Ethics, Boundaries, HIPAA & Confidentiality, and Fraud and Abuse

Ethics, Boundaries, HIPAA & Confidentiality, and Fraud and Abuse Ethical Principles and Practices A New Employee Orientation (NEO) and new CPSA staff Required Training Self-Study Module - June 2012

Module Objectives Upon completion of this module, you will be able to: • Consider ethics in decision-making • Understand boundaries and boundary violations • Know your role and responsibilities regarding HIPAA and client confidentiality • Recognize fraud and abuse and identify courses of action

Module Overview In this module, you will learn about Ethics, Boundaries, HIPAA & Confidentiality, and Fraud and Abuse. Since each of these topics includes important information, each is a section in this module. This module is an introduction to important topics that will affect your work each day… topics which should be discussed with your supervisor on an on-going basis. Let’s begin with Ethics…

Ethics

Understanding Ethics What are Ethics? • A set of principles of right conduct • A theory or a system of moral values • The rules or standards governing the conduct • of a person or the conduct of the members of • a profession (i.e., behavioral health) Merriam-Webster Dictionary: ethics: the discipline dealing with what is good and bad and with moral duty and obligation

Understanding Ethics Why do you need to complete training on Ethics? As behavioral health professionals, we must make every effort to always act in the best interest of the individuals we serve. The concepts of “Do no harm” and “Put the client’s best interest first” form the ethical basis of our work. At times, you most likely will encounter ethical situations that are challenging. If you find yourself hesitating, doubting or questioning a potential course of action, it may be an ethical situation! Consulting your supervisor when questions and issues arise can help you determine your best response or course of action.

Understanding Ethics • Organizational missions/values and Codes of Conduct usually guide professional behavior • Across agencies, ethics and values may vary slightly • Not all behavioral health workers may belong to a professional discipline with a Code of Ethics, but all agencies have a Code of Ethics which guides staff behavior. This Code of Ethics usually appears in the agency Policy and Procedures Manual. Ethical behavior is part of our profession’s - and your agency’s - mission and values… Be sure you know your agency’s requirements and expectations regarding your professional and ethical behavior!

Code of Ethics Most behavioral health professions (social workers, psychologists, certified substance abuse counselors, and others) have a Code of Ethics that defines appropriate behavior. • Though the Codes may vary for • different professional disciplines, • each supports doing no harm, and always acting in the client or individual’s best interest. Consider the code of ethics pertaining to your area of professional expertise, as well as your agency’s code of ethics/conduct when dealing with client contact, services and issues.

Ethics, Laws & Morals Ethics are distinct from, but closely tied to laws and morals…. Laws dictate what is legal; they are established by the government to protect the citizens, and are enforced by police and the courts. Morals are concerned with the judgment of human character; typically, morals have to do with the right conduct of people, and are often determined by societal norms. How do Ethics, Laws & Morals work together?...

Ethics, Laws & Morals Ethics are everywhere. Consider the following topics you’ve likely read or heard about in the news… • Capital Punishment • Death with Dignity (assisted suicide) • Right to Choose (abortion) • Stem Cell Research Some decisions or actions associated with these topics may be legal, yet a person may question or debate the ethical or moral correctness of these issues. We will encounter ethical situations in our work. Let’s find out our role when these occur…

Evolving Ethics Knowing your agency’s Code of Ethics is vital, but your relationship with ethics doesn’t stop there. It’s important to realize that ethics are constantly evolving. Considering the changes in the delivery of behavioral health services illustrates this. In the past, individuals receiving services were usually restrained, committed to hospitals against their will, forcibly medicated, and often had little or no say in the services/treatments they were subjected to. Today, we strive to include the individual in decision-making and service planning. Clinical teams include the individual and use natural supports to ensure services are the most appropriate and effective. The ethics of our profession dictate this client involvement and a focus on client rights and empowerment. It is also important to keep in mind that culture will have an impact on people’s/clients ethics and their views of correct/acceptable behaviors.

