Hello, this is Don Belesa. I'm the CEO and legal counsel of the American Association of Medical Assistants, and I'm very pleased to be able to present to you a module entitled Legal Overview for the Medical Practice. This is one of the modules for the assessment-based certificate in medical office basics. I would like to add that if you have any questions after you watch this, feel free to send me an email. You see my email address right under my name. Also, this will be provided in the last slide as well. All right, let's get started. First of all, let's talk about healthcare delivery settings. What are the different types of settings? Basically, there are two types of healthcare delivery settings. One is an outpatient setting, and the other is an inpatient setting. Just some quick definitions. An outpatient setting is also known as an ambulatory setting, such as a licensed provider office or a clinic. It is distinguished by the fact that in an outpatient setting, patients are able to come and go after they have been seen and treated by the licensed providers. Then the medical assistants play their role in this as well. Then patients are able to go home. They don't have to stay overnight or for an extended period of time. In contrast to that, there are inpatient settings. As the name implies, this is a setting in which the patient stays in a healthcare delivery environment and does not go home the same day. Some examples of this are hospitals, which are probably the best known inpatient settings, as well as some other inpatient settings, such as skilled nursing facilities known as nursing homes, assisted living facilities or settings of that type, also hospices. We have seen rehab facilities in recent years, which are inpatient, in which a patient stays for a period of time just to go through the rehab processes that have been recommended by the provider. I do want to mention that the laws in regard to outpatient and inpatient settings and what can be done and who can do it in these various settings will vary somewhat from state to state. Speaking of legalities, let's talk about state and federal law. In this day and age, it may seem that most things are governed by federal law. However, that's not the case in regard to healthcare. There are many aspects of health law that are governed by state law, not by federal law. One of the aspects that state law has authority over, as you see on the slide, is the scope of practice of health professionals. Scope of practice determines what a particular health professional is permitted to do and is forbidden from doing and whether the professional is able to undertake those tasks independently or whether the professional has to work under the authority and supervision of another health professional. The laws vary from state to state on what professionals are permitted to do. Now, let's talk about the federal law aspect. Reimbursement for medical care often comes under the federal law. For example, the most well-known reimbursement program is the Medicare program. Also, another aspect of federal law that really takes precedence in regard to healthcare regulation is the controlled substances law. There is a federal agency known as the Federal Drug Enforcement Administration, or DEA, that has authority to regulate controlled substances. This is a situation in which federal law is the primary governing law for controlled substances. The reason that this is controlled by federal law is because controlled substances are often within interstate commerce. Namely, they travel from one jurisdiction of the United States to another or one state to another. That is why controlled substances fall under federal law. I do want to add one other point, and that is telehealth. That's become very prominent in the last five or six years, especially because of the COVID-19 pandemic. The legal analysis in that case is complicated and has not settled at this time. I would just encourage you to keep in mind that telehealth laws may apply for the state in which the provider is located, as well as the state in which the patient is located. We have some additional information that we are preparing, and you will be informed on the AAMA website when that information is available. Now let's talk specifically about the legal categories of medical practice personnel. There are three main categories. The first one is licensed independent providers, and I will be defining that on the next slide. The second category is licensed professionals. They are different from licensed independent providers, but they do have the commonality of being licensed, and I will define that term as well in a few slides. Finally, there are unlicensed professionals, but these unlicensed professionals may be certified. Before we move on, let me give you some examples of licensed independent providers. They are physicians, as well as osteopathic physicians. Dentists would be considered licensed independent providers, as well as podiatrists and pharmacists. What are some examples of licensed professionals? Those would be individuals such as physical therapists, occupational therapists, registered dietitians, radiologic technologists, registered nurses, and licensed practical nurses. These are health professionals who are licensed, but they are not considered licensed independent providers because they only practice under the authority of another provider, usually a licensed independent provider. Finally, unlicensed professionals who may be certified. Some examples of these health professionals would be medical assistants, phlebotomists, medical coders, and office managers. We will get more specific as we move forward through these slides. Let's define these terms licensing and certification, very fundamental to understanding the different categories of health professionals. First of all, licensing has definite features. Number one, as you see, it is a mandatory requirement. If