UMGC Business Transactions Resource and Compliance Matrix Worksheet

User Generated

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Health Medical

University of Maryland Global Campus

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Why is something already written in the law and code section?

The law and code section has a  general reference to the law that applies.  Use this general reference to find the specific law that applies. (Use the Common Health Laws document)  Write the formal name of the law (the title) and write the code section for the law in the box.

For example, in the box to the right of scenario 1, it says “state licensing law”.  The scenario is for the state of Maryland.  Use your resources to find the Maryland state licensing law.  Write the name of the law and its Maryland Code section  in the box where it says “state licensing law.”

How do I cite and reference code sections?

Use the examples below, but fill in the proper code section numbers to cite the code.

-United States Code (U.S.C.) cite 42 U.S.C. 342 (2021)

-Maryland  Code 23-41-1 (2021)

How do I know complete the risk assessment?  How do I know if something is low, medium, or high risk?

Evaluate the risk by looking at the following factors.

Consequences.  Consider all of the practical consequences of the situation.  This includes poor clinical outcomes, legal liability, financial loss, reputational loss, and capacity loss such as a loss of use of technology.  If the practical consequences are serious, then there is a higher risk of harm.  If the practical consequences are low, then there is a lower risk.

Penalties.  Consider the legal penalties or non-compliance. The more severe the penalties, the higher the risk.  Lower penalties have a lower risk. Generally, criminal penalties can include jail or prison time so they will have higher penalties.

  • Likelihood.  How likely is it that the problem will arise?  If this is a common problem that occurs frequently, then there is a higher probability and  a higher risk.  If this is something that doesn’t commonly occur there will be a lower probability and lower risk.
  • Internal Controls.  What internal controls are in place that would limit the likelihood that this would happen?  If there are strong controls, this would lower the likelihood of a problem. In other words, if the company has a good policy, system, or protocol to ensure the situation is handled properly, the risk will be lower.  If there are weak controls, then this would increase the likelihood of a problem.  This often occurs when each manager makes there own decision on an issue.
  • Overall Risk.  Compare and contrast the risk assessment from the different areas to come to an overall risk assessment of high, medium or low.
  • Be sure to support your risk assessment with reasons to support your conclusion. Write in complete sentences.
  • For example, for the first scenario evaluate the risk of the  physician licensing situation and give it a rate of low, medium, or high.  Describe your reasons for the rating in simple complete sentences.

Do I need to support my risk rating?

Yes!

Give specific reasons to support your risk rating. Demonstrate your evaluation of the risk by including your supporting reasons.

What does it mean “A question you would ask the resource person to help you better know how to comply with the law”?

Underneath this section,  write one question that would help you know what to do.  The question should be something that the person you selected as the person as a resource could answer.  For example, you wouldn’t ask a finance person a legal question or a clinical person a business question.

Keep in mind that good questions lead to good answers and poorer questions can leave you without the information you want.  This is a chance to practice formulating good questions when you need help as a manager on the job.  Tip:  Avoid yes/no questions.

For example, if I selected the Medical Director as the person who would be my best resource, I might ask, “What steps did you take to become licensed in Maryland to practice as a physician?”  Tip:  Don’t select Medical Director as the role best able to help.

How do I decide on a managerial action to take to comply with the law?

Review risk management and legal compliance resources in the Classroom Law Library resources for Week 1 and Weeks 2 & 3/Business Transactions.  Feel free to use any part of the Classroom law library any time. Also use the Compliance Library and its documents. The textbooks and other classroom resources are also good sources of information.

Evaluate the different strategies to determine which strategy best applies to each scenario. Consider both immediate actions and long-term system wide solutions. Select the action that you feel will be the strongest to control the risk as you have assessed it.  Give reasons to support your choice. Tip:  Don’t use the same management action for all the scenarios. Management actions should be specific the the scenario.

Describe your action.  The best strategies are specific and actionable.  Include reasons to support your actions, so that it is clear why you felt this was the best course of action.

Unformatted Attachment Preview

Business Transactions Resource and Compliance Matrix Name: Date: Health care business situations 1. Your organization just hired a physician from out of state. The physician will need to become licensed in your state of Maryland. As an administrator, you have been asked to oversee the process to ensure the physician obtains a valid Maryland license to practice medicine. 2. You were reviewing the new physician contract and see that the physician will be paid a flat salary with bonuses from the hospital for increasing hospital admissions. 3. Your managed care organization (MCO) wants to build a new hospital and 2 new rehabilitation centers in your The Law and Code Section State licensing law Federal Antikickback Statute (AKS) State Certificate of Need Legal requirements and Penalties for non-compliance with the Law Risk Assessment Low Medium High (Give reasons to support your rating) Role of Person who can be a resource for compliance (Give reasons to support your choice) A question you would ask the resource person to help you better know how to comply with the law A managerial action you would take to comply with the law (Give reasons to support your action) state of Maryland. You are asked to spearhead the project. 4. You oversee the medical billing department. The billing manager responsible for day to day activities was out of the office for 6 months on a disability leave. The manager has just returned and discovered that the coders billed everything at the highest level of service whether there was documentation to support it or not during the 6 months the manager was gone. 5. Your hospital wants to expand and buy out a physician group in a nearby town. The physicians would become employees of your hospital. 75% of the physicians in your town and the nearby would be employed by your hospital when the venture is complete. 6.You are responsible for the profit/loss statements for your budget area each month. The Vice President over your area just asked you to ”improve” the numbers to show a profit even though the numbers show a loss. You have been told that the VP owns 60% of the shares of stock for your public corporation. Federal False Claims Act (FCA) Notice of Overpayment Rules Federal Antitrust law Joint Venture Guidelines Federal Sarbanes Oxley Act (SOX) Conflict of Interest 7. You are an entrepreneur and want to open up a home health company in Maryland. You want to be incorporated under Maryland law and operate as Home Care Inc. 8. You work for a family practice physician clinic. Two of the physician owners are also part owners of a nearby durable medical equipment (DME) store and a clinical lab. All physicians in the organization regularly refer patients to the DME store and clinical lab. 9. Your hospital is a non-profit organization and doesn’t pay taxes. The billing company at your hospital just sent word that it sent 50 unpaid claims to collections. You wonder if this should be considered charity care instead. 10. You work for a large health insurance company. The company wants to start a disease management program for its members by contracting with a national pharmaceutical to run the disease management program. State Incorporation Law Federal Physician Self-Referral Law (Stark) Federal Internal Revenue Service (IRS) tax law Federal Health Insurance Portability and Accountability Act (HIPAA) Business Associate Regulations
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1
Business Transactions
Resource and Compliance Matrix
Name:
Date:
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