Types of Consent and Payers

Types of Consent and Payers

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University of Phoenix Material

Types of Consent and Payers

Part 1: Complete the chart and questions that follow.

Type of Consent Define type of consent (20- to 45- words). Identify 4 principles of the consent (20- to 45- words). Describe the impact on the health care industry (45- to 90- words).
Informed Consent An Informed Consent is adocument that a patient must sign agreeing to what a physician has stated about a specific plan or procedure. The consent is made to protect a patient’ rights. Four basic principles of aninformed consent includeautonomy, beneficence, nonmaleficence, and justice. Aperson must be given adequatetime to make a decision and aphysician must do what he/shecan do to protect the patient. An informed consent can impact the health care industry in a positive and negative way. The positive thing about an informed consent is that a physician must inform a patient about a procedure before the consent is signed. This protects the physician from a law suit. The negative thing about a conformed consent is that, if the physiciandoes not explain everything to a patient and does not have specific things written on the consent, a patient can sign the consent without knowing certain things when can then cause a law suit. A law suit can impact an organization and a physician’s reputation.
Implied Consent An implied consent is anonverbal consent that is implied when a patient gives consent to treatment. An example of an implied consent would be that of a patient getting labs drawn and itis implied that a needled will be poking through the skin. Four basic principles of an implied consent include the consent must be given voluntarily, the patientmust understand the treatment,the patient must be an adult, and a patient has the right to refuse treatment. Another principle of the consent is that if in an emergency situation, an implied consent is used. An implied consent can impactthe health care industry in a negative way by it leading tomedical malpractice law suits.The implied consent in not aformal agreement and can cause physicians grief. It is implied when a person makes an appointment to see a physician that they aregoing to follow the physician’sorders for care. Medical malpractice can occur becausethe patient can assume something but can be incorrect.

Answer the each of the following questions using 90- to 175– words.

1. Describe 4 exceptions to consent.

There are circumstances where a physician does not need to get informed consent before treatment of a patient. The four exceptions of consent are emergency situations, the patient ask not to be informed, therapeutic privilege, also, when it relates to generally known risks. In this emergency situation, the patient might not be cognizant or in a position to give informed consent. However, the state of their medical condition has become a matter of some permanent damage or life threatening, in which the physician has the right to treat the patient accordingly. In therapeutic privilege, it might make the patient’s condition worse if they knew that their health condition was life threatening. Therefore, it is in the best interest if the patient do not know the risk involving their condition. There are patient that prefer not to know the health risks they are facing, and request not to be informed. Also, a physician do not need to inform patient of common knowledge risks, such as when swallowing a pill the patient has a risk of choking on the pill (Fremgen, 2014).

2. How do exceptions to consent impact the health care industry.

According to the FDA regulations provide narrow exception to the requirement for informed consent from each human subject, or his or her legally authorized representative, prior to initiation of an experimental intervention. Exception would apply to a limited research activities involving human subjects who need emergency medical intervention but cannot give consent because their life threatening medical condition and those who do not legally have an authorized person to representation. Per the FDA their regulation is to allow research with life-threatening conditions that may be available treatments are unproven or unsatisfactory to where it may not be possible to obtain any consent while trying to establish safe and ethical studies, also any additional protection. Members of the consultant to the IRB who is not otherwise participating in the clinical investigation. It states by the FDA that requirement is like which requires an independent assessment physicians not otherwise participating in the research when an investigational product is to be used in a life-threatening situation. Permits an exception from the requirement for informed consent for a group of subjects, the case-by-case independent determination is replaced by the general concurrence of a licensed physician. 

3. Describe 2 exceptions to consent within your state.

As with many rules, there are exceptions to consider. Within Washington state legislation has ruled under RCW.7.70.065, informed consent can be authorized for patients who are not competent at the time of the medical emergency (Washington State Legislature, 2016).As long as the consent is being provided for reasons other than incapacity, the authorized person would need to be one of the following :

The appointed guardian of the patient

The individual who has durable power of attorney allowing health care decisions to be made

The spouse or registered domestic partner

Children of the patient who are at least 18 years of age

The patients parents

Adult siblings of the patient

(Washington State Legislature, 2016)

However, before the authorized person can give consent on behalf of the patient, it must be determined that if the patient could make their own decision that they would consent to the proposed health care (Washington State Legislature, 2016). If this cannot be determined a decision must be made based on the patients best interests (Washington State Legislature, 2016).

Part 2: Complete the chart.

