Description
Complete the Business Transactions Resource and Compliance Matrix (Attached)
Business Transactions Resource and Compliance Matrix (Word Document)
Individually: Complete the matrix.
Use only classroom materials to complete the matrix. This would include the textbooks, web links, and the Classroom law library, and Compliance library.
Write in complete sentences except for the law and code section, risk assessment, and role identification sections.
Code citations should follow the following format:
42 U.S.C. § 1920 (2021)
Maryland Code § 29-405 (2021).
Regulations should following the following format
42 C.F.R. § 518 (2021)
Code of Maryland Regulations (COMAR) 01.02.1985.01
See Compliance Library and review “People as Resources for health care compliance.” (ATTACHED)
Take time to formulate good questions that will lead to a positive response.
Look for creative solutions to comply with the law.
Support your responses with strong reasons.
References
Showalter, S. (2020). The law of healthcare administration. (9th ed.). Health Administration Press. Chapter 5 (pages 176 – 177, 187 – 189), Chapter 12 (pages 459 – 469), Chapter 13 (pages 491, 495 – 498, 500, 502), and Chapter 15 (pages 571-572, 576 -579, 580 – 584, 588 – 590)
Perry, F. (2020). The tracks we leave: Ethics and management dilemmas in healthcare. (3rd ed.). ACHE Management Series. Chapter 4 (pages 45 – 63) and Chapter 10 – Failed Hospital Merger: Richland River Valley Healthcare Systems (pages 149 – 159)
HHS OIG Guidance (6:34)
Starting a Non-Profit: Compliance Basics (3:28)
Unformatted Attachment Preview
Business Transactions
Resource and Compliance Matrix
Name:
Date:
Health care business
situations
The Code
Section for
the statute
AND
1. Your organization just hired
a physician from out of state.
The physician will need to
become licensed in your state
of Maryland. As an
administrator, you have been
asked to oversee the process
to ensure the physician obtains
a valid Maryland license to
practice medicine.
2. You were reviewing the new
physician contract and see that
the physician will be paid a flat
salary with bonuses from the
hospital for increasing hospital
admissions.
The legal
requirements
stated in the
law
State licensing
law
Federal
Antikickback
Statute (AKS)
Penalties for
non-compliance
with the Law
Risk
Role of
Assessment Person who
can be a
Low
resource for
Medium
compliance
High
(Give
(Give
reasons to
reasons to
support
support
your choice)
your rating)
A question you
would ask the
resource person to
help you better
know how to
comply with the
law
A managerial
action you would
take to comply
with the law
(Give reasons to
support your
action)
3. Your managed care
organization (MCO) wants to
build a new hospital and 2 new
rehabilitation centers in your
state of Maryland. You are
asked to spearhead the
project.
4. You oversee the medical
billing department. The billing
manager responsible for day to
day activities was out of the
office for 6 months on a
disability leave. The manager
has just returned and
discovered that the coders
billed everything at the highest
level of service whether there
was documentation to support
it or not during the 6 months
the manager was gone.
5. Your hospital wants to
expand and buy out a
physician group in a nearby
town. The physicians would
become employees of your
hospital. 75% of the physicians
in your town and the nearby
would be employed by your
hospital when the venture is
complete.
6.You are responsible for the
profit/loss statements for your
budget area each month. The
Vice President over your area
State
Certificate of
Need
Federal False
Claims Act
(FCA)
Notice of
Overpayment
Rules
Federal
Antitrust law
Joint Venture
Guidelines
Federal
Sarbanes
Oxley
Act (SOX)
just asked you to ”improve”
the numbers to show a profit
even though the numbers
show a loss. You have been
told that the VP owns 60% of
the shares of stock for your
public corporation.
7. You are an entrepreneur and
want to open up a home
health company in Maryland.
You want to be incorporated
under Maryland law and
operate as Home Care Inc.
8. You work for a family
practice physician clinic. Two
of the physician owners are
also part owners of a nearby
durable medical equipment
(DME) store and a clinical lab.
All physicians in the
organization regularly refer
patients to the DME store and
clinical lab.
9. Your hospital is a non-profit
organization and doesn’t pay
taxes. The billing company at
your hospital just sent word
that it sent 50 unpaid claims to
collections. You wonder if this
should be considered charity
care instead.
10. You work for a large health
insurance company. The
company wants to start a
Conflict of
Interest
State
Incorporation
Law
Federal
Physician SelfReferral Law
(Stark)
Federal
Internal
Revenue
Service (IRS)
tax law
Federal
Health
Insurance
disease management program
for its members by contracting
with a national pharmaceutical
to run the disease
management program.
