WK7: Legal Considerations

What are examples of situations where patient authorization is NOT required to disclose PHI?

1. The patient requesting their own PHI or reporting to DHHS

2. Legal mandates (court orders, subpoenas, law enforcement requests)

3. Public health tracking (vital statistics, communicable diseases)

4. Reporting domestic violence or elder abuse as required by law

5. Health oversight audits (like Medicare audits)

6. Workers' compensation (to the extent required by state law)

What is the Individuals with Disabilities Education Act (IDEA) of 1997?

IDEA is a federal law ensuring that children with disabilities receive a Free Appropriate Public Education (FAPE) tailored to their individual needs, preparing them for higher education, employment, and independent living.

How do abusers attempt to control healthcare providers when attending PT sessions (4)?

1. intimidate clinicians with threats

2. excessively praise staff to appear as ideal caregivers

3. make frequent harassing calls/false complaints to superiors

4. create divisiveness among treatment team members

What is healthcare waste?

Waste is the overutilization of services or resources resulting in unnecessary healthcare costs (e.g., ordering redundant tests for defensive medicine or poor care coordination causing avoidable readmissions). It is the most common improper payment issue.

What are the APTA documentation guidelines when documenting suspected domestic violence in medical records?

Documentation must be completed during the visit, kept secure, and include:

1. The patient's exact words regarding injury causes

2. Detailed descriptions of injury size, location, and chronology

3. Inconsistencies between injury appearance and explanation

4. Color photos (with consent; face in at least one photo; 2 photos per major trauma area)

5. Investigating police officer details if reported

What common documentation errors trigger Medicare audit denials?

Common documentation audit errors include missing or incomplete plans of care, missing provider signatures or dates, failure to record total time spent on procedures/modalities, and missing recertifications.

What fraud violations were highlighted in the 2005 HealthSouth federal settlement?

HealthSouth paid 325 million USD to settle charges that included systematic fraudulent billing for therapy provided by unqualified personnel (aides/students) billed as licensed PT/PTA care, billing for unprovided services, and billing 1-on-1 care for concurrent group treatment.

What is elder abuse, and what did the Elder Justice Act of 2010 establish?

Elder abuse occurs when someone knowingly or negligently causes harm to an older adult (physical, emotional, financial abuse, abandonment, or neglect). The Elder Justice Act of 2010 provided federal funding and authority to Adult Protective Services (APS).

What 4 victim-blaming questions should physical therapy clinicians NEVER ask a victim of domestic violence?

Accusatory or blaming questions like:

1. Why don't you just leave?

2. Why stay with a person like that?

3. What did you do to aggravate your partner?

4. Did you do something to cause them to hit you?

What constitutes illegal workplace harassment?

Workplace harassment is unwelcome conduct based on race, religion, sex, age, or disability. It becomes illegal when enduring it is a condition of continued employment or it creates an intimidating, hostile, or abusive work environment.

What is the False Claims Act (FCA)?

Imposes civil and criminal penalties on anyone submitting claims for payment to federal healthcare programs (Medicare/Medicaid) that they know or should know are false

• 'Knowing' includes actual knowledge, deliberate ignorance, or reckless disregard

What is Administrative or Regulatory Law?

Rules and regulations created by governmental administrative agencies (local, state, or federal)

• State licensure boards and Physical Therapy Practice Acts fall under this category!

What is the legal definition of liability in medical law?

Liability refers to the legal state of being responsible for an action, error, or breach of duty. In healthcare, violating legal or ethical standards can create civil or criminal liability.

What clinical physical symptoms signal that a patient should be screened for domestic violence?

Clinical indicators include chronic unexplained pain, injuries during pregnancy, repeated or recurring trauma, hypervigilance (being easily startled), untreated gynecological problems, and overuse of pain medications.

Who is responsible for preventing and stopping workplace harassment?

While employees should clearly communicate or report unwelcome conduct, it is ultimately the legal responsibility of the employer to prevent and stop harassment from supervisors, coworkers, or non-employees (like patients).

Are physical therapy students and trainees permitted to access patient PHI under HIPAA?

Yes, only when necessary for training and educational purposes

What is HIPAA?

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. It is a federal law that establishes national privacy standards to protect individual medical records and personal health information.

Can a Physical Therapist Assistant (PTA) be sued for malpractice, and who shares that liability?

Yes, a PTA can be sued directly. However, legal liability often extends to the supervising Physical Therapist (PT) of record who delegated or oversaw the care.