a health professional is licensed, that means that under law, that individual must meet certain requirements, certain educational testing requirements, in some cases, experience requirements. It is illegal for an individual to work in a licensed profession unless that individual has met all of these mandatory requirements and is licensed and registered by a state agency. The second feature of licensing is that it is primarily state by state. It is not federal for the most part. Now, it is true that there are some professions that have reciprocity agreements or interstate compacts, which require or allow an individual who is licensed in one profession in one state to be able to move to another state and start practicing that profession fairly quickly and fairly easily. However, the key element of licensing is that it is primarily a state by state system. How does certification differ from licensing? The first point is that certification is voluntary. It is not mandatory. In other words, it's not required by state law, but it is voluntary. Again, contrast that with licensing, which is mandatory. In other words, if an individual practices a licensed profession without being licensed, that individual is violating the law. In certification, however, the certification is voluntary. It's not required to be held by the law, and therefore, there is no legal penalty if someone practices a certified profession without having the certification. The next feature is that certification, unlike licensing, is primarily national in scope. It is not primarily state by state. It is true, however, that some employers of certified professionals will insist that these individual employees be certified. Even though there's no legal requirement, remember certification is voluntary. It's not mandatory. Employers may, in effect, make a certification mandatory by only hiring professionals who have a certification. Now, one element I want to mention is that front office staff in a medical office or any provider office are sometimes asked to keep track of whether the individual professionals in the office are current with their licenses and their certifications. Keep in mind that all office staff, administrative front office, as well as clinical back office, have to be mindful as to whether the credentials, the licenses, and the certifications of professionals in the office are up to date. I also want to mention that in some cases, a national certification, which is voluntary, can be incorporated as part of a mandatory license. Even though the certification itself may be voluntary, the license incorporates that certification, and therefore, by virtue of the license being mandatory, renders the certification to also be required. Let's go back and talk about these licensed independent providers. A primary category is physicians, as I mentioned, doctors of medicine and doctors of osteopathic medicine, often known as MDs or DOs. I did indicate that some other licensed independent providers are dentists, pharmacists, podiatrists, optometrists, et cetera, but we'll mostly be concerned with physicians in this category of licensed independent providers. Let's look at the next category, and I label this advanced practice registered nurses, and there are actually four subcategories of advanced practice registered nurses, or APRNs. One category is certified registered nurse anesthetists, or CRNAs. A second category is clinical nurse specialists. Another category is certified nurse midwives. And finally, the most numerous category is nurse practitioners, known as NPs. So in some states, nurse practitioners are permitted to practice independently. In other words, they do not have to work under the authority of a physician. In other states, nurse practitioners do have to work under the authority of a licensed independent provider, usually a physician or an osteopathic physician. The laws in regard to nurse practitioner autonomy do vary greatly from state to state, so it's important that all personnel in the office be aware of what the law is in a particular state. Finally, the third category that I highlight of licensed independent providers is physician assistants, or PAs. By definition, physician assistants practice medicine under the authority of a physician. Keep in mind that physician assistants are much different from medical assistants. In some states, physician assistants, similar to nurse practitioners, are seeking to bring about legislative change so that they also will be able to work independently, in other words, not under the authority of a physician. However, there are only a few states that have moved in that direction, whereas with nurse practitioners, there are approximately 20 states that allow NPs to work autonomously without being under the jurisdiction and authority and supervision of a physician. So let's talk about some of the laws that govern these licensed independent providers. First of all, every profession has to have a practice act, and that is defined as a piece of state legislation that establishes the scope of practice for the profession, actually defines the profession, distinguishes the profession from other professions. So each state has its own medical practice act, nursing practice act, podiatry practice act, pharmacy practice act, etc. And keep in mind that these are state by state. Once again, this is an area of the health law that is governed primarily by state law, not by federal law. So we start with a state legislature, remember every state has its own legislature, enacting a practice act that provides the definition of the profession and determines the requirements for the profession, any educational requirements, examinational requirements, passing a test, often referred to as a licensing exam, and then registering with the state licensing board. That takes us to our next point, state licensing board. Each state has its own licensing board for each of