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LEGAL AND ETHICAL ISSUES in Medical Practice, Including HIPAA
PowerPoint presentation to accompany: Medical Assisting Third
Edition Booth, Whicker, Wyman, Pugh, Thompson
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3.1 Define ethics, bioethics, and medical law. 3.2 Discuss the
measures a medical practice must take to avoid malpractice claims.
3.3 Discuss medical documentation and how it applies to medical
law. Learning Outcomes
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3.4Discuss the various types of health-care legislation and their
impact on medical office practice. 3.5Describe OSHA requirements
for a medical office. 3.6 Describe procedures for handling an
incident of exposure to hazardous materials. Learning Outcomes
(cont.)
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3.7 Compare and contrast quality control and quality assurance
procedures. 3.8Discuss the impact that HIPAA regulations have in
the medical office. 3.9 Explain how to protect patient
confidentiality. 3.10Describe the different practice management
models. Learning Outcomes (cont.)
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Introduction Reasons to study medical law and ethics Function at
the highest professional level Avoid legal problems Add clip
art
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Medical Law and Ethics Knowledge of Medical Law and Ethics provides
insight into The rights, responsibilities, and concerns of
health-care consumers The legal and ethical issues facing society,
patients, and health-care professionals as the world changes The
impact of rising costs on the laws and ethics of health-care
delivery
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Medical Law and Ethics (cont.) Ethics is a standard of behavior.
Moral values serve as the basis for ethical conduct. Family,
culture, and society help form an individuals moral values. A law
is a rule of conduct or action. Governments enact laws to maintain
order and public safety. Criminal and civil laws pertain to
health-care practitioners.
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Medical Law and Ethics (cont.) Criminal law Crimes against the
state Criminal acts are Felonies or Misdemeanors Examples include:
Murder Arson Sexual Assault Burglary Civil law Crimes against the
person Includes a general category of laws known as torts Torts are
either: Intentional (willful) Unintentional (accidental)
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False imprisonment Assault Defamation of character Fraud Invasion
of privacy Open threat of bodily harm Interference with a persons
right to be left alone Damaging a persons reputation by making
false and malicious public statements An action that causes bodily
harm to another, including touching without permission Intentional,
unlawful restraint or confinement of a person Intentional Torts
Depriving or attempting to deprive a person of his or her rights
Battery
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Acts that are committed with no intent to cause harm but done with
a disregard for the consequences The term negligence is used to
describe such actions when health-care practitioners fail to
exercise ordinary care, resulting in patient injury Malpractice is
the negligent delivery of professional services Unintentional
Torts
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Contracts A contract is a voluntary agreement between two parties
in which specific promises are made for a consideration.
AgreementConsideration Contractual CapacityLegal Subject Matter
Four Elements of a Contract
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Types of Contracts Expressed contracts Clearly stated in written or
spoken words A payment contract is an example Implied contracts
Actions or conduct of the parties, rather than words, create the
contract A patient rolling up his or her sleeve to receive an
injection is an example
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Apply Your Knowledge What is the difference between law and ethics?
ANSWER: A law is a rule of conduct or action and is enacted by
governments to maintain order and public safety. Ethics is a
standard of behavior based on moral values that are influenced by
family, culture, and society.
