Professional Ethics and Boundaries in the Business of ...€¦ · • (from Stahl and Foreman (2005) Ethical Perspectives: Sexual Boundary Issues and the Chiropractic Paradigm, pg.

www.kmcuniversity.com 9/22/2018

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Professional Ethics and Boundaries in the Business

of ChiropracticPresented by:

Kathy Mills Chang, MCS-P, CCPC, CCCA

A Measure of Success?

In 1923, some of the world’s richest men attended a meeting in Chicago. These individuals included:

• Presidents of steel, utilities, gas, and securities companies

• Speculators in wheat futures and in stocks

• President of the NYSE

• A member of Calvin Coolidge’s Cabinet

• President of the Bank of International Settlements

To What End?

• 25 years later the story was not the same

• 2 died broke or in bankruptcy

• 1 was insane

• 1 died penniless and a fugitive from justice

• 2 had been to prison

• 3 committed suicide

The Ethics of Integrity

Know the Difference!

Professional Ethics Professional Boundaries

Professional Boundaries



Power Differential Issues with Boundaries

1. Transference

2. Fiduciary relationship

3. Inequality of power

1. Transference

• Patients develop dependency on chiropractor, unconsciously want doctor to fulfill unrealistic role

• Examples

• Dr. Perfect (idealization)

• Dr. Prince/Princess Charming (romantic idol, rescue)

• Dr. Good Parent (nurturing, parenting)

• Dr. Magical Healer (savior)

• Dr. Beneficent (devoted caretaker)

• Dr. Indispensable (only one who can cure)

• Dr. Omniscient (knows and understands all)

• (from Stahl and Foreman (2005) Ethical Perspectives: Sexual Boundary Issues and the Chiropractic Paradigm, pg. 46)

2. Fiduciary Relationship

• Patients trust doctor to make decisions in their best interest

• Patients trust doctor’s ethics, knowledge, confidentiality, and care

• Because of this trust…

Doctors are held to a higher standard

3. Inequality of Power

• Patients perceive DOCTOR as highly educated, trustworthy, possessing sound judgment, able to keep confidences

• Certain levels of disrobing accentuate power differential

• Pain clouds usual “logic filters”

Doctor-Patient Relationship

• Exercise the utmost care that he/she will do nothing to “exploit the trust and/or dependency of the patient”

• Sexual intimacies with a patient is unethical and is unprofessional conduct

• Patient entrusts his/her well-being to the doctor, making this a fiduciary relationship

• Can even be affected by expression personal beliefs to patients in ways that exploit their vulnerability or that can cause them distress

Types of Professional Boundary Violations

• Non-Predatory: Results not from intent, but rather from other factures, such as naiveté, insensitivity, etc.

• Predatory: Doctor/Staff actively pursue unprofessional relationships



It’s a Fine Line-Chiropractic is a Touching Profession

Best Practices for Safe Guarding• Hone excellent

communication skills

• Tell them what you’re going to do, then do it, then tell them what you did

• Act as a teacher and advocate

• Use plain and simple terms

• Avoid paternalistic role

Respect the Values Boundaries

• Don’t impose your values on the patient

• Respect their choices and values

• The final choice always rests with the patient

Informed Consent is a Form of Boundary

Respect Cultural

Boundaries

Cultural Sensitivity and Diversity

• Not everyone has the same religion, race, sexual orientation, and/or gender

• Choosing not to treat a patient or patient population is a business decision that should not be taken lightly

• Casual comments may offend or cause the patient more harm than the doctor’s treatment can fix



Harassment and the Work Place• Comments or actions affect

the tenor of the workplace

• Advances do not have to be sexual to cause harm

• Even if a team member leaves, s/he can still cause problems with 3rd party payers and legal authorities

• Lawsuits or audits can keep you from treating patients

• In a guilty until proven innocent situation –policies can protect you! Boundaries Within

Your Team

• Avoid unintended exploitation

• Treat your team like employees

• Have an open door policy

• Some language is offensive

• Social media boundaries with team and patients

Boundaries with Social Media

➢Office Policy should contain Social Media guidelines

➢Social Media should not become a distraction from daily responsibilities

➢Define Personal Social Media VS. Practice Social Media

➢Separate practice and personal Social Media

➢Do not create unreasonable expectation that will promote doctor replies

AMA Ethical Opinion 9.124

Professionalism In The Use Of Social Media

Developed November

2010

Recognizes Benefits Of

Social Media

Advises Practices To Understand

Boundaries Prior To Maintaining An Online Presence

AMA Ethical Opinion 9.124

AMA STATES PHYSICIANS:➢Must maintain patient privacy and

confidentiality standards

➢Must not post patient information

➢Must understand that social media “privacy settings” are not absolute

➢Must understand posted information

is permanent

➢Must monitor their presence to

ensure accuracy

AMA Ethical Opinion

➢Physician/Patient Online Interaction➢must maintain appropriate professional boundaries➢content should be kept separate