Applying Ethics What can you do when an ethical dilemma arises? • Stop… take no further action; step back from the situation • Gather all the facts regarding the issue/situation • Consider the impact (on the client, you, your agency) of your possible courses of action • Talk with your supervisor • Discuss with the clinical team, if indicated • Review your agency’s Code of Ethics and consider what company values and ethical principles are relevant When you find yourself in doubt, hesitating, or questioning yourself about how to proceed - you are probably faced with an ethical situation. Generally, before you proceed you should: There is a mnemonic device that can help you to remember this course of action…

Applying Ethics A mnemonic device that may be helpful with approaching ethical dilemmas… Evaluate your facts for accuracy Think about all possible courses of action Handle your decision as if it was going public Identify potential consequences of your decision Consider if your decision is setting a precedent Stop if you are in doubt - ask for direction Now, let’s move on to a related topic…

Boundaries

Exploring Boundaries What are boundaries? Boundaries are the invisible limits between professionals and the individuals we serve that protect the people we serve from exploitation or harm, and help protect us from physical, emotional, or legal ramifications. Boundaries: • allow for a safe, trusting, clinically-focused connection and relationship to exist between behavioral health workers and clients; • protect the space between the professional’s position of power and the client’s vulnerability. Establishing and maintaining clinically appropriate boundaries is one of the most important ethical foundations in our profession!

Boundaries: Who’s Responsible? Boundaries do not automatically occur - they must be established and maintained…. • It is our responsibility as behavioral health workers to establish and maintain boundaries - it is notthe responsibility of the individuals we serve to do either of these. • Once we discuss and establish boundaries with clients, we must help maintain these boundaries by regularly reminding clients about them and reinforcing these boundaries through our words and actions. Considerations for establishing boundaries…

Establishing Boundaries Boundaries should be discussed/established at the outset of the clinical partnership or relationship (and reinforced throughout the course of services)… Talk to your client about : • roles, responsibilities and expectations - for you and for them • what the clinical/professional relationship is and isn’t - how it differs from casual or personal relationships • appropriate and inappropriate behaviors and limits to services and your availability Note: Establishing boundaries with co-workers is also vital. Understanding the role of boundaries in these professional relationships may be difficult - this may be a topic to discuss with your supervisor.

Boundaries & Dual Relationships A dual relationship occurs when in addition to the professional relationship with the client - or former client - another relationship exists. This additional relationship may involve the client as a friend, partner, student, family member, or business partner. Dual relationship examples include: • Seeing the client outside the clinical setting/parameters - attending social events together, establishing a friendship, tutoring, dating. • Any business arrangement - buying from or selling to the client any item; having a client work on your house or car; having a client babysit your kids; getting a massage from a client. • Gift giving or receiving; doing favors for the client (outside of clinical actions) or having them do favors for you. • If you over self-disclose, and the client is ‘counseling’ you. Dual relationships may be confusing, harmful, or exploitive for the client. They should always be avoided, with current and former clients! If you have questions or concerns… seek supervision!

Crossing a Boundary Line Most behavioral health workers do not purposely cross boundaries or practice inappropriate behaviors. Boundaries often get crossed unintentionally - and the result is often seen by a change in behaviors (yours and/or the member’s) or changes in the clinical relationship: > late to or missed appointments > less client openness/honesty > reduced focus in clinical issues > reduced communication > a reduction/halt to clinical progress >change in attitude - yours or theirs > discomfort - yours or theirs • If you believe a boundary (yours or theirs) has been crossed… • discuss your concerns with the client (unless doing so would cause additional problems) • discuss the situation with your supervisor right away

Boundaries and Work Roles Establishing and maintaining boundaries in behavioral health used to be much simpler. Oftentimes, the client worked with one, or maybe two behavioral health staff when planning and receiving services, and there were clear lines/boundaries between these well-defined roles. In today’s behavioral health, in promoting the recovery model, clients find they often have several individuals and entities that make up their clinical team and provide services. Many roles/positions, including Support Specialists, may interact with clients in various settings - some of these non-therapeutic. All behavioral health staff, regardless of position or role, must be constantly aware of boundaries, always maintaining appropriate, ethical behavior and boundaries, even in casual settings.

