Chapter 21: Ethical/Legal Issues

ACCREDITATION, LICENSURE, AND CREDENTIALING

Licensure

To become a licensed physician in the United States, you must:

• Successfully complete a required course of education in a school that is licensed and accredited.

• Pass a standardized examination (USMLE for MD or DO, COMPLEX for DO).

• Obtain at least one state’s permission to practice.

To become a board-certified emergency physician (EP), you must also:

• Complete a required course of training in an accredited postgraduate emergency medicine residency program approved by the Accreditation Council for Graduate Medical Education (ACGME).

• Pass a qualifying examination and an oral certification examination as specified by the American Board of Emergency Medicine (ABEM) or American Osteopathic Board of Emergency Medicine (AOBEM).

State medical practice statutes vest authority in state medical boards to control access to licensure and regulate the profession. Courts usually cannot be persuaded to intervene unless the physician has exhausted administrative remedies. Unlike in the podiatric, chiropractic, dental, or other professions, medical licenses are unrestricted. Any licensed physician can perform neurosurgery or practice emergency medicine—if they can convince a hospital to allow it.

Grounds for denial of license and basis for revocation, sanction, and discipline of established license holders include:

• Fraudulent application statements

• Conviction of a felony

• Suspension or reduction of hospital privileges

• Unprofessional or immoral conduct

State boards of medicine discipline 2%-3% of physicians.

Credentialing

Hospital credentialing is specific to each institution. A committee of physicians and administrators grants an approved list of activities and procedures based on education, training, and experience. Hospitals may accept ABEM certification as a sufficient indicator of competence, but that may not always be the case. State boards, insurers, regulatory agencies, and others organizations may use denial and revocation of credentials as a basis for adverse action on payment, participation, and licensing.

COMPLIANCE AND CONFIDENTIALITY

In health law, compliance refers to conformity with rules, especially federal medical billing rules and patient confidentiality laws.

Billing

Billing for services requires both the CPT® (Current Procedural Terminology) and International Classification of Diseases (ICD) codes. One way to look at the two is that the CPT is what you did and the ICD is why you did it.

Current Procedural Terminology

• Forms the basis of Evaluation and Management (E&M) codes

• Consists of five levels of E&M codes plus the critical care code

• Owned and ...