the licensed professions. These boards are created by the respective practice act for each profession. And that is why, again, we have state boards in each state for all of the licensed professions. Now, these state licensing boards are given the authority by the state legislature, by the practice act, to issue regulations or rules. Those terms are used interchangeably. And those are similar to the practice acts. However, they're different in that they go into much greater detail about a particular profession, the scope of practice, the requirements, and any disciplinary actions that can be taken against a professional for violating the practice act or the regulations. If there are disciplinary actions that are to be brought against a professional, those would be initiated with the state board for that profession. So in that sense, a state licensing board can function in a way similar to a court in that it can make determinations as to whether a particular professional has violated any of the ethical or legal principles for that profession. Now, let's turn the corner and talk about legal duties that are owed to patients, and there are two primary duties that health professionals, all health professionals owe to patients. Those duties are, number one, the standard of care and number two, the obligation to provide full disclosure to patients and patients' representatives. Let's look at these individually. The standard of care may be defined as the quality of care that a certain professional owes to the patient. And that standard of care requires, first of all, a certain level of knowledge that professionals in this field need to know in order to provide safe care for patients. And the way this is often put is that professionals have to exhibit the knowledge and skill of the reasonably competent professional in that field. So there's an element of knowledge. There's also an element of skill that results in competent provision of care. Let's look at these two violations of the duty to provide a quality of care which meets or exceeds the standard of the profession. First of all, if a health professional provides care that falls below the standard of care, then that professional can be liable for negligence or malpractice. Note that I say liable because negligence or malpractice involves the area of law, which we know as civil law. It is not part of the criminal law, which I will discuss later. Secondly, remember that the standard of care can vary from profession to profession depending on the knowledge and the skill that a particular profession needs to have in order to provide safe care, reasonably competent care to patients. The second primary area of legal duty to patients is full disclosure to patients and or their representatives. A key term that we encounter in this context is informed consent. Patients must be told enough to know whether they want to consent to our particular course of treatment provided by a health professional. They not only need to consent, they must have enough information provided by the health care professional to make an intelligent or a meaningful or an informed decision as to whether they want the professional to provide a certain course of treatment. So the patient must understand and must agree or consent to that course of treatment. I represent or I mentioned representatives because in some cases, the patient himself or herself is not able to make a decision whether that's because of the patient's inability, because of physical or mental illness, or if the patient is a minor and doesn't have the capacity to understand the options. In that case, a patient representative, whether it's a parent or whether it's someone who is authorized by the patient to serve as a decision maker, would have to be given all the information by the health care provider and then be able to make an informed decision as to a certain course of treatment. Let's discuss a little bit more this idea of malpractice and the insurance or the professional liability insurance that is available to protect health professionals from any claims that the professional did not provide the standard of care required in that profession. So it's important for all individuals who work in the health care delivery setting to have some sort of coverage or professional liability, some type of insurance, malpractice or professional liability insurance. And why is that the case? Well, we have to answer this threshold question. As you see in the first section, who can be held liable for malpractice or negligence? And remember, that's defined as not providing a standard of care to the patient. There's one misunderstanding that the only health professionals who can be sued for malpractice or negligence are those who are licensed independent providers, your physician, et cetera. That is not the case. Rather, the correct answer to this question is that all parties in the delivery setting, even if they are unlicensed personnel, can potentially be held liable for malpractice or negligence. And this even applies to administrative staff, because every individual in a health care delivery setting is expected to provide a quality of care that meets or exceeds that of the reasonably competent health professional in that field. So if a front office staffer does not provide a quality of care that meets or exceeds that of the reasonably competent administrative staff in that delivery setting, that individual may be sued and may be held liable for malpractice in that profession. And this is why it is important that all parties in a health care delivery setting have some sort of malpractice or professional liability insurance. Second point, adequate and appropriate coverage for health professionals. It is important for all professionals to have some sort of malpractice or professional liability insurance, and this can be accomplished by the setting having a blanket coverage, as it's called, a