Integrity in Practice: Our Profession s Campaign to Prevent Fraud and Abuse

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1 Integrity in Practice: Our Profession s Campaign to Prevent Fraud and Abuse Presenters: Jeanne McCoy, PT, DPT, MS, NCS Sandra Levi, PT, PhD, CEEAA Patrick Withrow, PT, DPT, GCS

2 Course Objectives Course participants will review the Illinois Ethics requirement for licensure Course participants will analyze ethical situations by: Discussing the Illinois Physical Therapy Act with respect to ethics and professional regulation Reviewing the APTA Integrity in Practice campaign and associated resources Integrating the RIPS model as a means to address ethical situations Discussing select ethical situations using the resources available

3 Ethics Committee 2016 Members Jeanne McCoy, PT, DPT, MS, NCS Sandra Levi, PT, PhD, CEEAA Patrick Withrow, PT, DPT, GCS IPTA website Bringing an ethical concern to the Committee

4 Key Documents Code of Ethics for the Physical Therapist APTA Guide for Professional Conduct Physical Therapy Core Values Standards of Practice for Physical Therapy Illinois Physical Therapy Act PT Administrative Code

5 Ethics Requirements Section Continuing Education Beginning with the September 2016 renewal, at least 3 hours of the 40 hours must include content related to the ethical practice of physical therapy (PT) Beginning with the September 2017 renewal, at least 3 hours of the 20 hours must include content related to the ethical practice of physical therapy (PTA)

6 Intro to Ethics Ethics defined rules of behavior based on ideas about what is morally good and bad the principles of conduct governing an individual or a group

7 Basic Ethical Principles Autonomy Do no harm Nonmaleficence Beneficence Justice Fairly distributing burdens/benefits Right to selfdetermination Promote good, looking out for pt s well-being

8 Intro to Ethics Is morality Obeying the law? Pursuing what is good for ourselves? Producing the most good for the most people? Human well-being?

9 Intro to Ethics Where do ethics come from? Social norms Authority figures Religious orientation Popular culture

10 Codes of Ethics Provides helpful guidance to professionals Represents a consensus within a profession that enables practitioners to work cooperatively, compete fairly Gives support to professionals who may be asked to cut corners Official statement of the profession that promotes the public good and minimizes harm Promote public trust

11 Jurisprudence Jurisprudence = the study of law Exam is not required in Illinois (29 states for PT, 27 for PTA) All licensed PTs and PTAs should be familiar with the practice act and rules under which they are allowed to work (FSBPT) Standards of Practice for Physical Therapy: The physical therapist complies with all the legal requirements of jurisdictions regulating the practice of physical therapy.

12 Jurisprudence In a civilized life, law floats in a sea of ethics. Justice Earl Warren, 1962

13 Ethics and the Law Can we separate ethical and legal considerations? Engaging in dishonorable, unethical or unprofessional conduct (Sec. 17 (1)(H) of IL PT Act) could result in loss/suspension of license, up to $5,000 fine Gross and willful and continued overcharging for professional services, including filing false statements for collection of fees for which services are not rendered is considered unprofessional conduct (Section (a)(9) of the Administrative Code) Does ignorance of the law matter?

14 Disciplinary Action IDFPR publishes monthly report Enforcement actions Includes name, license #, discipline imposed, reason for the order(s) In 2015, 7 separate orders were documented for PT 6 individuals Compare to other HCPs Physician/chiropractor: 22 were disciplined Nursing: 65 were disciplined

15 Disciplinary Action Reprimanded and fined $2,500 due to deficient recordkeeping and improper billing of PT services Reprimanded as result of failing to maintain accurate PT treatment records Placed on probation as a result of excessive use of alcohol Placed in refuse to renew status for failing to maintain accurate records, improperly billing for services not provided Placed in refuse to renew status for deficient recordkeeping and improper billing of PT services Placed in refuse to renew status due to sister-state discipline in California Placed in refuse to renew status due to sister-state discipline in Wisconsin

16 Disciplinary Action The Department may refuse to issue or to renew, or may revoke, suspend, place on probation, reprimand, or take other disciplinary action as the Department deems appropriate, including the issuance of fines not to exceed $5000 (IL PT Act) Cease and Desist Order The court may issue a temporary restraining order If the injunction is violated, the Court may punish the offender for contempt of court

17 Section 17 Sec. 17. (1) The Department may refuse to issue or to renew, or may revoke, suspend, place on probation, reprimand, or take other disciplinary action as the Department deems appropriate, including the issuance of fines not to exceed $5000, with regard to a license for any one or a combination of the following 26 items total

18 Disciplinary Action Common behaviors in health care professions leading to disciplinary action Substance abuse Criminal convictions Patient Abuse and/or neglect Sister-state disciplinary action Sexual misconduct

19 Substance Abuse What does the Practice Act say? J. Habitual or excessive use or addiction to alcohol, narcotics, stimulants, or any other chemical agent or drug which results in a physical therapist's or physical therapist assistant's inability to practice with reasonable judgment, skill or safety What does the Code of Ethics say?