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Patient-Physician Contract Physicians Do not have to treat every
patient Do not have to return patient to original state of health
Do not have to make a correct diagnosis in every case Do not have
to guarantee success of treatment or operation Patients May choose
their physician May terminate a physicians services American
Hospital Associations Patient Bill of Rights
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Patient-Physician Contract (cont.) Physician rights Set up a
practice within the boundaries of his or her license to practice
medicine Select where to set up an office and establish office
hours Specialize Decide which services to provide and how those
services will be provided Physician responsibilities Use due care,
skill, judgment, and diligence Keep knowledge up-to-date Perform to
the best of his or her ability Furnish complete information and
instructions to the patient
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Patient-Physician Contract (cont.) Patient responsibilities Follow
physicians instructions and cooperate with care Provide relevant
information to the physician Follow the physicians orders for
treatment Pay the fees charged for services provided
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Patient-Physician Contract (cont.) Consent Expressed gives verbal
permission Implied actions imply permission Informed Patient
receives all information necessary to make a decision regarding
treatment Liability Legal responsibility for actions Understand
scope of practice Understand standard of care and duty of care
Health-care personnel are all held to the reasonable person
standard
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Apply Your Knowledge ANSWER: Patient responsibilities are: Follow
physicians instructions and cooperate with care Provide relevant
information to the physician Follow the physicians orders for
treatment Pay the fees charged for services provided Patients have
rights and responsibilities relating to health care. The rights are
determined by the Patients Bill of Rights. What are the patients
responsibilities?
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Preventing Lawsuits Lawsuits Add to cost of health care Take a
psychological toll on all involved Prevention Use of reasonable
care to prevent professional liability
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Malpractice claims are lawsuits by a patient for errors in
diagnosis or treatment Negligence cases are those in which a person
believes a medical professionals actions, or lack thereof, caused
harm to the patient Malpractice Latin term which means The thing
speaks for itself.
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Examples of negligence Abandonment Delayed treatment Legal terms
used to classify negligence Malfeasance - unlawful act or
misconduct Misfeasance - lawful act done incorrectly Nonfeasance -
failure to perform an act that is ones required duty or that is
required by law Malpractice (cont.)
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uty Patients must show that a physician-patient relationship
existed. erelict Patients must show that the physician failed to
comply with the standards of the profession. irect Cause Patients
must show that any damages were a direct cause of a physicians
breach of duty. amages Patients must prove that they suffered
injury. Patients must be able to prove all 4 Ds in order to move
forward with a malpractice suit. The 4 Ds of Negligence
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Malpractice (cont.) Settling malpractice suits Arbitration People
with special knowledge in the field listen to the case and decide
the dispute Court Written court orders (subpoena) are delivered to
involved parties. Subpoena duces tecum is a court order to produce
documents such as patient records Civil law Concerned with an
individuals private rights Torts Negligence Breach of contract
Failure to adhere to a contracts terms
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Law of Agency Employees are considered to be agents of the
physician while performing professional tasks Physicians are
responsible or liable for the negligence of employees Respondeat
superior is a Latin term meaning Let the master answer Malpractice
(cont.) Employees are also legally responsible for their own
actions, and they can be sued directly.
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Malpractice (cont.) Reasons patients sue Unrealistic expectations
Poor rapport and poor communication Greed and our litigious society
Poor quality of care
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The 4 Cs of Malpractice Prevention aring Sincere caring decreases
the likelihood that a patient will sue if outcomes are
unsatisfactory or adverse events occur. ommunication Develop trust
and respect with patients by communicating professionally and
confirming that you have been understood. ompetence Maintain
competence and update knowledge and skills frequently. harting
Documentation is proof of competence. Chart every conversation and
interaction you have with a patient.
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Terminating Care of a Patient Reasons for terminating care of a
patient Refusal to follow physician instructions Patient family
member complaints Personality conflicts Failure to pay for services
rendered Repeated failure to keep appointments When withdrawing
from care, a physician must Provide written notification Reasons
for withdrawing Recommend that the patient find another physician
Send by certified mail with return receipt requested Document in
the patient record reasons for terminating care and actions taken
to inform the patient
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Apply legal concepts to practice by Maintaining confidentiality
Practicing within the scope of training and capabilities Preparing
and maintaining medical records Documenting accurately Using proper
guidelines when releasing information Standard of Care
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Apply legal concepts to practice by Following legal guidelines and
maintaining awareness of health-care legislation and regulations
Maintaining and disposing of regulated substances appropriately
Following risk-management and safety procedures Recognizing
professional credentialing criteria Standard of Care (cont.)