Portability
and
Accountability
Act (HIPAA)
Business
Associate
Regulations
People in Health Care as a Resources for Compliance
Corporate Personnel
Tip: Start at the lowest level of the organization and work your way up the chain of
command.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Corporate Board of Directors – The senior officers of the company who are
responsible for strategic decision making for the organization
Chief Executive Officer (CEO) – The person who oversees the hospital or
managed care organization, or other health care organization.
Legal Counsel – A licensed attorney with experience in health care laws who
works for the hospital or health care organization.
Corporate Compliance Officer (CCO) – The person responsible to ensure
compliance to all laws throughout the organization.
Chief Information Officer (CIO) – The executive who oversees information
technology for the organization.
Chief Information Security Officer – The executive responsible to develop
information technology security practices.
Chief Medical Officer (CMO) – The doctor who oversees all clinical decision
making within the organization.
Clinical Nursing Officer (CNO) The chief nursing executive within the
organization.
Chief Business Development Officer (CBDO) – The executive who oversees
new business opportunities and growth for the organization.
Head of Medical staff – The doctor who oversees physicians within the
organization.
Chief Financial Officer (CFO)- The senior official in the organization who
oversees all financial transactions.
Clinical Specialists – People with clinical expertise in a certain area who can
provide expert opinion on clinical issues such as infection, ethics, cardiac,
skeletal, and/or other specific issues..
Human Resources professional – The person who coordinates recruiting, hiring,
onboarding, training, employee reviews, corrective action plans, and terminations
with employees.
Union Representative – In a union environment, the person from the union who
may represent employees when issues arise with management.
Health Information Technology (HIT) Manager – A manager responsible for
meeting all technology requirements and laws.
Compliance Committee Chair – The person who oversees the committee
focused on ensuring corporate compliance.
Ethics Committee Member – A member of the organizations ethics committee
that focused on ethical decision making.
•
•
•
•
•
•
•
•
•
•
•
Institutional Review Board (IRB) member – A person who is part of the
Institutional Review Board for the Organization.
Risk Manager – The person who works to identify, prevent, and correct risk
within the organization.
Risk Management Committee Chair – The person who oversees the risk
management committee to manage and reduce organizational risk.
Privacy Compliance Officer – The person responsible for HIPAA privacy and
security compliance within the organization.
Contracts Manager – The person responsible for vendor and/or contracting in the
organization.
Corporate forms and templates – Documents used by the organization to admit,
register, and discharge patients, document treatment, or remind patients of rights
or obligations.
Credentialing Manager – The person responsible to overseeing credentialing of
physicians, nurse practitioners, physician assistants, and other health care
professionals within the organization.
Nurse Manager – The nurse who oversees other nurses on a specific unit of
care.
Patient Liaison Manager/Ombudsman – The person who oversees those working
with patients to ensure that they have a positive outcome and experience with
patient care.
Billing Supervisor – The person who oversees the day to day billing operations of
the organization
Auditor – A person within the organization who conducts internal audits of billing
and/or other compliance to assess how well the organization is doing and to
determine where improvement is needed.
Government Employees as Resources
Tip: Start within the company before going to outside resources.
•
•
•
•
•
•
Health care attorney – An attorney with specialty experience in health care.
State licensing agency personnel – An administrator in the state licensing
department.
State Certificate of Need agency personnel – An administrator in the state
Certificate of Need department.
State Corporations agency personnel – An administrator in the state department
of Corporations who regularly licenses businesses.
State Tax Commission employees – State tax agency personnel familiar with
corporate taxation in the state for non-profit and for -profit organizations.
State Insurance Commission employees- The state health insurance employees
that oversees state health insurance compliance.
•
•
•
•
•
•
State Department of Health (DOH) employees – The employees who oversee
health requirements in the state including infectious disease, and other reporting
and compliance.
State Medicaid Department personnel – The state Medicaid employees who
handle day to day Medicaid issues.
IRS tax hotline employees – A phone link to an IRS representative with training
on taxes.
CMS Recovery Audit Contractors (RAC) auditors – Auditors who work on behalf
of CMS to audit health care organization billings to see if payments were proper
National Institutes of health Guidelines for stem cell research – Guidelines that
set the parameters for stem cell research.
Employment
Private Community Resources
•
•
Health Law attorney – An attorney outside of the company with expertise in
health law.
