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legal aspects
Legal Aspects Of Health Care Administration 14th Edition George D. Pozgar - Solutions
Wrongful discharge can be retaliatory or constructive discharge.
An employee who believes that he or she has been unfairly discharged should seek access to his or her employment contract (if applicable), employee handbook, human resources policies and procedures, minutes of pertinent meetings, written reports (typed or handwritten), as well as any employment
The fact that an employment contract is terminable at will does not, in all cases, allow an employer the absolute right to terminate the contract.
Employers can reduce exposure to liability for wrongful discharge by establishing and maintaining effective hiring practices.
Fairly balancing the rights and responsibilities of the employee and the needs of the organization is an extremely complex objective.■■ Rights and responsibilities run parallel to one another.■■ There is a corresponding duty to accept one’s responsibilities and at the same time respect
Employee rights include equal pay for equal work; refuse to participate in care for religious reasons, question patient care; freedom from sexual harassment; treatment with dignity and respect; report the employer for violation of the law; freedom from intimidation; privacy and confidentiality; and
Staff responsibilities include compassion; honoring patient wishes; maintaining confidentiality for both patients and employees; adhering to safe practices (e.g., comply with sterile technique protocols); exercise appropriate judgment; adhere to professional standards; report unethical behavior;
The U.S. Department of Labor is a department within the executive branch of government. Its mission is fostering, promoting, and developing the welfare of wage earners; improving working conditions; and advancing opportunities for profitable employment.
The Norris–LaGuardia Act was enacted by Congress to limit the power of the federal courts to issue injunctions in cases that involve or have grown out of labor disputes.
The National Labor Relations Board (NLRB) is responsible for administering and enforcing the NLRA. It also provides procedures through which employees can choose a union as a collective bargaining representative.
The National Labor Relations Act (NLRA) governs the labor–management relations of business firms engaged in interstate commerce.
In 1974, an amendment designating procedures that limit strikes in healthcare organizations was added to the NLRA. The amendment requires a 10-day strike notice; allows the NLRB to determine the legality of the strike; and allows time for the organization time to establish provisions that protect
Title VII of the Civil Rights Act of 1964, as amended by the Equal Employment Opportunity Act of 1972, prohibits discrimination in employment based on race, color, religion, sex, or national origin.
The Fair Labor Standards Act (FLSA) established minimum wages and maximum hours of employment.
The Equal Pay Act, essentially an amendment to the FLSA, prohibits sex discrimination in the payment of wages.
The Occupational Safety and Health Act of 1970 was enacted by Congress to ensure safe and healthful working conditions and to preserve human resources. Employers are required to provide a place of employment that is without recognized hazards that cause or are likely to cause death or serious
The Rehabilitation Act of 1973 provides protection from discrimination to handicapped employees and is applied to both public and private organizations.
The Americans with Disabilities Act of 1990 is legislation that further protects the rights of the disabled. The act prohibits job discrimination in hiring, promotion, and other requirements of employment against qualified individuals with disabilities.
There are two kinds of union security contracts:■■ Closed-shop contracts provide that only members of a particular union may be hired.■■ Union-shop contracts hold that continued employment is dependent on membership in the union.
Workers’ compensation is a reimbursement program for employees with work-related injuries.These programs are administered on a state-by-state basis.
Managed care is the process of structuring or restructuring the healthcare system in terms of financing, purchasing, delivering, measuring, and documenting a broad range of healthcare services and products.
Management rights include the right to receive a strike notice, hire replacement workers, restrict union activity to prescribed areas, prohibit union activity during working hours, and prohibit unionization of supervisors.
Labor rights include the right to organize and bargain collectively, solicit and distribute union information, picket, and strike.
Arbitration procedures begin when a union files a demand for arbitration either with the employer or with the arbitration agency named in the contract. The arbitrator’s decision is binding on both parties.
An injunction is an order by a court that instructs that a certain act be performed or not performed.
Affirmative action programs include collection and analysis of data on the race and sex of all applicants for employment, and a nondiscrimination statement in personnel policy and procedure manuals and employee handbooks.