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Administrative Duties and the Law Duties related to legal
requirements Insurance billing Patient consent forms Documentation
in the medical record Making appointments Appointment books are a
legal document State reporting requirements Births Abuse Certain
diseases Injuries from violent acts Deaths Phone calls Maintain
privacy
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Documentation Clear and complete Referrals Missed appointments
Dismissals Patient contact Medical record correction Medical
records Property of facility or physician Retention and storage
Based on state law
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Controlled Substances and the Law Medical assistants must follow
the correct procedure for keeping and disposing of controlled
substances Be familiar with correct dosages, potential
complications, and refill rules Keep prescription pads secure
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Legal Documents and the Patient States the types of treatment the
patient does and does not want in an event of terminal illness,
unconsciousness, or comatose state. Patients with living wills are
asked to name someone that will make decisions on their behalf
(durable power of attorney) if they are unable to do so. Uniform
Donor Card A legal document that states a persons wish to donate
one or more organs or whole body. Living Will (Advance
Directive)
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Legal obligation to maintain confidentiality of patient information
Discuss with patient privately Share patient information only when
appropriate Do not discuss the case with anyone outside the medical
office Confidentiality Issues
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Apply Your Knowledge What are the 4 Cs of malpractice prevention?
ANSWER: The 4 Cs of malpractice prevention are caring,
communication, competence, and charting. Bravo!
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Federal Legislation Affecting Health Care Health Care Quality
Improvement Act (1986) Improved the quality of medical care
nationwide National Practitioner Data Bank Encourages peer review
Federal False Claims Act Qui tam To bring action for the king and
ones self Control three types of illegal conduct False billing
claims Kickbacks Self-referrals
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OSHA Regulations The Occupational Safety and Health Administration
(OSHA) is a division of the U.S. Department of Labor Regulations
describe precautions that must be taken to protect workers from
exposure to infectious diseases such as Human immunodeficiency
virus (HIV) Hepatitis B virus (HBV)
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OSHA requires that medical practices follow Universal Precautions
Hospitals are required to follow Standard Precautions, which is a
combination of Universal Precautions and body substance isolation
guidelines Both Universal Precautions and Standard Precautions were
developed by the Centers for Disease Control and Prevention (CDC)
OSHA Regulations (cont.)
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Protective Gear The law requires that the employer provide all
necessary protective clothing to employees free of charge.
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Decontamination All exposed work surfaces must be sprayed with a
10% bleach solution or other agent approved by the Environmental
Protection Agency (EPA) Sharp equipment To prevent exposure, sharps
are to be placed in a leak- proof, puncture-resistant, color-coded,
labeled container Exposure incidents Incidents are to be reported
immediately Current procedures may need to be modified OSHA
Regulations (cont.)
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Post-exposure procedures Employers must offer a free medical
evaluation to exposed employee Employers must also refer the
employee to a licensed health-care provider for blood sampling,
appropriate treatment, and counseling Employees may refuse
treatment by signing a waiver When a medical worker is first
employed, the employer must offer within 10 days the opportunity to
have the HBV vaccination at no cost OSHA Regulations (cont.)
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Laundry All laundry must be labeled and bagged appropriately
Hazardous materials Employers must keep an inventory of all
hazardous materials in the workplace (MSDS sheets) Training
requirements All employees that may be exposed must be given free,
annual training during work hours OSHA Regulations (cont.)
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General Regulations General work area laws restrict: Eating and
drinking Smoking Applying lip balm and cosmetics Handling contact
lenses Storing food or drinks in refrigerators used to store blood
or other potentially infectious materials Refrigerators must have
thermometers Required procedures for on-the-job injuries OSHA
Regulations (cont.)