20 Criminal Convictions What does the Practice Act say? C. Conviction of any crime under the laws of the United States or any state or territory thereof which is a felony or which is a misdemeanor, an essential element of which is dishonesty, or of any crime which is directly related to the practice of the profession What does the Code of Ethics say?

21 Patient Abuse and/or Neglect What does the Practice Act say? N. Abandonment of a patient O. Willfully failing to report an instance of suspected child abuse or neglect as required by the Abused and Neglected Child Reporting Act P. Willfully failing to report an instance of suspected elder abuse or neglect as required by the Elder Abuse Reporting Act What does the Code of Ethics say?

22 Sister-State Disciplinary Action What does the practice act say? K. Revocation or suspension of a license to practice physical therapy as a physical therapist or physical therapist assistant or the taking of other disciplinary action by the proper licensing authority of another state, territory or country What does the code of Ethics say?

23 Sexual misconduct What does the Practice Act say??? What does the Code of Ethics say? 4E. Physical therapists shall not engage in any sexual relationship with any of their patients/clients, supervisees, or students

24 Section 17 (2) Determination by a circuit court that a licensee is subject to involuntary admission as provided in the Mental Health and Developmental Disabilities Code operates as an automatic suspension Board must recommend that the licensee be allowed to resume his practice Tax evasion

25 The Code Sec. 17 (1)(H) Engaging in dishonorable, unethical or unprofessional conduct Section Unprofessional Conduct

26 Unprofessional Conduct 1. The promotion of the sale of services, goods, appliances or drugs in such manner as to exploit the patient or client for the financial gain of the practitioner or of a third party 2. Directly or indirectly offering, giving, soliciting, or receiving, or agreeing to receive any fee or other consideration to or from a third party for the referral of a patient or client Federal anti-kickback statute

27 Federal Anti-Kickback Statute RehabCare Group Inc. has agreed to pay $30 million to resolve government allegations that it paid kickbacks to gain access to Medicare and Medicaid patients in Missouri nursing homes Source: St. Louis Post-Dispatch

28 Unprofessional Conduct 3. Revealing of personally identifiable facts, data or information about a patient or client obtained in a professional capacity without the prior consent of the patient or client, except as authorized or required by law 5. Delegating professional responsibilities to a person when the licensee delegating such responsibilities knows or has reason to know that the person to whom the responsibilities were delegated is not qualified by training, experience, or licensure to perform them

29 Unprofessional Conduct 6. Failing to exercise appropriate supervision over persons who are authorized to practice only under the supervision of a licensed physical therapist Sec. 2 (6): Aides must have on-site supervision of PT or PTA Sec. 2 (7): PTAs must have general supervision of a PT PT must maintain continual contact with the PTA including periodic personal supervision/instruction to insure the safety/welfare of the pt Sec. 2 (8): Students must have on-site supervision PT shall be readily available for direct supervision/instruction to insure the safety/welfare of the patient

30 Unprofessional Conduct 10. Failing to maintain a record for each patient that accurately reflects the evaluation and treatment of the patient Defensible documentation Limit abbreviations Demo skilled care Report functional progress toward goals Use standardized tests/measures

31 Summary Know the Practice Act, Administrative Code, Code of Ethics Ignorance is no excuse ethical/legal practice is YOUR responsibility!

32 References Gabard DL, Martin MW. Physical Therapy Ethics. Philadelphia, PA: F.A. Davis Company; Kornblau BL, Starling SP. Ethics in Rehabilitation: A Clinical Perspective. Thorofare, NJ: SLACK, Inc.; Pozgar GD. Legal and Ethical Issues for Health Professionals. Burlington, MA: Jones & Bartlett Learning, LLC; ceexam.aspx

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34 Good People

35 GOALS 1. Understand the integrity terminology. 2. Understand 5 fraud and abuse laws. 3. Understand APTA s integrity in practice campaign and resources. 4. Use the RIPS model to analyze a current integrity issue

36 Integrity in Practice Terminology Fraud Abuse Waste Integrity

37 What Is Fraud? Fraud: intentional deception or misrepresentation that a person makes to gain a benefit to which they are not entitled

38 What Is Abuse? Abuse: Payment for items or services that the provider is not entitled to and for which the provider has not intentionally misrepresented facts to obtain payment

39 What Is Waste? Waste: incurring unnecessary costs as a result of deficient management practices, systems, or controls

40 What Is Integrity? Integrity: Conduct that conforms to an accepted standard of right and wrong ( Maintaining compliance in all areas of practice, from coding and billing, to patient services.