blanket policy for all individuals who work in a delivery setting, or in some cases, it's better to have individual coverage for each health professional. Another area in which front office staff need to be mindful of is making sure that the premiums for this malpractice policy or policies are paid on time and kept up to date. If a premium is not paid on time and if there is a claim, then it's quite possible that the malpractice coverage could be forfeited and the professional who is alleged to have violated the standard of care and is being sued for malpractice may not have the benefit of the coverage because the premium was not paid on time. Finally, let's take a look at legal liabilities that are not covered by malpractice insurance. I mentioned a few minutes ago that malpractice is in the category of civil law, not criminal law. And health professionals can be sued, can be charged criminally if they do something that is a violation of the criminal laws of the jurisdiction. The key point to remember here is that the malpractice insurance coverage almost universally does not apply to criminal violations. So there really is no insurance policy that can protect a health professional against any criminal acts. When we talk about professional liability insurance, we're talking about protection from civil wrongs such as malpractice. Now, another area that's not covered by malpractice insurance is practicing without a license. In other words, if a health professional goes beyond the scope of practice that is set forth in the Practice Act of the state and the regulations of the state board, then having an insurance policy for malpractice would not cover that. So we do have to be especially careful in a delivery setting to especially avoid any practicing without a license and to avoid any criminal acts by the health professional. Let's talk about another legal duty, and namely, this is the duty of confidentiality. The general legal principle is that patients have a legal privacy interest in their personal information. Patients do not forfeit. Their privacy once they agree to be treated by a health care professional, so that confidentiality still applies in a health care setting. And that's why health care professionals of all types, whether they be licensed independent providers or licensed professionals or professionals who are certified but not licensed, and whether their clinical personnel or administrative personnel need to be aware of these general legal principles of privacy that apply to patients and their information. Once again, I will reiterate that all staff, clinical and administrative, must know and abide by confidentiality requirements. And one point to keep in mind is that these requirements of confidentiality apply to oral communication by staff, as well as to any written communication. Now, a very well-known federal law is the Health Insurance Portability and Accountability Act, often known as HIPAA. This is a federal law and it has established privacy and security standards for health professionals. And there are three key definitions that we need to unpack to understand the HIPAA law. And I should mention here that HIPAA is covered in greater depth and detail in some of the other modules in this assessment-based certificate and medical office basics. So I will just be covering the very basic definitions and you'll get some very good treatment of these concepts in other modules under the ABCMOB. But first, let's look at these three key definitions. The first definition is a covered entity. Who are covered entities? Secondly, who are business associates? And finally, what is protected health information under the HIPAA statute and its regulations? Covered entities, there are different categories, three primary categories. First of all, health care providers are covered entities under HIPAA. And this includes both individual health care professionals, as well as entities such as clinics or health systems or partnerships of health professionals. So health care providers and their structures under which they work and practice. A quick note here is that these health care providers are covered by HIPAA only if they transmit health information electronically in connection with health care. Now, this is virtually all providers right now. But technically, if a provider does not transmit health information electronically, that health care provider is not covered by HIPAA. A second subcategory of covered entities is health plans such as insurance or third party payers that offer coverage for health care services. And we're familiar with the insurance companies that provide coverage for health care. We're also familiar with governmental plans such as Medicare and Medicaid, which I'll discuss shortly. And finally, there's another category under covered entities known as health care clearinghouses. These are entities that collect information and provide it to other parties in order to make the health care system run efficiently. So under covered entities, health care providers and their groups. Remember, this can be individuals as well as entities. Secondly, insurance plans or third party payer plans, both private and governmental, and finally health care clearinghouses. How does the HIPAA law define business associates? These are entities, companies, individuals that provide certain services to health care covered entities. There are billing companies, for example, that contract with health care providers to provide billing services. Also, there are insurance companies. We talked about malpractice companies. There are other insurance companies under this category of business associates. Finally, legal counsel that provides legal assistance to health care providers would fall under this category of business associates, as well as accounting firms that do the books for health care providers, both individuals and entities. Also, there are companies that do utilization