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OSHA Regulations (cont.) Required documentation Intended to protect
health-care providers Exposure control plan Keep necessary records
as indicated OSHA inspections Done in response to complaints and at
random Non-compliance Fines Suspension of laboratory payments from
Medicare
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Apply Your Knowledge List 4 things that OSHAs general work area
laws restrict? ANSWER: General work area laws restrict: (list any
four of these) Eating and drinking Smoking Applying lip balm and
cosmetics Handling contact lenses Storing food or drinks in
refrigerators used to store blood or other potentially infectious
materials
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Quality Control and Assurance The Clinical Laboratory Improvement
Amendments of 1988 ( CLIA 88 ) Set standards for the quality of
work performed in a laboratory and the accuracy of test results
Medical office laboratories must comply with CLIA regulations and
have a quality assurance program Three categories of laboratory
tests Waived Moderate-complexity High-complexity
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Elements of the quality assurance (QA) program Written policies on
standards of patient care and professional behavior A quality
control (QC) program Training and continuing education programs
Instrument maintenance program Documentation requirements
Evaluation methods Quality Control and Assurance (cont.)
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Quality Control and Assurance (cont.) The laboratory QC program
must cover Patient preparation procedures Collection of specimens
Labeling Preserving and transporting specimens Test methods
Inconsistent results Use and maintenance of equipment Personnel
training Complaints and investigations Corrective actions
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What are the three categories of laboratory tests? Apply Your
Knowledge If a medical office performs laboratory procedures, what
two things must the office do? ANSWER: The office must comply with
CLIA regulations and have a quality assurance program. ANSWER: The
three categories are waived, moderate-complexity, and
high-complexity. Right!
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HIPAA Health Insurance Portability and Accountability Act (1996)
Improve efficiency and effectiveness of health-care delivery
Protect and enhance the rights of patients Access to health-care
information Control inappropriate use or disclosure Improve the
quality of health care by restoring trust in the health-care
system
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Title I: Health Care Portability Increases workers ability to get
health-care coverage when starting a new job Reduces workers
probability of losing existing health-care coverage Helps workers
maintain continuous health-care coverage when changing jobs Helps
workers purchase health insurance on their own if they lose
coverage under an employers group plan and have no other
health-care coverage available
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Title II: Prevention of Health Care Fraud and Abuse, Administrative
Simplification and Medical Liability Reform HIPAA privacy rules
Give patients more control over their health information Set
boundaries on the use and release of health-care records Establish
appropriate safeguards to protect the privacy of health information
Hold violators accountable if they violate patients privacy rights
Strike a balance when public responsibility supports disclosure of
some forms of data
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HIPAA (cont.) HIPAA allows the provider to use health-care
information for: ayment perations reatment Providers are allowed to
share information to provide care to patients. Providers are
allowed to share information to receive payment for the treatment
provided. Providers are allowed to share information to conduct
normal business activities, such as quality improvement.
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HIPAA (cont.) Protected health information (PHI) Uses Movement
within an organization Disclosure Transmitted between or among
organizations Managing and storing Sharing Patient notification
Notice of privacy practices Security measures HIPAA Security Rule
Computer networks The Internet Disks, other storage media, and
extranets Chart Reception area and clinical stations Fax, copier,
and printer
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HIPAA (cont.) Violations and penalties Civil Criminal For knowing,
wrongful misuse of health information Administrative simplification
Standardizing patient information Standardized codes
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Apply Your Knowledge While you are documenting on the computer, you
are called to a patient room for an emergency. What should you do
before leaving the computer? ANSWER: You should close the patient
record and log off the computer to protect the confidentiality of
patient information.
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Confidentiality Issues and Mandatory Disclosure Principles for
preventing improper release of information 1. When in doubt, do not
release information. 2. It is the patients right to keep patient
information confidential or disclose it. 3. All patients should be
treated with the same degree of confidentiality. 4. Be aware of all
applicable laws and of the regulations.
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Confidentiality Issues and Mandatory Disclosure (cont.) Principles
for preventing improper release of information 5. When necessary to
break confidentiality and when there is a conflict between ethics
and confidentiality: Discuss it with the patient. If the law does
not dictate what to do in the situation, the attending physician
should make the judgment based on the urgency of the situation and
any danger that might be posed to the patient or others. 6. Get
written approval from the patient before releasing
information.