➢If A Physician Becomes Aware Of Unprofessional Content Posted By A Colleague They Should:➢ Immediately bring to colleagues attention➢ Remove immediately ➢ Notify appropriate authorities if not removed promptly



AMA Ethical Opinion

Physicians Must Understand Online Actions:

➢can negatively affect their professional reputation and medical careers

➢can undermine public trust in the medical profession

• Chiropractic ethics

• Business ethics

• Reimbursement ethics

• Compliance ethics

Chiropractic Ethics

Business Ethics



The Far-Reaching Hand of Business

• Healthcare is a regulated business

• Following the rules is a part of the business of healthcare

• Compliance, Coding, Documentation, and Finances are all highly regulated aspects of business

Apply Accurate and Complete Coding

• Consistency – no matter who is paying

• Goal - high quality health data to payers

• Appropriate code – one that best describes the service

Document to the Proper Standard

Run the Business Like a Business

• Have proper insurance

• Pay your taxes and fees

• Charge and pay sales tax where appropriate

• Treat your team members as you wish to be treated

• Get help when you need it

Just Last Month…Hits Close to Home!

Evil? Or the Appearance

of Evil?



Reimbursement Ethics

Inducement Violations• Per the OIG: “incentives

that are only nominal in value are NOT prohibited by [inducement law]

• No more than $15 per item or $75 in the aggregate annually• Even one free

examination, x-ray, or therapy is a risk

38

False Claims Act Violations• Establishes liability when

any person or entity improperly receives from or avoids payment to the Feds

• Prohibits “knowingly presenting or causing to be presented, a false claim for payment or approval

False Claims Act Violations• Prohibits “knowingly

presenting or causing to be presented, a false claim for payment or approval”• Examples:

• Waiving deductibles or co-payments and not reporting to carriers

• Up-coding for higher reimbursements

• Down-coding based on payer type

And Now for the Double Whammy!



Financial Transactions in

Healthcare

• One of the most highly regulated issues

• One of the four areas OIG noted as worthy of focus

• Critically important to get it right

Avoid Dual Fee Schedules

What is and isn’t a dual fee schedule? Get the facts straight

• Misrepresents charges to carriers

• False Claims Act violation• May violate provider

agreements

Compliant Time of Service Discounts

Discount is based on viable bookkeeping savings

– May or may not be defined

– Often not defensible or unreasonable

– May not be permissible on Federally insured patients

• HIPAA Compliance

• OSHA Compliance

• OIG Compliance

• PCI Compliance

HIPAA Privacy is the Law• Protection for the

privacy of Protected Health Information (PHI)

• Sets the standard for how to maintain privacy for personal information and focuses on confidentiality

What is HIPAA Security ?• The Health

Insurance Portability and Accountability Act (HIPPA) sets Security Standards for the Protection of Electronic Protected Health Information or ePHI.

• This act is also known as the Security Rule



Security Rule vs. Privacy Rule

• Access Control

• Audit Controls

• Integrity Controls

• Transmission Security

• Workstation and device security

• Minimum Necessary Standard

• Access Permissions

• Who can change PHI?

• Use and Disclosure for TPO

• Workstation and device privacy

What is ePHI?

ePHI is “individually identifiable” “protected health information” sent or stored electronically

An individual’s past, present, or future physical or mental health or condition

The past, present, or future provisioning of health care to an individual

The past, present, or future payment-related information for the provisioning of health care to an individual

OSHA

•The Occupational Safety and Health Administration (OSHA) governs workplace safety

•Many states have their own version of OSHA that may have stricter rules and/or resources

•OSHA will conduct a free, onsite audit to help you get to legal

Blood Born Pathogens• Even if your doctor does not offer

acupuncture or venipuncture this must be addressed

• OSHA has direct minimum guidelines

• Your policy should address:

oHow to handle blood or other body fluid spills

oTreatment for open wounds or lacerations

oHepatitis B vaccinations and/or declination for employees who might come in contact with body fluids (even if your doctor is anti-vaccine)

oWhat to do in the event of a needle stick and/or contact with body fluids

• “If it is wet and not yours, DON’T TOUCH IT”



Bottom Line: Be Careful!

What Is PCI Compliance?

•The Payment Card Industry Data Security Standard (PCI DSS) applies to any company that accepts credit card payments

•PCI-DSS is only mandatoryif you are processing credit card data.

•No need to keep CCs on file to charge for payment plans

Automate One-Time Payments Automate Recurring Payments

Compliance = Safety

Define Ethics for You and

Your “House”



Set the Tone for Team and Patients with Values and MIssion

Be, Do Have!

Need [email protected]

Professional Ethics and Boundaries in the Business of ...€¦ · • (from Stahl and Foreman (2005) Ethical Perspectives: Sexual Boundary Issues and the Chiropractic Paradigm, pg.

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