- Forbids employment of children 16-18 in harazardous jobs (mining, logging, woodworking, meatpacking, and manufacture jobs). Minors 14 & 15 may work outside school hours: Work must be between 7AM-7PM, not exceed 3 hours on school days or 18 hours in school week or 40 hours when no school.
False Claims Act: (7)
False Claims Act: 1. Person is liable if they knowingly present a false claim to payment. a. Ignorance of falsity of claim is not a justifiable excuse. b. Even if you are not personally involved in the billing process, submission of a false claim knowingly is still violation c. Billing person is responsible for acquiring information to ensure accuracy of claims submission. d. Organizations must have a mechanism for verifying the accuracy of claims submitted. 2. A claim is one request for payment , irrespective of the number of false codes on the claim 3. No proof of specific intent to fraud is needed
Two parts of the Federal False Claims ACT
Federal False Claims Act (FA). The FCA provides in pertinent part as follows: (a) Liability for certain acts. Any person who (1) knowingly presents, or causes to be presented, to an officer or employee of the U.S. Government or a member of the Armed Forces of the U.S. a false or fraudulent claim for payment or approval...Is liable to the U.S. Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person... b) Knowing and knowingly defined. For purposes of the section, the terms "knowing" and "knowingly" mean that a person, with respect to information (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information, And no proof of specific intent to defraud is required
Health Informatics Standards ---defining measures & definitions
Health Informatics Standards (American national Standards Institute)-- established USHIK (US Health information knowledgebase) to guide the development of definitions
HIPPA & patient confidentiality
Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires patient confidentiality in almost all circumstances. The exception is to disclose PHI for purposes of disease control and surveillance. In that statute, congress recognized that electronic transmission of health information could improve the efficiency of the healthcare system, but also recognized the importance of protecting the privacy of individually identifiable health information." Therefore, Congress required the Secretary of HHS to adopt various standards for electronic exchange of information, such as standards for transmissions, data elements, and code sets; as standard unique health identifier; electronic signatures; and security of health information. Congress directed the Secretary of HHS to make recommendations to congress with one year on the protection of privacy. In addition, Congress gave itself three years to enact privacy standards by means of additional legislation. Under the HIPAA statute, if Congress failed to enact privacy standards by new legislation within three years, the Secretary of HHS was required to adopt standards for the protection of privacy by means of a rule. Most individuals and organizations that are subject to the rule must have been in compliance by April 14, 2003, although small health plans had until a year later to comply.
Hill-Burton Act:
Hill-Burton Act: a. Federal legislation that assisted hundreds of communities to build non-for-profit hospitals during the post war era (World War II). b. This Act provided federal funding to improve the physical plant of the Nation's hospital system.----aka established community hospitals. Hospital began to implement quality controls and systems for employed physicians and private practice physicians affiliated hospital c. Hospitals that received funding were required to provide free medical care to the needy. Most of the participating hospital were in areas with middle class and not built in poorer communities. d. Community hospitals became the leading employers of healthcare professionals. HillBurton Act, states that Healthcare facilities that have received funding for construction and modernization under the Federal Hospital Survey and Construction Act have an obligation to provide a "reasonable volume" of services to persons who are unable to pay for such services.
How to decide if reasonable accommodation can be provided?
How to decide if reasonable accommodation can be provided? i. Look at the particular job involved and determine its purpose and essential job function. ii. Consult with the individual with the disability to identify potential accommodations that may be needed; iii. if several accommodations are available and possible, preference should be given to the individual's preferred accommodation.
ICD-9, CM----defining measures & definitions
ICD-9, CM-description and classification of disease & identification and coding of diagnoses and procedures
Implementation of facilities plan:
Implementation of facilities plan: i. Indicates the requirements and way they will be met ii. Descriptive statements are then expanded into drawings for space and fixed equipment iii. Approval can be time consuming; approval needed before building occupation.
