Overview
In order to complete this case study, refer to this week’s readings for policy information required to analyze and make recommendations on this case.
As a healthcare quality fraud analyst, you are responsible for identification of root causes and providing recommendations in an action plan to ensure compliance with federal and state quality policies.
Instructions
Read the Department of Justice story, “
South Jersey Doctor Charged in Health Care Fraud Billing Scheme
.” Then, write a 1–2 page report in which you:
Summarize three quality issues in the case that resulted in fraudulent billing and coding.
Describe three violations that were stated in the case, including how the violations applied based on regulations.
Illustrate how this case could be used as a training tool for your organization. You may base your work on the Department of Health and Human Services Office of Inspector General (DHHS-OIG), the Center for Medicare and Medicaid Services (CMS), and the Department of Justice (DOJ) information on quality, fraudulent billing, and so on.
Link to the story:
https://www.justice.gov/usao-nj/pr/south-jersey-doctor-charged-health-care-fraud-billing-scheme
Chapter 6
Individual Rights
in Health Care
and Public Health
Chapter Overview
• Describes the meaning and importance of the
“no-duty-to-treat” principle
• Explains generally how the U.S. approach to health
rights differs from that of other high-income
countries
• Describes the types and limitations of individual legal
rights associated with health care
• Describes the balancing approach taken when
weighing individual rights against the public’s health
Background
• “No-duty-to-treat” principle
– Individuals have no legal right to health care
services or to public health insurance
– No general legal duty to provide care for health
care providers
Individual Rights and Health Care:
A Global Perspective
• United States is one of the only high-income nations
that does not guarantee health care as a fundamental
right.
• Some two-thirds of constitutions worldwide address
health or health care.
• Including language respecting health rights in a
constitution does not guarantee that the right will be
recognized or enforced.
Individual Rights and the
Healthcare System
(1 of 3)
• Healthcare rights categorized in three ways:
1. Rights related to receiving services explicitly
provided under health care, health financing, or
health insurance laws
– For example, rights under EMTALA,
Medicaid, or the Affordable Care Act (ACA)
Individual Rights and the
Healthcare System
(2 of 3)
2. Rights concerning freedom of choice and freedom
from government interference when making health
care decisions
– One of the most important healthcare rights is
the right of individual patients to make
informed decisions about the scope and course
of their own care. This includes the right to
refuse treatment.
Individual Rights and the
Healthcare System
(3 of 3)
3.The right to be free from unlawful discrimination
when accessing or receiving health care
– Discrimination in health care can occur on the
basis of race/ethnicity, socioeconomic status,
disability, age, and gender.
Individual Rights in a
Public Health Context
(1 of 3)
• One simple way to think about individual
rights in a public health context is to use a
balancing approach—what might the
appropriate legal trade-offs be between private
rights and public health and welfare?
Individual Rights in a
Public Health Context
(2 of 3)
• Police powers
– Represent government authority to require
individual conformance with established standards
of conduct
– Standards are designed to promote and protect the
public’s health, safety, and welfare, and to permit
government control of personal, corporate, and
other private interests.
Individual Rights in a
Public Health Context
(3 of 3)
• Prevailing view is that the Constitution empowers
government to act in the name of public health but
does not require it to do so.
• This interpretation refers to what is known as the
“negative constitution”—the idea that the
Constitution does not require government to provide
any services, public health or otherwise.
• This approach to constitutional law derives from the
fact that the Constitution is phrased mainly in
negative terms.
Chapter 7
Social
Determinants of
Health and the
Role of Law in
Optimizing
Health
Chapter Overview
• Describes the meaning of “social determinants of health”
and the significance of social factors on individual and
population health
• Describes how law can create or perpetuate health-harming
social conditions
• Explains how law can be used to ameliorate health-harming
social conditions
• Explains how innovative interventions to improve health,
such as medical-legal partnership, can help address healthharming social conditions at the individual and population
levels
Background
(1 of 2)
• Health disparity—when one population group
experiences a higher burden of disability or illness
than another group
• Healthcare disparity—denotes differences in access
to healthcare services or health insurance, or in the
quality of care actually received
• Health equity—a situation in which everyone has the
opportunity to attain his or her full health potential
• As long as these disparities exist, a society cannot
achieve health equity.
Background
(2 of 2)
• Many factors contribute to health and healthcare
disparities, including:
– Individual behaviors, healthcare provider bias, cultural
expectations and differences, location and financing of
healthcare systems, social factors, and more
• Disparities appear through different lenses.
– Race, ethnicity, socioeconomic status, age, geography,
language, gender, disability status, citizenship status,
and sexual identity and orientation
Determinants of Health
• According to the Centers for Disease Control and
Prevention (CDC), determinants of health are “factors
that contribute to a person’s current state of health.”
• Biological factors—genetic mutation that could increase
chances of developing a disease (sickle cell anemia)
• Psychosocial factors—conflicts within one’s family that
may lead to stress, anger, and/or depression
• Behavioral factors—alcohol/drug use, smoking,
unprotected sex
• Social factors—conditions in which people are born and
that affect their daily lives and overall well-being as they
move through various stages of life
Defining Social
Determinants of Health
• Social determinants of health (SDH)—social
conditions into which people are born and that affect
their daily lives and overall well-being as they move
through life
– World Health Organization (WHO) defines SDH
as: “the conditions in which people are born, grow,
live, work and age”
– Centers for Disease Control and Prevention (CDC):
SDH are shaped by the distribution of money,
power, and resources at both local and national
levels
Types of Social Determinants
of Health
(1 of 2)
• Access to high-quality educational opportunities
• Access to medical care services
• Access to social media and other technologies
• Availability of community-based resources and
opportunities for recreational activities
• Availability of resources to meet daily needs
Types of Social Determinants
of Health
(2 of 2)
• Culture
• Language/literacy
• Public safety
• Residential segregation
• Social norms and attitudes
• Socioeconomic conditions
• Transportation options
The Link Between Social Determinants
and Health Outcomes
• While most diseases and injuries have multiple
causes, and while several factors and conditions
contribute to a single death, the overwhelming weight
of evidence demonstrates the powerful effects of
socioeconomic and related social factors on health.
Law as a Social Determinant
of Health
(1 of 2)
• The law can be used to design and perpetuate social
conditions that can have terrible physical, mental, and
emotional effects on individuals and populations.
• The law can be utilized as a mechanism through which
behaviors and prejudices are transformed into
distributions of well-being among populations.
Law as a Social Determinant
of Health
(2 of 2)
• Laws can be determinative of health through underenforcement.
• The law can be used to structure direct responses to
health-harming social needs that result from things like
impoverishment, illness, market failure, and individual
behavior that harms others.
Right to Criminal Legal Representation
Versus Civil Legal Assistance
• While the right to legal representation exists in
criminal matters, there is no right to a lawyer in
civil matters.
• Common civil legal matters involve immigration
status, domestic violence, disability law, family
law, housing needs, public benefits (e.g., Medicaid,
food stamps, Social Security), employment
disputes, and special education needs.
Combating Health-Harming Social Conditions
Through Medical-Legal Partnership
• Medical-legal partnerships function as a patient care
team that includes both medical and legal
professionals.
– A legal services attorney is embedded in a medical
care setting (hospital, community health center, etc.)
to address underlying social conditions that
negatively affect patient health but whose
remediation is outside the expertise of traditional
healthcare providers.
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