41 Terms Fraud Abuse Waste Integrity

42 Major Fraud and Abuse Laws 1. False Claims Act 2. Federal Anti-Kickback Statute 3. Physician Self-Referral Law 4. Exclusion Authorities 5. Civil Monetary Penalty Law

43 False Claims Act Prohibits the knowing submission of false claims or the use of a false record or statement for payment to Medicare or Medicaid Monetary penalties of between $5,500 and $11,000 per claim, plus 3 times the damages sustained by the government License sanctions and exclusion from federal program Strong Incentive for whistleblowers to report fraud

44 Federal Anti-Kickback Statute Prohibits anyone from knowingly and willfully offering or receiving a form of payment in return for referring a patient to another provider for services or items covered by Medicare and Medicaid Payment can include anything of value (e.g., cash for referrals, free rent, gifts) Safe harbors permit non-abusive arrangements

45 Physician Self-Referral Law Prohibits physician referrals for certain health care services (e.g., physical therapy) when there is a financial relationship with an entity unless an exception applies Financial relationships include ownership and compensation

46 Integrity in Practice: Relationships

47 Physical Therapist Relationships With Payers Coding and billing Enrollment Documentation

48 Physical Therapist Documentation Is a record of patient care Is a communication vehicle among providers Demonstrates compliance with federal, state, payer, and local regulations Can demonstrate appropriate utilization

49 Relationships With Physicians and Other Referral Sources Rental of office space Medical directors Gifts to physicians

50 Physical Therapist Relationships With Patients Gifts to patients Waiver of coinsurance Collecting cash from Medicare beneficiaries

51 Integrity in Practice: APTA Integrity in Practice Campaign and Resources

52 The Campaign Education Choosing Wisely Outcomes Registry Leadership and Advocacy

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54 Material presented at IPTA 2016 REVITALIZE Conference

55 Evidence-Based Practice, Ethics, and Professionalism To protect against the risk of fraud, abuse, and waste, incorporate clinical practice guidelines and evidence-based patient care decisions about appropriate health care for specific clinical conditions More information:

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58 Taking Action

59 If There s a Problem Contact compliance officer Immediately stop submitting problematic bills Seek knowledgeable legal counsel Determine whether there are any overpayments that need to be returned Disentangle from problematic relationships When appropriate, consider reporting information to OIG or CMS

60 The Campaign Education Choosing Wisely Outcomes Registry Leadership and Advocacy

61 RIPS Model Swisher L, Arslanian L, Davis C The Realm-Individual Process-Situation (RIPS) Model of Ethical Decision-Making HPA Resource 5(3)1-6; 2005

62 The RIPS Process 1. Define Problem 2. Analyze Problem 3. Make Decision 4. Implement, Evaluate, Re-assess

63 Step 1: RIPS Framework for defining the problem Realms Individual (Moral) Process Situation Individual/ Interpersonal Organizational/ Institutional Societal Sensitivity Judgment Motivation Courage Issue/ Problem Dilemma Distress Temptation Silence

64 Realms Individual Behavior of self or others Organizational/ Institutional Policies, organizational culture Societal Systems and structures

65 Individual Process What does the ethical problem require? Moral Sensitivity Recognizing and interpreting the problem Moral Judgment Moral Motivation Moral Courage Judging what action is right or wrong Prioritizing values/ethical principles Having the courage to do the right action

66 Situation Issue/ problem Dilemma Distress Temptation Silence Important values challenged Not possible to do 2 right courses of action Know right action, but not authorized to do it Choice between a right and a wrong Values challenged, but no one is speaking up

67 Step 2: Analyze/ Reflect Facts and context from step 1 Stakeholders Consequences: Intended and unintended Laws, duties, obligations, ethical principles Professional resources (e.g., Code of Ethics)

68 Right vs. Wrong Tests: Potential Courses of Action (Kidder) Legal Stench Mother Front page Professional Ethics

69 Step 3: Make decision Rule-based Ends-based Care-based

70 Step 4 1 Implement 2 Evaluate 3 Re-assess

71 The RIPS Process 1. Define Problem 2. Analyze Problem 3. Make Decision 4. Implement, Evaluate, Re-assess

72 Other Resources: apta.org>practice & pt care>ethics & professionalism Code of Ethics APTA Guide for Professional Conduct Standards of Ethical Conduct for the PTA Guide for Conduct of the PTA Core Values

73 Group Scenario (from Nancy R. Kirsch PTinMotion Ethics in Practice articles)

74 Small Group Discussions

75 Integrity in Practice 2016 JO McCoy, S Levi, P Withrow Takeaway #1: For 2016/2017 license renewals, 3 hours of continuing education must include content related to the ethical practice of PT for PTs/PTAs Takeaway #2: Ignorance of the law is no excuse! Takeaway #3: Choose Wisely Takeaway #4: Make each decision as if it were the one decision for which you would be remembered. (Walter Burke, Texas Instruments as per UIC Handbook for Good Ethical Practice)