What is Title I of the Americans with Disabilities Act (ADA)?

Prohibits employment discrimination against qualified job applicants or employees with disabilities who can perform essential job functions, with or without reasonable accommodations

What is Common Law?

Law developed through judicial decisions made by judges in court cases over time, originating historically from English Common Law

What 5 billing practices for physical therapy services are considered improper or fraudulent by federal payers?

1. Billing for unprovided or unnecessary care

2. Billing for services performed by physical therapy aides

3. Billing for PTA care without required PT supervision

4. Upcoding (using higher-paying procedure codes)

5. Billing 1-on-1 direct codes when treating multiple patients concurrently

What are the 4 categories of healthcare malpractice liability?

1. Professional negligence (substandard care delivery)

2. Intentional misconduct

3. Patient injury from abnormally dangerous treatment activities

4. Patient injury from dangerously defective medical products

Are communicable diseases like HIV/AIDS considered legally reportable 'notifiable diseases' that override confidentiality?

No

What is Constitutional Law?

Constitutional Law is the highest priority source of law in the US legal system. It stems directly from the US Constitution and takes precedence over all other state and federal laws.

How are professional responsibilities divided between PTs and PTAs regarding patient relationships and supervision?

1. PTs are personally responsible for the PT-patient relationship and supervising PTAs and aides

2. PTAs are personally responsible for their direct PTA-patient interactions and supervising non-licensed staff working alongside them

What is the 'In-Office Ancillary Services' (IOAS) exception under Stark Law?

The IOAS exception allows physician practices to employ or contract physical therapists directly in their offices and refer Medicare/Medicaid patients internally without violating Stark Law self-referral bans.

What is the Physician Self-Referral Law (Stark Law)?

Stark Law prohibits physicians from referring Medicare/Medicaid patients for Designated Health Services (DHS) to an entity with which the physician (or family member) has a financial relationship, unless a specific statutory exception applies.

What 5 behavioral signs during PT appointments might indicate a patient is experiencing domestic abuse?

1. An accompanying partner who refuses to leave the room or controls answers

2. Frequent missed appointments or treatment noncompliance

3. Statements that medication is withheld

4. Lack of independent transport, phone access, or finances

5. 'Therapist-hopping' across multiple clinics

When is written patient authorization required to share medical records?

1. The patient's lawyer or insurance company

2. The patient's employer (except in worker's compensation claims)

3. Family members (unless they hold a durable power of attorney for healthcare)

What is the OSHA Bloodborne Pathogens Standard (BPS)?

Safety regulation designed to protect healthcare workers from exposure to bloodborne infectious diseases (like HIV, Hepatitis B, and Hepatitis C) using mandatory infection control protocols

What is the Exclusion Statute?

The Exclusion Statute mandates that the Department of Health and Human Services (DHHS) ban providers convicted of Medicare fraud, patient abuse/neglect, or health-related felonies from participating in or receiving payments from federal healthcare programs.

Why are kickbacks prohibited in healthcare?

Kickbacks distort clinical decision-making, encourage overutilization, raise overall healthcare costs, freeze out honest competitors, and degrade quality of care by leading physicians to order treatments for profit rather than patient need.

What is Statutory Law?

Statutory Law consists of statutes and legislation formally enacted by legislative bodies at either the federal level (US Congress) or state level.

What is healthcare fraud?

Healthcare fraud is an intentional deception or intentional misrepresentation made to obtain a benefit or payment for which the person/entity is not entitled (e.g., billing for services never rendered or falsifying documentation).

What is the Notice of Privacy Practices (NPP) in healthcare?

A document informing patients how a covered entity (healthcare provider) uses and discloses their PHI; must be provided on the very first day of service during a face-to-face exchange

What are reasonable safeguards under HIPAA, and what is the 'Minimum Necessary Standard'?

Reasonable safeguards are practical steps to protect PHI (e.g., locking file cabinets, speaking quietly in waiting areas, using computer passwords). The Minimum Necessary Standard requires providers to disclose only the minimum PHI needed to accomplish a specific purpose.

What components are defined in a state's Physical Therapy Practice Act?

Practice Acts outline requirements for initial licensure (US and foreign-educated), continuing education units (CEUs), temporary permits, relicensure schedules, mandatory reporting of unethical conduct, scope of practice (e.g., direct access/practice without referral), and disciplinary grounds.

What are the four primary sources of law in the United States, listed in order of priority?