Health maintenance organizations (HMOs) are the most highly regulated form of managed care organization (MCO) and are health systems that are responsible for the financing and delivery of a wide range of comprehensive services to their enrolled populations.
Independent practice association (IPA) models provide care to subscribers through contracts with independent physicians.
Staff models normally contract with physicians as full-time employees.
Entities through which employer health benefit plans and health insurance carriers contract to purchase services for covered beneficiaries from a selected group of providers are called preferred provider organizations (PPOs). Exclusive provider organizations (EPOs) limit beneficiaries to
IPAs are legal entities of physicians who have organized to negotiate contracts to provide their services. Group practices are physician groups that have only one or a small number of service delivery locations, whereas in a group practice without walls, physicians organize to share administrative
Management service organizations (MSOs)provide services such as practice management, marketing, managed care contracting, billing, and personnel management for physicians.
A vertically integrated delivery system is any organization (e.g., rehabilitation facility, physician practice) that merges to provide a broader range of services to patients.
A horizontal consolidation involves a merger of similar or identical businesses in the same consumer marketplace. A new healthcare entity, for example, is created when a hospital medical center merges with one or more smaller community hospitals in the same or surrounding communities.
Federal qualification of HMOs is voluntary, and those that are federally qualified must provide or arrange for basic services for members as needed and without limitations on time, cost, frequency, extent, or nature of services provided.
Most state HMO laws require that an application for a certificate of authority be accompanied by a description of proposed marketing plans. A regulator must approve this plan.
Utilization review (UR) is a process through which a third-party payer assesses the medical necessity of a course of treatment. Prospective review is the determination of whether to pay for a treatment before the treatment is administered, concurrent review takes place during the treatment, and
Congress passed the Health Care Quality Improvement Act (HCQIA) of 1986 to encourage continued participation in peer-review and credentialing activities. The act grants immunity to persons who supply to professional review bodies information that may result in adverse decisions against a physician.
A fiduciary is obligated to deal fairly and honestly with plan members. The duty not to mislead is derived both from the common law of trusts and the statutory language in the Employee Retirement Income Security Act of 1974.
Price fixing is when two or more competitors collude to decide on the price that will be charged for services or goods. For MCOs, there is a danger that provider-controlled organizations will be seen as a horizontal conspiracy between competitors that acts as a mechanism for price fixing.
The Affordable Care Act (ACA) is designed to increase the number of Americans covered by health insurance, while decreasing the cost of the insurance. Controversy, however, continues to swirl around the ACA by politicians, insurers, and policyholders.
Medical malpractice insurance is affected by the cyclical nature of the insurance market.
Insurance is a contract in which the company providing the insurance agrees to assume some of the risks of the insured party for consideration or the payment of a premium. The three primary components of an insurance policy are identification of the covered risks, specification of the amounts
By creating a large pool of individuals, an insurance company can balance its risk—the possibility that loss will occur—enough that it should be able to both cover claims and return a profit to shareholders.
The three primary categories of risks are property loss, personal liability, and legal liability.
Occurrence policies cover all accidents during a policy year, regardless of when they are reported, whereas claims-made policies cover claims made or reported during the policy year, no matter when they occurred.
Standard liability policies include (1) insurance agreement, (2) defense and settlement, (3)policy period, and (4) amount payable by the insurance company.
Policy conditions require that if the insured does not comply with the conditions of the policy, forfeiture of the policy and nonpayment of claims against it could result.
Professional liability insurance covers negligence and assault and battery that result from failing to obtain consent to a medical or surgical procedure.
Conditions of an insurance policy include notice of occurrence, notice of claim, assistance of the insured, other insurance, assignment, subrogation, changes, and cancellation.
Healthcare professionals are encouraged to obtain malpractice insurance because they can be held liable for their own negligence. The drawbacks include the encouragement of being named in malpractice suits.
Professional liability does not cover intentional torts and sexual assault.
Self-insurance is a practice in which a healthcare organization periodically sets aside a certain amount of money to cover malpractice losses and expenses.
An injured party may request settlement of a claim prior to instituting legal action.
When a claim is settled, the plaintiff signs a general release, which states that the plaintiff surrenders the right of action against the defendant.
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