review. And these companies that review contracts and determine whether a health care provider is abiding by the contractual obligation of providing services would be under this category of business associates. Now, the third definition is protected health information. Obviously, a very important definition. Health information that is protected under HIPAA, first of all, is that information which is created or received by a health care provider. And also, another key point is that this protected health information must be individually identifiable. If it's just information that is collected for a group, but is not individually identifiable, that information would not fall under the authority of the HIPAA statute. Now, let's talk about some other details of protected health information. So examples of protected health information is information that's individually identifiable, that discusses a certain health status or condition of a patient. That is protected information and understandably so because an individual's health or a certain disease or condition they have is something that no one has a right to know other than the individual himself or herself and those to whom the individual shares that information. A second point of coverage that's considered protected health information is any treatment that a patient has received or is receiving or will be receiving. That once again is protected health information because an individual has a privacy right to not have that disclosed to any parties other than those that the patient permits. And finally, any payment information that's linked to a certain patient is also private and would be covered by the HIPAA statute in regard to protected health information. Once again, keep in mind that there are other modules that cover this in much greater detail, but hopefully this has laid the foundation for you to understand the HIPAA statute. Let's look at the legalities of title usage in the medical practice. The first point, the first question is which health professionals may be referred to as physicians or doctors. This is actually a very controversial and important issue. I mentioned before that there are two categories of physicians under the laws of each state. One category is medical doctors or MDs and the other category is doctors of osteopathic medicine or DOs. In all states, these individuals are permitted to be referred to as doctors or physicians. The reason this is controversial is that some licensed independent providers who are not physicians would like to be able to be referred to as doctor. And this would apply to advanced practice registered nurses such as nurse practitioners or some physician assistants. And the reason that these professionals believe that they should legally be allowed to be called doctor is because their degree that they have obtained in order to become a physician assistant or a nurse practitioner may be a doctoral level degree. However, they do not receive an MD degree or a degree in osteopathic medicine. So in some states, they may not be referred to as doctor, even though their degree may be a doctoral level degree. Second point, which health professionals may be referred to as nurse. This is actually a very important point and also a controversial point. Only registered nurses or RNs and LPNs, licensed practical nurses, in a few states, they are referred to as licensed vocational nurses. So only RNs and LPNs or LVNs may be referred to as nurses. Medical assistants may never be referred to as nurses. Dietitians may not be referred to as nurses, nor radiologic technologists or laboratory technologists. These individuals are technically not nurses and should never be called nurses. In fact, the laws of some states make it illegal for anyone other than an RN or an LPN to be referred to as a nurse. And finally, what are the legal consequences of improper use of these titles, whether the title doctor or the title nurse? In some cases, those who use a title improperly, for example, if a phlebotomist is called a nurse, then that phlebotomist can be held to a higher standard of care than a phlebotomist. And remember we said that standard of care is unique to each profession. So the standard of care for a registered nurse is different from the standard of care of a phlebotomist or someone who just performs venipuncture. So if in a setting of delivery, a phlebotomist is referred to as a nurse, and perhaps even refers to herself or himself as a nurse, that could have legal complications because that phlebotomist might be held to the standard of care of an RN. And because of that, if the standard of care provided by a phlebotomist is not that of an RN, there can be a legal action, not only against the individuals, but also against the office or the clinic or the health system. Secondly, remember I talked about the dangers of being accused of practicing a profession without a license. If a certain health professional that is not licensed is referred to as a licensed professional, then that individual could be accused of practicing a licensed profession without a license. So for example, in most states, almost all states, radiologic technologists or x-ray technologists are required to be licensed to have certain education, pass a test, and to register with the state board of radiography. If there is someone in a health setting that is permitted to do limited scope x-rays, limited scope radiography, but not the full array of radiographic procedures, and if that individual is being called an x-ray tech, but really is not, then that individual could be held liable for practicing radiologic technology without a license as an x-ray technologist or a radiologic technologist. So these use of titles are very important. Let's talk about another area of law, and this is federal law, moving back to the federal domain, and that is the No Surprises Act, which was an act of Congress in 2020 that has