1. Medical Records and Managed Care
Medical Law and Ethics
Sources of Law
Medical Records and Managed Care
Herzing University Online HC 310 Medical Law and Ethics 1

2. Behavioral Objectives
Distinguish between public and private law, civil and criminal law, and tort and contract actions.
Identify the two specific procedural protections that the due process clause generally requires and when they are required.
Discuss the concept of equal protection.
Give examples of the rights encompassed by the constitutional right to privacy.
Explain what happens when local, state, and federal law overlap.
Discuss how the courts make law, defining the principles of stare decisis and res judicata. 
Name the three branches of government and outline the responsibilities of each.
Herzing University Online HC 310 Medical Law and Ethics 2

3. Behavioral Objectives
Define utilization management/review. 
Explain the role of patient information with respect to the utilization review process.
Identify the characteristics of the managed care industry that have changed the nature of patient records.
Describe the changes in medical records standards made in response to the growth of managed care
Describe the information protected by the HIPAA privacy rule and explain how privacy rules affect health plans
Herzing University Online HC 310 Medical Law and Ethics 3

4. Terms Tort Contract Law Stare Decisis Res judicata
Herzing University Online HC 310 Medical Law and Ethics 4

5. Terms Utilization Review Managed Care Health Maintenance Organizations
Preferred Provider Organizations (PPO)
Independent Practice Association (IPA)
Physician/Hospital Organizations (HPO)
HIPAA
Herzing University Online HC 310 Medical Law and Ethics 5

6. Definition of Law
The law is: “a system of principles and processes by which people who live in a society create stability and deal with their disputes and problems, seeking to solve or settle them without resort to force” (Roach, pg. 2)
The law essentially establishes standards by which we govern behavior between individuals and individuals and the government.
Herzing University Online HC 310 Medical Law and Ethics 6

7. Sources of Law Constitution of the United States Statutes
Legislature
Federal law supersedes state law
State law supersedes local law
Rules of Administrative Agencies
Federal Register
Herzing University Online HC 310 Medical Law and Ethics 7

8. Sources of Law Court Decisions
Interpretations of statutes and regulations
Constitutionality
“Common Law”
Doctrine of stare decisis
Court must follow precedents of higher court unless conditions have changed, applies to courts in the same court system
Res judicata
Herzing University Online HC 310 Medical Law and Ethics 8

9. Public Law and Private Law
That law which deals with the relationships between private parties
Public Law
That law which deals with the relationship between private parties and the government
Rights and duties of individuals and organizations
Herzing University Online HC 310 Medical Law and Ethics 9

10. Civil Law and Criminal Law
Non-criminal law
Contracts, property ownership, divorce
Rights of private citizens
Criminal Law
System of law that deals with those who commit criminal acts
Body of rules and statutes that is utilized to define prohibited conduct by governments
Also deals with punishment related to that conduct
Herzing University Online HC 310 Medical Law and Ethics 10

11. Tort and Contract Actions
Tort action
Negligence
Civil proceeding which judges the relief that may be granted to those who have suffered harm from the wrongful acts of others
Tortious conduct
Contract action
Breach of contract
Compensation
Herzing University Online HC 310 Medical Law and Ethics 11

12. Due Process Constitutional guarantee
Legal proceedings are to be fair and unbiased
Laws shall not be arbitrary or unreasonable
Fifth Amendment Due Process Clause ratified in 1791
No person shall “be deprived of life, liberty, or property, without the due process of law”
Restricts the powers of the Federal Government
Herzing University Online HC 310 Medical Law and Ethics 12

13. Equal Protection Fourteenth Amendment to the Constitution
Concept that special privileges or discrimination is against the law
Also seen as the Equal Rights Amendment
Herzing University Online HC 310 Medical Law and Ethics 13

14. Constitutional Right to Privacy
Griswold v. Connecticut (381 U.S. 479)
Roe v. Wade (410 U.S. 113) 1973
Penumbral right, not clearly defined in the Constitution
Viewed as the privacy rights of individuals to make decisions about their own family, life and lifestyle without government interference
Herzing University Online HC 310 Medical Law and Ethics 14

15. Over Laping Laws Federal Laws, if more strict supersede State Laws
State Laws, if more strict supersede Local Laws
Herzing University Online HC 310 Medical Law and Ethics 15

16. Branches of Government
Three branches
Legislative
Executive
Judicial
Separation of powers
Herzing University Online HC 310 Medical Law and Ethics 16

17. The Medical Record
Originally developed as a business record for hospitals and physicians
Contemporary use is for health information which is subjected to state and federal regulations
“owned” by the provider and by the client/patient/participant
PHI – personal health record development
Herzing University Online HC 310 Medical Law and Ethics 17

18. Utilization Review Instituted by Medicare and Medicaid in 1966
Professional Standards Review Organizations – 1972
Need was generated by the increasing cost of health care
Herzing University Online HC 310 Medical Law and Ethics 18

19. Managed Care Health Maintenance Organization Act of 1973 Includes:
Preferred Provider Organizations
Point of Service
Focuses on quality of care and lower cost outcomes
Herzing University Online HC 310 Medical Law and Ethics 19

20. Types of Managed Care Organizations
Health Maintenance Organizations (HMO)
Deliver healthcare services to specific populations
Staff
Group practice
Network
IPA
Direct Contract
Point of Service
Herzing University Online HC 310 Medical Law and Ethics 20

21. Types of Managed Care Organizations
Consolidated Medical Group
Physician/Hospital Organizations (PHO)
Management Services Organizations
Foundation Model Integrated Delivery System
Physician Ownership Model Integrated Delivery System
Utilization Review Organizations
Pharmacy Benefits Managers
Herzing University Online HC 310 Medical Law and Ethics 21

22. Preferred Provider Organizations
Employer health benefit plans and health insurers contract to purchase healthcare
Utilization review and management part of the organization
Providers agree to accept reimbursement from insurers
Incentives for patients to use participating providers
Herzing University Online HC 310 Medical Law and Ethics 22

23. Independent Practice Association
IPA
Independent physicians contract with an IPA to be part of the contract with an HMO
Capitation for physician services
Herzing University Online HC 310 Medical Law and Ethics 23

24. Managed Care and Health Information
Decisions must be based on the system as a whole
Records are not in one place, but scattered among different providers
Employers may collect and store health information
Encouraged EHR
Herzing University Online HC 310 Medical Law and Ethics 24

25. HIPAA
HIPAA’s focus has been on the individual’s privacy rights related to health records
Exceptions to the HIPAA Privacy Rule are the mandatory reporting laws
Herzing University Online HC 310 Medical Law and Ethics 25

26. Medical Records Standards
Federal, State laws, requirements and regulations related to paper or electronic healthcare information
Medical Records may also be known as the “Legal Medical Record”, LMR
Accrediting organizations in managed care
National Committee for Quality Assurance (NCQA)
The Joint Commission (TJC)
Herzing University Online HC 310 Medical Law and Ethics 26