Results of ‘Crossing the Line’ • FOR YOU / YOUR AGENCY: • you or your agency could be sued • you may lose your job • loss of your professional license / your agency could be sanctioned; you may ruin your/your agency’s professional image and reputation • FOR THE INDIVIDUAL SERVED: • damage to theirphysical, emotional, or mental well-being • leaving services or the discontinuation of services • client may not want to access behavioral health services in the future Let’s look at a couple of scenarios about ethics and boundaries…

Scenario 1 In a casual conversation at work, one of your colleagues tells you that she ran into the father of a former child client. Although the child is no longer a client with your agency, she is still receiving services from another system provider. Your colleague goes on to tell you that she had always thought the father was attractive and as the two of them were talking recently she decided to ask him out for coffee. Your friend tells you she has a date with him this weekend. What ethical topic does this involve? What do you do? Click on this box for answers

Scenario 1 - Discussion What Ethical topic does this address? The issue deals with Boundaries and Dual Relationships. What do you do? The legal issue - There could be a stipulation against relationships with former clients in your agency’s code of conduct. There may also be a statute of limitations (how long a client must be gone from the agency before establishing a relationship). If none of these apply then there is no legal issue. The ethical and moral issue- The relationship with the daughter was established within a power-differential dynamic, so it is not advisable and probably not ethical for your co-worker to pursue a relationship with the father. You should advise your co-worker of these ethical issues; discuss this situation with your supervisor.

Scenario 2 When you first meet Cordell, you think he seems familiar, but it’s not until later that you realize you are providing services to your neighbor’s 17 year-old son. You typically have dinner with his mother once a month at a home owners’ association picnic. You sometimes talk about your work at these picnics, but you don’t ever use names… do you continue working with Cordell? What ethical topic does this involve? What do you do? Click on this box for answers

Scenario 2 - Discussion What Ethical topic does this address? The issue deals with Boundaries and Dual Relationships. What do you do? The legal issue - There are no legal issues involved. The ethical and moral issue-This is a classic example of a dual relationship (since the client is the son of a friend you have regular contact with). You should discuss the situation with your supervisor and explain to Cordell that you must transfer his case to another behavioral health worker. Next, we’ll examine confidentiality and privacy…

HIPAA, Privacy and Confidentiality

Understanding Confidentiality • Confidentiality is our professional responsibility to protect the privacy and personal information of the individuals we serve. • Maintaining confidentiality is part of being ethical and setting good boundaries. • Laws, including HIPAA (Health Insurance Portability and Accountability Act), protect privacy and highlight the legal importance of confidentiality. In our profession, we often need to share information with others about the individuals we serve. In order to do so legally and ethically, an Authorization of Release of Information form must be signed by the client, and maintained in their clinical record.

Limits of Confidentiality Keeping client confidentiality does have limits (sometimes called ‘exceptions’) that often center around safety issues. The following situations would allow us/mandate us to break confidentiality: • Client is a danger to themselves • Client is a danger to others (in this case we are also obligated to warn that person or persons about this danger - called “Duty to Warn”) • Abuse, neglect or exploitation of children or dependent adults - you are a ‘mandated reporter’ of these situations • A client-signed Release of Information • Certain medical emergencies or legal proceedings Get direction from your supervisor before breaking client confidentiality!

HIPAA • The Health Insurance Portability and Accountability Act of 1996 is a federal law that protects personal protected health information (PHI) held by covered entities (i.e. your agency). • Gives patients the right to examine their information and clinical/health records. • The ‘Privacy Rule’ regulates how covered entities use and disclose individually identifiable health information (PHI). • The ‘Security Rule’ establishes a national set of security standards for protecting certain health information that is held or transferred in electronic form. A little more on PHI…

Protected Health Information (PHI) PHI: Individually identifiable health information that is transmitted or maintained in any form or medium by a health care / mental health care entity. Examples of PHI: • client name, DOB, address, SSN, photo, etc. • a list of medications taken by a specified individual • a list of names of individuals diagnosed with ADHD in the past year by a specific provider • use of real service documentation (even with name deleted) in training that includes specific details about an individual where he/she could be identified due to her unique challenges and situation PHI must be protected - not shared - at all times (unless a safety issue is present or authorized by client to share)