created certain definitions and put restrictions on what patients may and may not be billed. So let's talk about some of these basic definitions. First definition is balanced billing, and that may be defined as billing for the difference between the total cost of a procedure and the amount for that procedure that is covered by insurance. So once again, balanced billing is defined as billing for the difference between the cost of the procedure and what the insurance company, the third-party payer, pays. So let's take an example. Let's say a certain medical procedure costs $1,000 and the third-party insurance carrier pays for $800 of that $1,000 procedure. So the balance remaining is $200, and balanced billing in this case would be for a provider to charge the patient for that $200 that is not picked up by the patient's third-party insurance company, and we'll see what this law says about that. Another definition is in-network and out-of-network. How do we define in-network? In-network may be defined as services by a provider who is part of the network specified in the health insurance coverage of the patient. So in-network services, once again, are defined as services by a provider if that provider is part of the network that is included in the health insurance policy of the patient. So what are out-of-network services? Well, those may be defined as services that are provided by a provider who is not part of the network defined by the third-party payer, by the health insurance company that is paying for the services of an individual who is part of that plan. So we have in-network services and out-of-network services. Now what this No Surprises Act does primarily is to prohibit balanced billing, and we understand that definition of balanced billing. So balanced billing is prohibited for these four categories of services. Number one, emergency services, specifically emergency services provided by an out-of-network provider, namely a health professional who is not part of the network for the health insurance company for a patient. This law says that it's not legal to bill for any unpaid balances that are provided by an out-of-network provider only in emergency situations. This applies only to emergency services. Second category for which balanced billing is prohibited by this federal law, federal law, any non-emergency services. So we talked about emergency services. Now we're going to talk about non-emergency services. Any non-emergency services that are provided by an out-of-network provider, and remember that's a provider who is not part of the coverage offered by a particular health insurer at an in-network facility. So if we have a health professional that is not part of a network of the health insurance company but provides these services at a facility that is part of the network, then these non-emergency services cannot be subject to balanced billing. The health insurance company is not permitted to bill the patient for the difference between the total cost of a service and the amount that the insurance company covers. Remember this applies to non-emergency services provided by an out-of-network provider but done in an in-network facility. Third category, hospital price transparency. The No Surprises Act essentially requires hospitals to publicly disclose their prices. In the past, this was a problem with hospitals not being forthcoming and letting it be known what they would charge for various services performed in the hospital. But this law changed that and hospitals must now publicly disclose the prices of the services they provide. And fourthly, another aspect of the No Surprises Act is the Good Faith Estimate provision. And essentially, this element of the No Surprises Statute says that the hospital must provide a good faith estimate of expected charges that an uninsured patient may encounter. So this is just a little bit of the directed at uninsured patients. And upon their request, the hospital must provide an estimate, a good faith estimate, as accurate as possible given the circumstances of what the charges the patient will have to pay for the particular condition. So keep these in mind as elements that are forbidden by federal law from being charged to patients. Let's get back to this question of informed consent. And the real issue that we need to address in greater detail is who has the legal authority to make these decisions in regard to health care for a patient. Now, first of all, the patient himself or herself should be given the opportunity to make decisions about health care. However, as I mentioned before, if patients do not have the mental capability or the physical capability to make a meaningful decision, then the decision must be made by what is known as a patient representative, someone who is designated by the patient as one who is able to make a decision on health care matters. Now, this patient representative can be designated by a written document of the patient or can be designated orally. But it's very important for any health care provider and any medical office or provider office to know who has the legal authority to make decisions to make decisions in regard to health care for the patient. One situation that we often encounter is children who makes the decision for a child who is a patient and does not have the capacity to make a decision. In such cases, a parent or a legal guardian who has that authority as specified in any legal documents would be the individual who has the legal capacity to make the decision for a minor child. So a key question, legal capacity, who has the capacity to offer consent, to offer meaningful informed legal consent for a patient? It really will depend on several of the factors I've just mentioned. The second point, informed consent, explanation and understanding. Remember that there must be a sufficient explanation to a patient or a patient representative in regard to what the medical