Imagine that you’re the comptroller of a health care organization striving to comply with the challenges of reconciling ethics and law in your department.
Watch the following 2 videos:
1 – “Ethics and Law in Health Care Finance”
Transcript :
Why do you have to learn about ethics on law in a healthcare of Finance course? Does that make sense? Well, look, let’s start with ethics exactly what it is.
Ethics is nothing more than certain principles that guy human behavior to decide right from wrong.
It is a branch of moral philosophy to guide people’s behavior.
The problem is that different people may have different ideas or interpretation. What is right? From what is wrong? And therefore ethics is something that could be interpreted differently by different people. There is no one concrete set of rules because different interpretations as I said by people of right or wrong yield different result and different consequences. Look the expression of Ethics is very abstract that is not concrete right on the other hand. What is law? Well, you see law is a much more systematic set of rules and regulations that governs the actions of people’s behavior.
It is very concrete. It is not vague law is created with a purpose of normalizing or standardizing human behavior some examples that come to my mind are to speak limits respecting stop signs and yield signs.
Law has a binding nature to it. He means that if you break the law you have to pay the consequences for violating the law.
So again, what do we need to learn about ethics and law in a healthcare of Finance course? Well, here’s the most important reason it comes to my mind. We need to uphold the greatest compliance principles in our daily jobs, and I want you to consider the word compliance and underline that because compliance is the bridge that unites ethics on law.
All Healthcare organizations have compliance programs to make sure that it’s employees are following policies and procedures and rules to remain within compliance with an ethical and legal Frameworks.
Let me give you an example to illustrate what I’m stating here in my job. I have to take annual educational programs on compliance and I have to pass quizzes successfully on the content of the module related to ethics policy and procedures at work.
Furthermore I have to review and sign annual attestations forms.
To disclose to my employer any types of conflicts of interest or unethical behavior that I might have witnessed in their previous year. This is real. This is happening every year in all the hospitals that belong to my employer.
What are some of the Practical applications of this Concepts? Well, let me ask you this. How do you know if you’re making the right decision or not when you’re facing an ethical dilemma? I’m going to test give you a test and the test consists of three questions that you need to ask.
The next time you face a situation of an ethical dilemma ask yourself number one.
Is it legal? Look if it is not legal you might as well stop right there, right? It makes your decision a lot easier. Don’t do it.
Number two, is it balanced? What does that mean? Well, is that the pros more convenient towards me than the cons or the other way around in other words is a decision that I’m about to make in facing that ethical dilemma is benefiting too much myself. I supposed to making sure that I have equity in the decision that I’m making and then third and finally ask yourself this question.
How will it make you feel if the decision you’re about to make was published on the front page of the newspaper? So in a nutshell ethics is doing more than the law requires unless than what the law allows.
You see ethics is the ceiling law is the floor.
Ethics are like a tree and the branches of that tree.
You keep bending them and it will break or another analogy is ethics are like rubber bands.
You keep stretching them and they will break. This is all for now.
2 -“Fraud, Waste, and Abuse in Health Care”
Transcript:
Corporate compliance is essential in every single Healthcare organization on a daily basis.
In order to remain compliant, we must learn about fraud abuse and waste in healthcare facilities.
Let me give you some statistics here in 2020. The healthcare costs reached 4.1 trillion dollars, which is approximately 20% of the GDP.
Out of those 4.1 trillion dollars. He has been identified from 2020 that 60 billion dollars or 15% was due to fraud waste and abuse caused by doctors providers such as hospitals nursing homes patients and staff or employees.
So let’s go ahead and Define each and every one of them fraud waste and abuse.
Fraud is defined as knowingly and willfully executing a scheme in order to defraud a healthcare benefit program.
Examples include billing for services that were not rendered.
Altering claims to or a medical record so that you can get a higher payment.
Or over utilization of services waste.
While waste is a careless overuse of healthcare services.
This happens when ordering unnecessary prescriptions scheduling excessive office visits. We’re ordering excessive lab orders. What about abuse? Well abuse our actions. I may either directly or indirectly result in unnecessary health care costs. This involves payments for items or Services when there is no legal entitlement to that payment in other words, the provider has not knowingly and or intentionally misrepresented those facts in order to obtain that payment there are multiple federal laws to protect the public one law that comes to my mind immediately is the false claims act FCA. This is a civil law that protects the government and the public from being overcharge or so goods or services. There is no specific intent requirements. There are also criminal penalties for submitting false claims. Another federal law is not as the anti-kickback statute or AKs now, this is a civil but this is a criminal law that prohibits the knowing and willful payment.
Of remuneration to induce a reward patient referrals.
Kickback can result in example such as the over utilization of services increased program costs.
And Corruption of medical decision making processes.
Same thing with regard to Patient steering.
Unfair competition is another example a third law here that we’re discussing in regard to Federal Protection is physician self referral better known as the Stark law.
this law prohibits Physicians from referring patients to receive designated Healthcare Services payable by either Medicare or Medicaid from businesses in which either the physician or the immediate family member of that physician has a financial relationship.
Some examples are clinical Labs Physical Therapy occupational therapy speech therapy or outpatient prescription services from a pharmacy owned by a doctor or family member.
It is a strict liability statute. This means that proof of specific intent to violate. The law is not a requirement.
In my experience as a healthcare administrator, I can tell you that learning about this different federal laws will provide you with greater guidance on how to prevent fraud waste and abuse.
in order to remain compliant
After watching the videos, respond to the following prompts:
How are ethics and compliance in finance relevant in your department?
Why are ethics and compliance so important to the health industry overall? Provide 1 example and ensure it relates to finance.