Kinds of Scale
Kinds of Scale (See figure 6.7) a. Classification of diseases, procedures, and prescription drugs are nominal scales b. DRG is a nominal scale c. Nominal scales generate attributes measures----a binary value for each case
Legal definitions of the sexual harassment law:
Legal definitions of the sexual harassment law: a. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical contact of sexual nature constitute harassment when: i. Submission to such contact is made either implicitly or explicitly a term of condition for employment. ii. Submission to or rejection of such conduct by an individual is used as basis for employment decisions that affect the individual. iii. Conduct has purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile, or offensive work environment.
Maintaining confidentiality of information:
Maintaining confidentiality of information: a. HIPPA= privacy and confidentiality protocols b. IS (information security) designs and maintains systems to protect files against unauthorized use. c. Controls used in operations to maintain confidentiality: i. Identification cards, passwords, & voice readers ii. Finger prints & retinal readers d. Centralized archiving and monitoring of data use and users protect against inappropriate use of archive. i. Reporting must be constructed in ways that prevent inference about persons from statistical analyses. e. Compliance programs involve supporting steps to reduce risk of damage from loss of confidentiality of information that's automated (ie driving records, credit records and tax files.)
Difference between Medicaid and Medicare?
Medicaid is a means-tested, social welfare program that uses tax revenues to provide health coverage for persons who cannot afford private health insurance. Unlike Medicare, with is a purely federal program, Medicaid is operated and funded by both state and federal governments. This situation gives rise to occasional disputes over the powers and duties of each level of government. The federal Medicaid statute is known as Title XIX of the Social Security Act. By means of the statute, Congress makes an offer to the government of each state. If a state establishes a medical assistance program that meets all federal standards, the will receive a federal financial participation (FFP) stipend. This usually is about half of the cost of operations.
Establishment of Medicare
Medicare was established by federal statute, which if referred to as Title XVIII of the Social Security Act (1965). It is a purely federal program administered by the CMS, which is part of the Department of HHS. To implement the program, CMS has adopted regulations, which are contained in the Code of Federal Regulations and the Federal Register. In the Balanced budget Act of 1997 (BBA), Congress also created Part C for the Medicare program, which allows each beneficiary to choose from a variety of managed care plans or remain with the traditional feeforservice program under Parts A (hospitalization) and Part B (outpatient, lab, home health, etc.).
Modeling Future Need of Physicians:
Modeling Future Need of Physicians: a. HCO should be properly sized to the community it serves b. If too many physicians than needed, then skills may be lost due to lack of practice, income and satisfaction goals of physicians may not be met, and physicians may seek to give unnecessary treatments to earn money. c. If too less of physicians, then overworked physicians- endangering the quality and adequate choice of physicians. d. One solution is to plan staff size as part of strategy and long-range plan.
National Bureau of Standards--defining measures & definitions
National Bureau of Standards-- definitions for time, energy, distance, and weight
Obtaining regulatory approval:
Obtaining regulatory approval: a. Certificate of need= government-issued permission to proceed with capital investment; a form of regulatory control over hospital investments. b. Within the framework of competition between HCO, collaboration and communication are common. c. Per se violation law states that conversation between competitors cannot include collusion to set prices, divide or establish markets, or exclude competitors d. Actual negotiation of mergers and acquisitions is the role of the CEO and governing board, but the planning executive takes role in providing data that assists in decisions making
Ownership of Community Hospitals: (5)
Ownership of Community Hospitals: a. Community hospitals have, historically, been controlled either by government (state, federal, or local) or by non-profit organizations. b. Federal & State community hospitals tend to have special purposes, such as care for special groups (eg.military, mentally ill, or hospitals attached to universities). c. Non-profit hospitals are owned by corporations, established by nongovernmental groups to meet community needs. d. Three types of ownership for hospitals: non-profit, for-profit, and government. e. AHA plays a major role in collecting hospital statistics (beds, admissions, discharges, size, & revenue). General trend is for smaller hospitals in urban hospitals disappear (either bought by larger institutions or go out of business). Rural hospital have mostly turned into outpatient care centers due to the existing need for convenient primary care services
Pension and retirement administration
Pension and retirement administration: a. Workforce adjustment strategy i. Bonus offered for early retirement as way of adjusting the workforce ii. A method of workforce reduction iii. Advantage of older workers is that they are amenable to reduced hours, have reliable work habits, and less likely to have unpredictable absences. b. Pensions funded by cash reserves and retiree's health insurance premiums are shown as liability on balance sheet c. Pension issues are handled by HR or management firm/fund trustees i. Can include retirement counseling (management of pensions and health insurance benefits) d. Pensions are regulated by ERISA i. ERISA regulations specify the employer's obligation to offer pensions, to contribute to them if offered, to vest those contributions, and to fund pension liabilities though trust arrangements ii. ERISA regulates the pension but not the retirement benefits (ie. Medicare supplementation, amount of Social security, benefits not paid if employee leaves before vesting, retirement incentives) e. Federal law allows older worker, including healthcare worker, the right to continue working without a mandatory retirement age.