procedure is all about. What are the risks involved? What are the potential benefits? Other details. For a consent to be informed or meaningful, there must be enough information provided so that the patient or the patient's representative is able to make a decision. Now there are certain situations involving minors, as I mentioned. So who consents to medical treatment for a minor? Usually that is the custodial parent or the parent who has legal authority to make those decisions. In some cases, if there is no longer a family unit, if the parents of the child are no longer legally married, in some cases, the divorce decree may specify which parent has the legal authority to make a decision, or if the parents jointly, in a joint custody situation, have to agree on a decision to either allow a certain medical procedure or not allow a procedure. Now, there are situations in which an individual who has not yet reached the age of majority, namely 18, and therefore is still a minor in the eyes of the law, can be considered what is known as an emancipated minor, and an emancipated minor is one who meets the criteria of the state and is no longer subject to the authority of parents, and therefore may make independent decisions in regard to agreeing to a certain medical procedure. And the bottom line here is that it's important that staff, both clinical and administrative staff, know who has the legal authority to give consent to a procedure, whether it is a particular patient representative, whether it is the patient herself or himself, whether it is a parent or parents who have the authority legally to issue a consent for a minor child, whether it's an emancipated minor, or who is given the legal authority. An important aspect of the medical office is for administrative front office staff to understand who has that legal authority so the staff does not assume that any parent that comes in with the child is the parent that has the legal authority to offer consent. Let's talk about some federal programs. Medicare is well known, obviously, and it applies primarily to individuals who are 65 years of age or those who are deemed disabled under the Medicare statute and its regulations issued by the Department of Health and Human Services. This is a federal program, and there are various categories of Medicare. Once again, this is just a very basic treatment. Some of our other modules address this in greater detail. So let's look at these parts of Medicare. Part A is for inpatient services and is also referred to as basic hospitalization. Patient B is for outpatient or ambulatory services. So provider visits would usually fall into this category, as well as appointments for diagnostic tests for a blood draw, for example. Part C is for prescription drugs, and this involves drugs that are prescribed by a provider and that are filled at a pharmacy. And these costs are covered to a great extent by this part of Medicare. And finally, there's Medicare Advantage, which may be defined as a private option that combines Part A and B and offers additional benefits. I want to mention one other aspect, and that is Medicare Supplement or Medigap insurance. And this is defined as private insurance that covers out-of-pocket costs. So anything that is not paid for or picked up by one of these parts of Medicare can be paid by a Medigap plan, which again is a private insurance plan over and above the government plans under Medicare. Now let's talk about Medicaid. Unlike Medicare, which is a prior, excuse me, a federal plan, Medicaid is a joint federal and state plan, as I indicate on this slide. And there are some differences between Medicaid coverage between the various states. So keep in mind that Medicaid is a coverage for low-income recipients, whereas as we saw with Medicare, that coverage is primarily for individuals who are age 65 or have a disability under the law, whereas Medicaid applies to low-income recipients. Let's talk about the eligibility for Medicaid. Primarily low-income families would qualify, as well as qualified pregnant women and children. Once again, these laws vary somewhat from state to state. Some states have more generous coverage under Medicaid, and others have less generous coverage. Another subcategory of eligibility requirements is supplemental security income. So an individual who would be receiving supplemental security income is covered under Medicaid programs. And finally, in some states, there's another category for other medically needy groups. And this will once again, vary state by state. Finally, the coverage includes both inpatient and outpatient services, and laboratory and imaging services. So in that sense, the coverage is similar to the Medicare coverage that we have discussed. Let's move on to another very important federal law, that is the Health Information Technology for Economic and Clinical Health, or known as the HITECH Act. And the features of this statute, which was adopted in 2010, is that this federal law incentivizes the use of electronic health records, also known as EHRs. At that time, 2010, a lot of the health care providers were still using paper records. And the provisions of the HITECH Act were successful in changing that so that the vast majority of providers use not paper records, but electronic health records. Also, the purpose of the HITECH Act was to establish some technology standards for electronic health records for software additions of electronic health records. And there was standardization that was achieved, so that health care or electronic health records would be able to communicate with each other. And there would not be the situation of a patient whose one provider is on one system, and perhaps a specialist is on a different system. So the standardization brought about by the HITECH Act resulted in greater facility of information exchange between health care providers. We need to talk about the Affordable Care Act, or