Financial Laws and Regulation in Health Industry - Assignment Example

Financial Laws and Regulation in Health Industry Question 1 The five elements pertaining to the establishing a false claim under the False Claims Act must determine that the claim was falsely submitted and that it was submitted knowingly. The government must establish that the individual submits the claim with actual knowledge, in deliberate ignorance, or recklessly disregarding for the claim’s falsity or truth, the claim was against the United States or a department (Boese, 2010). The prosecution must prove beyond reasonable doubt that a claim for property or money is made. Also, it must be established whether the claim was false, fictitious or fraudulent. Another element that must be proven beyond a reasonable doubt so as to secure a conviction is that the false, fictitious or fraudulent claim was material (Salcido, 2009). When the United States government provides any portion of money or property that is required or demanded, or the state decides to reimburse a contractor, grantee or recipient the requested or demanded money, false claim documents do not need to be submitted directly to the government as the provision virtually covers everything that is of value. Finally, the false claim is also founded on the element an individual has possession, custody, or control of a property or money used by the government, and lastly, intending to defraud the government. Question 2 Defines and limits the circumstances under which entities utilize and disclose the Protected Health Information (PHI) Everyone in the health care sector must maintain the privacy of personal information, especially when it comes to sensitive health care information in electronic from. According to Shauren and Levsey (2001) argue that the HIPAA privacy standards do not permit the covered entities from using or disclosing individually identifiable health information that has been transmitted or maintained electronically. However, this requirement is not only limited to the record in which the information is appearing but also applies to the actual information itself. As a consequence, any information that has been transmitted by computer, fax, telephone or electronic hand held device is actually protected by the HIPAA Standards. Establishing certain individual rights regarding the PHI The privacy standards state that any individual has rights over the health information. The rights are as named below: the right to amend the PHI, the right to inspect and copy the PHI, the right to request restrictions on particular uses and disclosures PHI, and the right to receive an accounting of the disclosures of their PHI. The consequences of non compliance are that the penalties of both the organization and the individual responsible for the breach are substantial. The civil penalties are determined on a tier structure based on the level of severity and intent of the violations. Require the covered entities to adopt the administrative safeguards to protect the confidentiality and privacy of PHI Among the needed administrative safeguards are the establishment of a compliant system, designation of a privacy officer, implementation of a compliance training programs for all applicable staff, and the implementation of appropriate sanctions for violations of the privacy requirements (Latham & Watkins, 2001). This is to ensure that the covered entities must comply with the security standards with respect to e-PHI. The compliance requires that the covered entity must ensure integrity, confidentiality, and availability of all e-PHI covered entities creates, receives, maintains, protect against any reasonably anticipated threats to the security or integrity of such information. Question 3 According to Pratt (2000: 383) argue that Stark law, also known as ‘the physician referral law’ prohibits a physician from making referrals for particular designated health services (DHS) payable by the Medicare to an entity with which he or she has a financial relationship (investment, ownership, or compensation), unless an exception applies. They include: 1. Clinical laboratory services 2. Physical-therapy services 3. Occupational-therapy services 4. Radiology and other diagnostic services (excluding screening mammography). 5. Radiation-therapy services and supplies 6. Durable medical equipment and supplies 7. Enteral and parenteral nutrients, equipment and supplies. 8. Prosthetics, orthotics, and prosthetic devices; 9. Home health services and supplies 10. Outpatient prescription drugs 11. Inpatient and outpatient hospital services. Question4 Qui tam The name Qui tam is the shortened version of an oft abbreviated in Latin phrase. It roughly means, “He who prosecutes for himself as well as the king.” (Doyle, 2009). Qui tam is a provision in the False Claim Act that allows individuals who are affiliated with the government file actions on the behalf of the government. The persons who are filling under the Act stand to receive a portion of approximately 15-25 percent of any recovered damages. This is attributed to the fact that the person who prosecutes in the name of the government also shares in the proceeds of any successful litigation or settlement. Although Qui tam is frequently punitive, it is generally a civil procedure. It therefore enlists the public in the recovery of civil penalties and forfeitures. Being a creature of antiquity, once common, today qui tam lives on in the federal law in the False Claims Act and in two minor examples found in patent and Indian protection laws. Moreover, the federal qui tam statutes have actually survived two types constitutional challenges, those based on the doctrine of separation of powers and those based on rights of defendants in criminal cases. The courts have gone ahead and found the rights required in criminal cases inapplicable because qui tam’s actions are civil matters. HIPPA Privacy Rule The privacy rule standards addresses the issue of disclosure and use of individual’s health information referred to as ‘protected health information’ (PHI) by the organizations subject to the privacy rule known as ‘covered entities’, as well as standards for individuals standards for individual’s privacy rights to comprehend and control how their health information is utilized. The core objective of the privacy rule is to ensure that the individual’s health information is properly protected while permitting the flow of health information required to provide and promote high quality health care and to protect the well being and health of the public. In that sense, the rule strikes a balance that allows important uses of information while protecting the privacy of the individuals who seek care and healing. Given the recent diverse nature of health care market place, the Rule is designed to be flexible and comprehensive to cover an array of uses and disclosures that need to be addressed (Chaput, 2010) Emergency Medical Treatment and Active Labor Act (EMTALA) EMTALA is a US Act of Congress passed in 1986 as part of Consolidated Omnibus Budget Reconciliation Act (COBRA). It stipulates that hospitals must provide care to anyone requiring emergency healthcare treatment regardless of the citizenship, the ability to pay or legal status. There are no provisions for reimbursement. On the contrary, the cost of emergency care required by EMTALA is not directly covered by the government. The participating hospitals may only transfer or discharge the patients requiring emergency treatment under their own informed consent, after stabilization, or when their conditions needs transfer to a hospital that is better equipped to administer the treatment. EMTALA applies to almost all hospitals in the US with the exception of the Indian Health Services hospitals, Shriners Hospital for Children, and Veteran Affairs hospitals. EMTALA has impacted on the US’s health care sector by improving the health services of the uninsured. However, it has brought cost pressures on hospitals because the emergency care sometimes goes uncompensated. This result in inflated medical bills to those who can pay because as the medical bills go up, health care providers shift the costs to those who can pay or it goes uncompensated. Compliance programs These are systematic procedures that are instituted by an organization to ensure that the provisions of the regulations imposed by any government agency are being met. Health care providers in all settings implement the compliance programs so as to ensure ethical business practices in accordance with compliance program from the DHS Office of the Inspector General (OIG). This is necessary due to the increased severity of penalties established by HIPAA. For example the federal government monitoring activities include: comprehensive error rate testing (CERT) program and the IOG. Therefore, by ensuring ethical business practices through the compliance programs, providers of health care reduce the risk of civil and criminal litigation. Reference List Boese, J. T. (2010). Civil False Claims and Qui Tam Actions. New York: Cengage Learning. Chaput, B. (2010, February). Retrieved May 6, 2013, from What are the objectives of the HIPAA Privacy and Security Rules: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/ Doyle, C. (2009). Qui Tam: An abbreviated Look at the False Claim Act and Related Federal Statutes. New York: Congressional Research Service. Latham, & Watkins. (2001). HIPAA privacy standards raise complex implementation issues. Health Finance Manager , 55 (1), 42-47. Pratt, S. (2000). The Lawyer's Business Valuation Handbook:Understanding Financial Statements, Appraisal Reports, and Expert Testimony. Chicago: American Bar Association. Salcido, R. (2009). False Claim Act. New York: Sage. Shauren, A. W., & Levsey, K. (2001). Complying with Health Insurance Portability Act Privacy Standards. Finance Mnager , 49 (11), 501-507. Read More