Real estate investment:
Real estate investment: i. Can be purchased or leased ii. Requires board approval with finance department involvement iii. Can lease all or part of facility including equipment
Define Reasonable Accomodation
Reasonable Accommodation Definition= an attempt by the employers to adjust, without undue hardship to the organization, the existing working conditions to fit employees with disabilities. This may involve restructuring the jobs, alter work schedules, reassign individuals to different tasks, adjust training materials, and provide readers with interpreters. i. No strict guidelines exist for determining undue hardships for the organization. ii. The law suggest comparing the cost of the accommodation with the employer's operating budget. The overall size of the organization, type of operation and nature & cost of the accommodation may be considered.
Reasonable Standard:
Reasonable Standard: A. Reasonable woman standard is used to assess and compare how a reasonable woman would react to a similar situation as the plaintiff. B. Reasonable person standard= Used to assess and compare how a reasonable man or woman would react to a similar circumstance.
Severity Adjustment:
Severity Adjustment: a. Performance measures are adjusted for the severity of the illness b. Two approaches for severity adjustment i. Patient conditions other than diagnosis used to weigh severity. ii. Medicare prospective payment system- DRG assigned based on discharge diagnosis; Diagnosis with similar costs are grouped together
Space Allocation:
Space Allocation: a. Each space should be used/disposed in a way that optimizes achievement of the organization mission b. Space is unique, prestigious, and confers symbolic rewards c. Well-run organization address shortage of space and reallocations by incorporating space use and facility needs in long-range planning, developing facilities plan that translates service decisions to specific available/needed space. d. Each unit must submit formal request and approval for space. e. Facility plan 2 function i. Describes necessary additions/reductions in space inventory ii. Translates service decisions into specific or available space
Stark Law & 4 Exceptions to the ban of self-referral:
Stark Law & 4 Exceptions to the ban of self-referral: a. Referrals for services provided by other physicians in same group b. Office ancillary services furnished by the referring physicians or individuals under his supervision. c. Ancillary services must be billed by the physician or group practice and they must be provided in group's building or another building used by group d. Does not apply when physician refers health plan members (HMO) despite incentives given to doctors by such plans
Hospital Labor Relations Act
The Fair Labor Standards Act of 1938 establishes standards for minimum wages, overtime pay, record keeping and child labor. The Hospital Labor Relations Act regulates labor relations between employers and employees while providing employees with rights of free association, union organizing and collective bargaining. Don't confuse these!
The Sherman Antitrust Act deals with federal antitrust matters. There are 3 elements that a prosecutor must prove to find guilt:
The Sherman Antitrust Act deals with federal antitrust matters. There are 3 elements that a prosecutor must prove to find guilt: 1. There must must be a contract, combination, or conspiracy, with requires at least two independent parties 2. Must have an effect on interstate commerce; and 3. Must demonstrate a restraint on trade.