the ACA, also known as Obamacare. And some key elements accomplished by this statute. Number one, this statute expands access to affordable health care insurance. And it is for those who cannot afford health insurance themselves. And it also encourages preventive care, rather than just relying on patients going to a health care provider when the patient becomes sick. By encouraging preventive care, it's possible to avoid the occurrence of sickness and therefore improve the health of the nation. Secondly, the Affordable Care Act enables states to expand Medicaid coverage. As I just said, the coverage in Medicaid varies greatly from state to state. And the ACA was successful in removing some limitations on state coverage. And finally, Obamacare did lessen the burdens of pre-existing conditions. This was especially difficult for people moving from one job to another job. And prior to the ACA, the new insurance plan under the new employer would sometimes not cover pre-existing conditions. So that served as a disincentive for patients who wanted to move from one job to another, and yet were reluctant to do so because of problems that would be encountered in regard to pre-existing conditions. Let's talk about the Occupational Safety and Health Administration regulations known as the OSHA regulations for health care delivery settings. And the focus here is mostly on safety. And there are three aspects that I will discuss. First, bloodborne pathogens. Second, ionizing radiation, in other words, x-rays. And finally, hazard communication. Remember, these provisions are directed primarily at those individuals who work in health care facilities. So this is a safety federal requirement. For bloodborne pathogens, there are requirements in terms of exposure control and limitations that health care facilities must implement in order to control any exposures of bloodborne pathogens. What needs to be followed in the health care environment is universal precautions, or a standard way of treating any type of spill or leakage of dangerous substance. Also, there is a standard way of handling sharp objects, how they are to be disposed of, how the risk of transmission of disease by handling of sharps in the office setting can be minimized. And finally, what to do in case there is an exposure of an employee to a bloodborne pathogen. Ionizing radiation, as I said, applies to x-rays. And it can also apply to other diagnostic imaging equipment. Equipment needs to be checked periodically. And there are safety requirements that have been established. Finally, hazard communication addresses what staff needs to be informed about in terms of workplace hazards. Any structural dangers that have been detected in the setting, or any electrical or chemical threats must be disclosed thoroughly so that employees know what to do. Any emergency exits and emergency routes must be brought to the attention of employees and must be clearly marked and indicated. Also, there must be certain posters that appear in the health care delivery setting. And the OSHA law does allow for random inspections by government inspectors to make sure that all of these safety provisions are being followed. Finally, and let's close with this advanced directives. As a general definition, essentially advanced directives are estate planning documents. And the purpose is to have end-of-life situations handled as desired by the individual. Each individual has the legal authority to determine how end-of-life situations will be handled. And advanced directives are a way of ensuring that that does happen. So let's talk about a living will and a difference between living will and a durable power of attorney for health care. A living will is a written legal document expressing the type of medical care or treatments that are wanted and not wanted by the individual in case of a life threatening situation. So living wills essentially are directed to health professionals and health professionals are to follow the elements of the written living will, so that the intent of the individual is followed. Now, durable power of attorneys are much different. This document has to name an attorney in fact, or someone who is authorized to make decisions for the individual. It doesn't specify particular tasks or procedures that are to be done or not done. But rather, it gives that authority to specific individuals to make decisions. Oftentimes, a durable power of attorney will list one primary attorney in fact, and then can list other successor attorneys in fact, in case the first individual is no longer able to serve. In some cases, there can be joint authority given to two or more individuals in terms of making decisions. And keep in mind that the durable power of attorney for health care is limited to health care decisions as the title implies. There are many other different types of powers of attorney. So a front office staffer or any health professional must understand the difference between a power of attorney for financial transactions, or for doing other non health related matters. But the only document that controls in a health care setting is a durable power of attorney for health care. We've come to the end of this presentation. Thank you for this opportunity. I do want to once again encourage you to email me any questions that you might have about any of the matter that I covered. You see my email address dbalasa.aama-ntl.org. I would encourage you to listen to the other presentations in this assessment based certificate in medical office basics. And our hope at the double AMA is this will give individuals who are new to the health care delivery setting enough information to be able to learn more in regard to legal matters. Thank you again.

legal considerations

medical practice

healthcare delivery settings

state laws

scope of practice

federal laws

licensing

certification

malpractice insurance

Medicare

end-of-life situations