Clinical Experts in the Community – Clinical experts who may be available for
consultation when a specific issue requiring certain expertise arises.
Laws, Compliance Tools and Managerial Actions
Success Tip: Talk about the law, compliance tools and managerial actions in all
coursework.
•
•
•
Evaluate what the law requires the organization to do.
Evaluate how compliance tools can be used to ensure legal compliance or
correct legal problems.
Evaluate how specific management actions can be taken to use compliance tools
and ensure legal compliance.
What is a law?
A law arises from a Constitution, statute, regulation or court decision at the federal or
state level. It sets the standard of conduct of what is required. Laws often include
penalties that state what will happen if the requirements of the law are not met. This
can include financial penalties or jail time. For example, HIPAA ;aw has both civil and
criminal penalties.
Tip: Always start by knowing what the law requires and what the penalties are for noncompliance.
Examples:
Federal/State Type of Law
Citation Example and Web Link
Federal
U.S.
Constitution
U.S. Const. Art I
https://constitution.findlaw.com/
Federal
Statute
United States
Code (U.S.C.)
Regulation
Code of
Federal
Regulations
(C.F.R.)
Federal
Cases
U.S. Supreme
Court
42 U.S.C. 325 (2021)
https://www.law.cornell.edu/uscode/text
U.S. Court of
Appeals
Jones v. Smith, No. 3:2021cv12349 (2nd Cir. 2021)
https://law.justia.com/cases/federal/appellate-courts/
U.S. District
Markson v. Knox, No. 1:2021cv01334 (Md. Ct. 2021)
Federal
Federal
29 C.F.R. 151 (2021)
https://www.ecfr.gov/
Advocate Health Care Network v. Stapleton, No. 1675 (2017)
https://www.supremecourt.gov/opinions/slipopinion/21
Court
https://law.justia.com/cases/federal/district-courts/
State
State
Constitution
Maryland Const. Art. IV
https://law.justia.com/constitution/maryland/
State
State Statute
Maryland Mental Health Facilities §10-404 (2018)
https://codes.findlaw.com/
State
State Rule
COMAR 09.11.02.01C(2)(a)(i) (2020)
https://dsd.maryland.gov/Pages/COMARHome.aspx
State
State Cases
North Hospital v. Zenick, No. 34ag/21 (MD. Ct. App.
2021)
https://law.justia.com/cases/maryland/
What is a Compliance or Risk Management Tool?
A compliance or risk management tool is something that is used to help an organization
comply with the law. Any tool that is used to solve a problem should be evaluated to
determine how it will apply to correct the specific problem. For example, a general tool
such as a corporate checklist would need to be adapted to include items on the
checklist to ensure that the company met a specific compliance goal such as avoiding
discrimination in hiring.
Tip: Any managerial tool should be adjusted to meet the specific problem. Evaluate
how to use the general principles of the tool to correct specific problems. Give reasons
to support how your tools resolve the legal problem.
Tip 2: Use the week 12 managerial tools for compliance links throughout the course
to assist with compliance tools for assignments.
Examples:
Tool Examples
How it could be used to limit risk or comply with the law
Litigation Hold Letter
A litigation hold letter is issued to ensure that electronic and
other evidence is preserved for litigation by putting a hold
on destruction of relevant evidence while litigation is
pending.
A contract should comply with the law and include contract
clauses to limit the risk of the organization should a dispute
arise. A contract should be adapted to meet the needs of
the specific situation and risks.
Contracts and Contract
Clauses
Cloud Based Contract
Management System
Corporate documents
including policies and
procedures
Enterprise Document
Management (EDM)
System
HHS OIG Compliance
Protocol
COSO Internal Control
Framework
Health Information
Technology
Code of Ethics from a
Professional
Organization or from
the Hospital, Clinic or
Care Facility
Security Risk
Assessment (SRA)
Health Information
Technology or other
Internal Audits
Checklists
A cloud based contract management system helps ensure
that the organization complies with the requirements of the
contract and tracks the life cycle of the contract to limit risk
from non-renewal or renegotiation.
Corporate documents set the standards, vision, rules for
the organization to meet. They ensure consistency of
managerial actions and should be complied with. Any
management actions should comply with both law as well
as organizational documents and policies.
An Enterprise Document Management System (EDM)
creates is a way to keep all organizational documents in
digital forma for prompt review and retrieval. This gives the
organization a system wide process to manage, use, and
archive documents.