Uniform Guidelines on Employee Selection Procedures:
Uniform Guidelines on Employee Selection Procedures: A selection rate for any race, sex, or ethnic group which is less than fourfifths (4/5) (or eighty percent) of the rate for the group with the highest rate will generally be regarded by the Federal enforcement agencies as evidence of adverse impact, while a greater than four fifths rate will generally not be regarded by the Federal enforcement agencies as evidence of adverse impact.
Title VII of the Civil Rights Act of 1964
Title VII of the Civil Rights Act of 1964 prohibits discrimination in Voting, Public Education, Hiring and Promotion. It does not prohibit discrimination based on disabilities. This is covered under the Americans with Disabilities Act (ADA) of 1990. The basic premise of all Equal Opportunity Laws, however, is that employment decisions including hiring, promotion, compensation and benefits, and training opprtunities should not be based on non nob related characteristics such as age, gender, race, or disability. The age limit that forbids discrimination against men and women by employers, unions. Employment agencies, state and local governments, and the federal government, is 40 years of age. The ADA provides substantial protection to individuals with disabilities such as epilepsy, blindness, and deafness. It does not protect those with Gender identity disorders. The ADA also does not cover those who present a direct threat to others or themselves.
Two key laws govern public health and safety:
Two key laws govern public health and safety: i. Worker's compensation (state law) ii. OSHA (Federal law)= workplace safety and inspections
Two types of sexual harassment recognized by the EEOC as employment discrimination:
Two type of sexual harassment recognized by the EEOC as employment discrimination: 1. Quid pro quo a. Job-related benefit is offered or made available to an employee in exchange for the employee's submission to sexual advances. 2. Hostile environment sexual harassment a. Sexual behavior in the work setting is perceived as offensive and undesirable.
Types of Physician Compensation Arrangements
Types of Physician Compensation Arrangements (All notes for this=See table from pg 308) a. Medicare creates a multiplier each year that is adjusted for geographic location. b. PPO, Medicaid and HMOs create their own multiplier that can be compared with that of Medicare. c. Physicians cannot charge more than agree-on fee. Payments for employed physicians go to employer; physician incentives can be offered based on earnings. d. Two incentive modifications can be made to fee schedule: i. Cash for tasks not included in CPT (eg. Cash for reaching quality and satisfaction targets or preventative targets) ii. Withhold contract- predetermined fraction of the payment is withheld and deposited in trust account (if costs exceed the expectations, then entire account is forfeited by physician) e. Capitation can be global (assigning one physician the economic result of all are, professional care only with exclusion on institutional costs
Clayton Act
Under the Clayton Act, section 7 prohibits mergers and acquisitions that may reduce the level of competition in the marketplace, especially if the effect "may be substantially to lessen competition, or to tend to create a monopoly."
Understand the impact of legal considerations on all human resources management activities and functions.
Understand the impact of legal considerations on all human resources management activities and functions. a. Employee- Employer relationships are governed by legal concept of agency, in which the employer /organization empowers the employee to carry out duties, services, or work. b. The actions of the employee are a direct reflection of the organization's beliefs. i. The complex legal environment around HR management is under constant federal scrutiny and reform. ii. In addition, the legal requirements imposed on an organization sit according to industry and state specific regulations. Therefore, managers must learn about work environment regulations. c. To be prudent, law-abiding decisions, the manager must understand the employee and employer's rights. d. Attentiveness to legal requirements is important at all managerial levels, given that senior managers and board members are the ones charged liable if a violation occurs at any level of the organization.
Understand the rationale for government intervention in the workplace to prevent discrimination.
Understand the rationale for government intervention in the workplace to prevent discrimination. a. Passage of anti-discrimination laws is a form of workplace regulation. b. Non-discriminatory employers gain a competitive advantage over employers who practice do illegal discrimination because they have greater access to more qualified candidates.
VII of Civil Rights Act of 1964- Who's exempt?
VII of Civil Rights Act of 1964- anti-discrimination law in areas including voting, public education, employment, and public facilities. Covers all organizations except: religious organizations that employ a certain religion, organizations that hire Native Americans or are near reservations, private clubs which are tax-exempt, US government-owned corporations.