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police officer enters the physicians office where you work and
requests information about a patient. May you release this
information? What should you do? Apply Your Knowledge ANSWER: No,
you should not be the person to release this information. You
should refer the officer to the patients physician, who will make
the judgment based on the urgency of the situation and any danger
that might be posed to the patient or others.
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Code of Ethics Principles of right and wrong Laws are based on
ethical considerations Medical professionals are expected to act
ethically Will have a positive effect On your reputation Employers
practice
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Code of Ethics (cont.) Bioethics Pertains to issues that arise due
to medical advances Principles of medical ethics have developed
over time dating back to Hippocrates A document called the Patients
Bill of Rights lists ethical principles that protect the
patient
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Apply Your Knowledge Mr. Jones would like to try a new treatment
for his Parkinsonism, but physician refuses to discuss a new
treatment with Mr. Jones because he morally disagrees with this
type of treatment. This is an example of what type of issue and
what should the physician do? ANSWER: This is an example of a
bioethical issue. The physician should refer the patient to another
physician who specializes in this treatment. Good Answer!
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Labor and Employment Laws Title VII of the Civil Rights Act of 1964
Law prevents employers from discriminating in hiring or firing or
firing on the basis of race, color, religion, sex, or national
origin Civil Rights Act of 1991 Provides monetary damages in cases
of intentional employment discrimination Sexual harassment The
victim has the responsibility to let the harasser know that the
conduct is offensive The victim should also report any instance of
sexual harassment to a supervisor or the personnel department
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Labor and Employment Laws (cont.) Age Discrimination in Employment
Act (ADEA) of 1967 Prohibits discrimination in hiring or firing
based on age for persons aged 40 or older 1976 Discrimination Act
Makes it illegal to fire an employee based on pregnancy,
childbirth, or related medical conditions
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Labor and Employment Laws (cont.) Titles I and V of the Americans
with Disabilities Act of 1990 Ban discrimination against disabled
persons in the workplace Mandate equal access for the disabled to
certain public facilities Require all commercial firms to make
existing facilities and grounds more accessible to the
disabled
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Labor and Employment Laws (cont.) 1938 Fair Labor Standards Act
Prohibits child labor and firing employees for exercising their
rights under the acts wage and hour standards Provides for overtime
pay and a minimum wage Equal Pay Act of 1963 Requires equal pay for
men and women doing equal work Family Leave Act of 1991 Allows
employees to take unpaid leave time for maternity, for adoption, or
for caring for ill family members
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Apply Your Knowledge What are your responsibilities if you feel you
have been a victim of sexual harassment? ANSWER: The victim has the
responsibility to let the harasser know that the conduct is
offensive and should also report any instance of sexual harassment
to a supervisor or the personnel department.
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Legal Medical Practice Models Be aware of laws governing the
practice model of your place of employment Four types of practice
models Sole proprietorship Single physician Partnership Two or more
physicians practice together Contract specifies rights,
obligations, and responsibilities
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Legal Medical Practice Models (cont.) (Types of practice models,
continued) Group practice Three or more licensed physicians
Physicians share the collective income, expenses, facilities,
equipment, records, and personnel for the practice Professional
corporation Corporation is a body formed and authorized by law to
act as a single entity Physicians who form corporations are
shareholders and employees of the organization Incorporators and
owners have limited liability in case lawsuits are filed
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Apply Your Knowledge What is the difference between a group
practice and a professional corporation? ANSWER: A group practice
is three or more physicians who share the practice income,
expenses, and facilities. In a professional corporation the
physicians are shareholders and employees of the corporation.
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In Summary To perform effectively as a medical assistant you must
follow All state, federal, and individual practice rules and laws
AAMA Code of Ethics for medical assistants OSHA safety regulations
for the medical office CLIA QC and QA guidelines HIPAA
guidelines
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Let no one come to you without leaving better and happier. Mother
Theresa