Identify 3 Third-Party Payers Describe third-party payer (20- to 45- words) Describe the legal issues that regulate the third-party payers (45- to 90-words). Describe an applicable law that regulates the third-party payers (45- to 90- words). Describe the impact that the legal issue and applicable laws have on the third-party payers (45- to 90- words).
Blue Cross/Blue Shield Blue Cross Blue Shield is a private insurer. Customers of BCBS can include large companies as well as individual persons. BCBS is one of the largest private insurances in the US. BCBS carries both HMO (Health Maintenance Organization) plans and PPO (Preferred Provider Organization) plans. HMO plans offer a range of health services to member for a prearranged fee per member. HMO plans require members to choose a Primary Care Physician in order to manage their care. HMO plans have very patient centered reimbursement criteria in which providers are “graded” on performance. This can also affect the rates and amounts in which they are reimbursed for services. Those primary care providers that participate with HMO plans must follow strict protocols if they chose to discharge a patient to avoid abandonment. Patient Protection and Affordable Care Act (PPACA) of 2010 has mandated coverage of preventative services such as: immunizations, alcohol misuse screening and counseling, blood pressure screening, depression screening, diet counseling, obesity screening and counseling, tobacco use screening, pregnancy services, among other “preventive” services.” (Buff, 2014). Obama put this law into place so every insured American has rights to preventative care. The Patient Protection and Affordable Care Act (PPACA) of 2010 has had a huge impact on the cost of health insurance for private third party payers. Many organizations that provide health insurance for employees have felt the hit of this law and deductible and premium rates have increased significantly. This law has been a huge turning point in health care in the US and many are stating it is the reason for the significant increase in health care costs.
Medicare   Medicare has a complicated and in-depth process for determining reimbursement rates for services for physicians. Physician reimbursement from Medicare has a process. First, coding must be fitting of the service provided by utilizing current CPT codes. Appropriate coding of the diagnosis using ICD-10 codes, and the Centers for Medicare and Medicaid Services (CMS) determination of the appropriate fee based on the resources-based relative value scale (RBRVS)” (Beck, 2007). The Balanced Budget Act of 1997 included the Primary Care Health Practitioner Incentive Act, directly affects payment of services performed by advanced practice nurses. The Act removed Medicare Part B restrictions and allowed APRN’s to provide professional services, allowing direct Medicare reimbursement. However, the rate of reimbursement directed to APRN is 85% of the physician fee rate. (Balanced Budged Act of 1997). Certain criteria must be met in order for APRN’s to receive reimbursement for Medicare. The sservices must also be medically necessary, actually provided, accurately documented in the medical record. The APRN must also have a Medicare provider number and be submitted timely. Additionally, providers accepting Medicare reimbursement must agree to “accept assignment,” meaning that they will not bill patients for costs above the Medicare payment for a service. (Buppert, 2002; Richmond et al., 2000).
Medicaid   Health information management and the sharing of medical information is an example of a legal issue Medicaid and Medicare. The law has required States to have MMIS (Medicaid Management information Systems) capable of paying claims and retrieving health information to the standards of the Health and Human Services in which compliance is measured. (Rosenbaum, et. all, 2016). HIPPA- A law created in 1996 to ensure the safety of the release of patient health information. HIPAA also known as The Health Insurance Portability and Accountability Act of1996, “established federal standards and requirements concerning guaranteed issue and renewability of health coverage, limits exclusions for preexisting medical conditions, provides for credit against maximum preexisting condition exclusion periods for prior health coverage, prohibits individual discrimination based on health factors, and limits disclosure of personal health information” (HIPAA, 1996). HIPAA laws apply to both private insured as well federal and state insured. Due to the rise in the use of EHR systems (electronic health record) standards have been set in place to adhere to HIPAA law regulations and Federal MMIS standards. The security of protected personal health information (PHI) is highly monitored and regulated for third party payers in order to monitor health care quality and patient safety concerns. (Rosenbaum, et. all, 2016).

References:

Balanced Budget Act of 1997. (1997). 42 USC 4511, 4512.

Beck, D. E., & Margolin, D. A. (2007). Physician Coding and Reimbursement. The Ochsner Journal, 7(1), 8–15.

Buppert, C. (2002). Billing for nurse practitioner services: Guidelines for NPs, physicians, employers, and insurers. Medscape Nurses, 4, 1-14.

Buff, MJ, TD Terrell. Journal of American Physicians and Surgeons. 2014 Sept; 19(3): 76. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.691.1755&rep=rep1&type=pdf

FDA. (2016). Exception from Informed Consent for Studies Conducted in Emergency Settings: Regulatory Language and Excerpts from Preamble – Information Sheet. Retrieved from http://www.fda.gov/RegulatoryInformation/Guidances/ucm126482.htm

Fremgen, B. F. (2014). Medical Law and Ethics 5th Edition. Pearson.

Gunn PP, Fremont AM, Bottrell M, Shugarman LR, Galegher J, Bikson T. Med Care. 2004 Apr; 42(4):321-7.

Health Insurance Portability and Accountability Act (HIPAA) of 1996, Pub. L. No. 104-191, 110 Stat. 1936. See also U.S. Dept. of Labor, Fact Sheet: HIPAA, at http://www.dol.gov/ebsa/newsroom/fshipaa.html (last visited June 23, 2004); U.S. Dep’t of Labor, Frequently Asked Questions About Portability of Health Coverage and HIPAA, at http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html (last visited June 23, 2004).

Rosenbaum, S., MacTaggart, P., & Borzi, P. C. (2006). Medicaid and Health Information: Current and Emerging Legal Issues. Health Care Financing Review, 28(2), 21–29.

Washington State Legislature (2016). Actions for Injuries Resulting From Health Care. Retrieved from www.app.leg.wa.gov/RCW/default.aspx?cite=7.70&full=true#7.70.065

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