Disclosure & Confidentiality Disclosure is the release, transfer or provision of access to PHI to parties outside the entity holding the information. The Minimum Necessary Standarddirects that we disclose (with client permission/authorization) only the minimum information necessary to accomplish an intended communication of information. • When disclosing information, ask yourself: • “Does this person need to know what I am telling him/her?” • “Is there an appropriate Release of Information form in the chart/file regarding release of this information to this recipient?” Disclosure must only occur when the recipient has some direct bearing on the individual case. For instance, disclosure to the individual’s Vocational Rehabilitation Counselor may be appropriate; disclosure to a Case Aide not involved may not be.

More on Confidentiality Persons with substance use and/or HIV positive status are protected by additional laws and documentation guidelines… Information on substance use and HIV status is highly confidential due to its nature. This information can only be released with specific written authorization from the individual identifying these two areas. Consult your supervisor before releasing any information regarding substance use or HIV / AIDS status.

Maintaining Confidentiality Specific practices ensure confidentiality is maintained in all communication forms. These include the following recommendations and requirements: • Electronic Communication: • Encrypt confidential emails, especially those containing any client PHI - find out how this is done at your agency! • Use password protection on your computer - do not share your password! • Don’t store PHI on shared drives, removable drives or portable devices which can be stolen or misplaced. • Lock your computer/workstation when not in use - even if you step away from your computer only for a minute! • Find out your agency’s email and faxing security rules and regulations.

Maintaining Confidentiality (cont.) • Verbal Communication: • Don’t listen to messages or make phone calls on speaker phone if others may hear - always be aware of your immediate surroundings when talking about clients, on the phone or otherwise. • Avoid talking about individual client issues or sensitive matters on cell phones or in public places - even if you don’t use the client’s name, you may still talk about issues/situations that make them identifiable. • When answering calls from outside your agency, and you don’t know the caller, do not divulge whether a person is a client at your agency. • Always be aware that whenever you speak in your office, your building or out in public, what you say may be overheard. • Be cautious when sharing information over the phone - make sure you know the identity of the person you are speaking with and make sure an appropriate Release of Information is in the file/clinical record.

Maintaining Confidentiality (cont.) • Written Communication: • Secure records in secure/locked cabinets or rooms. • Be cautious when using or transporting files; turn files/client information over on your desk if someone approaches; lock files in your desk if stepping away from your desk, even momentarily. • Written materials/records should never be taken out of the building unless under special circumstances - check your agency policy. • Don’t leave documents on fax machines, copiers, or in any public spaces - retrieve items immediately. • Shred or properly dispose of unnecessary documents - this includes all written information (post-it notes, messages, fax cover sheets, etc.).

Impact of Violations • HIPAA violations can be civil (unknowingly/unintentional violation) and criminal (knowingly/intentional violation) in nature - both could result in substantial fines and/or prison terms. • Privacy violations can lead to damaging a member’s reputation, cause stigma around a particular issue and lead the member to lose trust in you, your agency and the Behavioral Health System. • Violations of confidentiality can also cause damage to the member’s emotional and/or physical well-being which may delay their recovery process. Let’s consider a couple more scenarios…

Scenario 3 You are attending an interagency training meeting with several people from partner agencies. One of the staff at your agency is in charge of a training session during the meeting. She is passing out a detailed service plan that she says she created to use for this training. She begins to go through the service plan discussing the medications which the “client” is taking. As she continues to talk you recognize that this is an actual client that you used to see when you worked at another agency. A couple of staff members from that agency are also in the meeting. What ethical topic does this involve? What do you do? Click on this box for answers

Scenario 3 - Discussion What Ethical topic does this address? The issue deals with Confidentiality - specifically HIPAA and PHI What do you do? The legal issue - There is an issue with breaking HIPAA laws regarding Protected Health Information. The ethical and moral issue- Along with being a legal issue, it is ethically inappropriate to breach client confidentiality and privacy by disclosing PHI, even when not divulging the client’s name. You should take the training person aside and explain to her how she has just violated HIPAA laws - even though it was unintentional. Review this situation with your supervisor.