The HHS OIG Compliance protocol provides elements an
organization can use to comply with the law and limit the
risk of fraud and abuse.
The COSO Internal Control Framework provides a number
of controls that can be used in order to reduce risk within an
organization. General principles of control can be adapted
to manage specific organizational risks..
Health Information Technology can be used as a
compliance and risk management tool when the tool is set
up to comply with specific legal requirements and to limit
risk of non-compliance.
A Code of Ethics sets an ethical standard for those who
belong to the organization. Many organizations require a
person to sign the Code of Ethics as indication that they
agree and will comply with the ethical standards. This
ensures high ethical behavior which improves the likelihood
of legal compliance as well and limits the risk of
wrongdoing.
This is an assessment of the security risk to health
information within an organization. It is required by law and
helps ensure compliance with the law.
Internal audits give an organization a chance to catch
problems before an outside auditor, government regulator,
or accreditation agency comes in and finds a problem. This
allows the organization to correct the problem in order to
comply with legal requirements.
Checklists can be for a variety of activities and include a
surgical checklist, hiring, termination, or evaluation checklist
to ensure that all steps for safety are taken before a
procedure or activity. Checks can ensure consistency in
legal compliance no matter who is conducting the activity.
AHRQ, NCQA, Joint
Commission
Guidelines. and HHS
OIG Compliance
Guidelines
Sample Forms and
Documents
Training Tools
Guidelines provide a tool to meet high standard of practice.
They are not enforced like the law, but set high standards
that improve compliance and prevent problems.
Sample forms can help an organization set up a form for
patient intact, informed consent, consent refusal, prevent
violence, or encourage patient safety, ensure advanced
directives comply with state law, or take other actions in a
way that minimizes risk and complies with the law.
Formal training tools can be used to provide employee
training on HIPAA, OSHA Safety, or other issues to
encourage patient safety, legal compliance, etc.
What are Managerial Actions?
Managerial actions are things that you can DO as a manager to comply with the law.
These actions may include ways to use compliance and risk management tools to
comply with the law. Something that the government does is not a managerial action.
For example, issuing a litigation hold letter would be a managerial action to preserve
evidence when a lawsuit is anticipated.
Tip: Any recommended managerial actions should be specific to the problem and
correct the problem, reduce the risk, and prevent future problems. Always explain how
the recommended action will do this. Include reasons to support your recommended
managerial actions.
Examples:
Managerial Action
Related Tool
Legal Problem it could correct
Issue a Litigation
Hold Letter as soon
as you know a
lawsuit will be filed.
Add an arbitration
clause to a contract
to keep a contract
dispute out of court
and the public
limelight.
Create a new policy
on bullying to
prevent bullying in
the workplace.
Litigation Hold Letter
This would ensure evidence is
preserved for the lawsuit that is
anticipated before issuing the
litigation hold letter.
This could keep an contract issue
form going to court and limit
public exposure to the issue.
Contract clauses
Corporate Documents
When an issue arises a policy
can be created to prevent the
issue in the future and ensure
that if it arises it is consistently
Train employees on
Training Tools
how to use the
health information
technology system to
keep PHI private and
secure with a quiz at
the end of training as
a knowledge check..
Establish a
Corporate Documents
corrective action
plan for an employee
who is chronically
late to work with a 30
day follow up
meeting.
Create a checklist for Checklists
patient discharge to
ensure everything
that needs to be
completed prior to
discharge is
completed.
Conduct an internal
Audits
medical record audit
to see if initial visit
coding is supported
by the medical
record
documentation.
Create a hospital
Forms and Guidelines
protocol for opioid
use disorder (OUD)
screening based on
national guidelines to
ensure consistent
screening of all
patients.
handled in conjunction with the
policy.
Any training should be specific to
the legal problem and provide
specific information to employees
so that the problem is less likely
to recur.
This allows the manager to
correct a problem a specific
employee is having. It should be
followed up with review to see if
the corrective actions were
properly implemented by the
employee after a preset period
such as 30, 60 and/or 90 days.
This ensures that patient meets
medical criteria for discharge, has
received any training or
medication for discharge, and
that the discharge is in
compliance with the law.
An internal audit allows the
organization to review its own
records related to legal standards
and make needed changes to
comply with the law before an
outside auditor, regulator or
accreditor comes in to audit and
finds a problem.
Protocols ensure consistent
actions for all who do the same
activity.
Forms ensure that the
information that needs to be
captured to comply with the law is
on the form.
Purchase answer to see full
attachment