1. Constitutional Law (highest priority; derived from the US Constitution)

2. Statutory Law (enacted by federal or state legislatures)

3. Common Law (created by judicial court decisions)

4. Administrative / Regulatory Law (created by government agencies; includes State Practice Acts)

What physical therapy services are provided to children under IDEA?

1. Early Intervention Services (for infants and toddlers)

2. Special Education School-Based Services (for school-age children)

3. Screening, evaluation, and multidisciplinary treatment planning (such as developing an Individualized Family Service Plan - IFSP)

What is the Anti-Kickback Statute (AKS)?

The AKS is a criminal law prohibiting anyone from knowingly receiving or paying 'remuneration' (cash, free rent, gifts) in exchange for referring patients for services covered by Medicare or Medicaid.

What rights do patients have over their medical records under the HIPAA Privacy Rule?

Patients have the right to examine their records, obtain copies, and request corrections

• can also request extra privacy restrictions (like not calling their workplace), which become legally binding if the provider agrees

What is the difference between direct and indirect screening questions for domestic violence?

• Direct Questions directly address physical harm (ex. 'Your bruise looks painful. Did someone hit you?')

• Indirect Questions probe general relationship dynamics (ex. 'How does your partner feel about you coming to physical therapy?')

When is a parent NOT considered the personal representative of a minor patient under HIPAA?

1. A court appoints someone else to make decisions

2. State law allows the minor to consent to a service without parental consent (ex. mental health)

3. The parent agreed to a confidential relationship between minor and provider

4. The minor is legally emancipated

What is a 'reasonable accommodation' versus 'undue hardship' under Title I of the ADA?

• Reasonable accommodation = Any workplace modification that allows a disabled employee to apply for or perform a job that an employer must provide upon request

• Undue hardship = significant difficulty or extreme financial burden that prevents an employer from providing the reasonable accommodation

How does the ADA define a disability?

1. A physical or mental impairment that substantially limits one or more major life activities

2. Having a record of such an impairment

3. Being regarded by others as having such an impairment

What is the purpose of state Licensure Laws in physical therapy?

Licensure laws give licensed professionals the exclusive legal right to practice physical therapy in that state. Their primary objective is to protect the public and consumers against professional incompetence.

What is negligence in physical therapy, and what is Duty of Care?

Negligence occurs when a patient suffers harm because a clinician failed to do what a competent practitioner would do under similar circumstances. 'Duty of Care' is the legal obligation of clinicians to provide reasonable care to prevent patient harm.

What are 'major life activities' under the ADA?

Major life activities include essential daily living tasks (ADLs) such as seeing, hearing, speaking, walking, caring for oneself, performing manual tasks, cardiorespiratory functions, and learning.

What is healthcare abuse?

Healthcare abuse involves receiving payment for services without legal entitlement, BUT without knowingly or intentionally misrepresenting facts (e.g., unbundling billing codes or billing for non-medically necessary care).

How is domestic violence defined?

AKA Intimate Partner Violence - IPV, or battering; abusive behavior within an intimate relationship

• coercion

• threats

• isolation

• physical abuse

• sexual abuse

• emotional abuse

• economic control

What is OSHA and what is its role in healthcare?

OSHA (Occupational Safety and Health Administration) is a federal agency that enforces workplace safety standards. Under Section 5 (General Duty Clause), employers must protect workers from recognized health hazards.

What is healthcare malpractice?

Healthcare malpractice is liability-generating conduct by a healthcare professional associated with an adverse patient outcome. It is governed by civil law derived from Common Law.

What is confidentiality in healthcare?

Confidentiality is an ethical principle and legal rule requiring healthcare workers to keep patient information private. Providers cannot share details about a patient with third parties unless required by law or authorized in writing by the patient.

What key guidelines are included under OSHA Universal Precautions?

1. Wearing Personal Protective Equipment (PPE) around bodily fluids

2. Disposing of sharps/needles in designated biohazard containers

3. Washing hands immediately after removing gloves

4. Immediately reporting needle sticks or blood splashes to supervisors

What is Protected Health Information (PHI) under HIPAA?

Any individually identifiable health data in oral, written, or electronic form

• covers past, present, or future physical/mental health conditions

• healthcare provision

• payment details

What is the Americans with Disabilities Act (ADA) of 1990?

The ADA is a civil rights non-discrimination law that protects individuals with disabilities from discrimination in employment, public accommodations, state/local government services, and telecommunications.