Scenario 4 You work at an agency that provides therapy. You and another employee are in the company break room when you overhear two therapists discussing a client’s marital issues. Your co-worker tells you that from what she is hearing she knows who the client is and that she plays softball with the client’s partner. What ethical topic does this involve? What do you do? Click on this box for answers

Scenario 4 - Discussion What Ethical topic does this address? The issue deals with Confidentiality What do you do? The legal issue - There is not a legal issue involved in this scenario. The ethical and moral issue- The therapists are breaching confidentiality. You should approach the therapists and let them know you can identify the client they are referring to - they are breaking confidentiality. You should discuss this event with your supervisor. On to our last topic, Fraud and Abuse…

Fraud and Abuse

Fraud and Abuse: Introduction Monitoring and minimizing fraud and abuse is a vital component of being ethical in this profession… • Fraud and abuse can adversely affect the ability of an organization to effectively provide services. • Fraud and abuse can result in an organization being sanctioned and fined into the tens or hundreds of thousands of dollars. As an employee of an entity receiving public funds (government money) you are mandated to report fraud or abuse - whether it is known, or even suspected.

Fraud and Abuse: Definitions What is fraud? Fraud is an act of intentional deception or misrepresentation made by a person with knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. This includes any act that constitutes Fraud under applicable Federal or State law.

Applicable Laws & Regulations • 31 USC § 3729- 3733 False Claims Act • A.R.S. 13-2311 Fraudulent Schemes and Practices • A.R.S. 36-2918 Medicaid False Statements • A.R.S. 36-2918.01 Duty to Report Fraud and Abuse • A.A.C. R9-22-101 Civil Monetary Penalties & Assessments

Fraud and Abuse: Definitions What is abuse? Abuse includes (sometimes unintentional) activities that are inconsistent with standard fiscal business or medical practices that result in unnecessary costs to AHCCCS, ADHS/DBHS and/or your agency. Note:Individuals receiving services can also commit acts of abuse (for example, loaning or selling an AHCCCS identification card).

Fraud and Abuse - Penalties Regardless of whether an action is intentional or unintentional fraud or abuse, there are legal consequences - often involving fines, sanctions, restitution and possible incarceration… If convicted of fraud, a person is usually charged with a criminal offense. If convicted of abuse, a person is usually charged with a civil offense.

Types of Fraud and Abuse • Financial misconduct • Fraudulent reporting of services • Billing for services not rendered • Billing for unnecessary services • Billing for a higher level of service than was performed • Misrepresentation of credentials • Falsification of records • Waste and wasteful practices are now being looked at as forms of abuse.

Examples of Fraud and Abuse • Examples: • A staff member reports visiting a member’s house for one hour, but was only there for 30 minutes • A staff member encounters for therapy, but doesn’t meet the billing qualifications • A staff member writes inaccurate information in the chart • A staff member submits encounters/claims for services that are not a medical necessity • Personal purchases on the company credit card • Theft of inventory items • Theft of cash from deposits • Falsifying time card with time not worked • Using company vehicle for personal use • Using company phone for personal long-distance calls

F & A: Your Responsibility If you know of or suspect fraud or abuse, it is your responsibility to contact: • your supervisor • OR your supervisor’s supervisor • OR your agency Compliance Officer • OR Human Resources at your agency If outside or additional assistance is needed, contact: CPSA Fraud and Abuse Hotline: 520-318-6964 ADHS/DBHS Compliance Officer: 866-569-4927 AHCCCS Office of Program Integrity: 602-417-4045 * Calls can be made anonymously* Let’s look at a couple final scenarios…

Scenario 5 As a new employee, you are assigned to shadow Vera, a highly respected clinician at your agency. Vera tells you about how important billing units and correct billing codes are, and you observe her documentation. You notice a pattern that she documents sessions for at least 1 hour, and sometimes even longer, when she rarely spends even half that time in the session. Is Vera committing fraud or abuse? What, if anything, should you do? Click on this box for answers

Ethics, Boundaries, HIPAA & Confidentiality, and Fraud and Abuse