HCS Ch 11

The Ethics in Physician Referral Act of 1989

• Providers were referring pt to medical services in which they or family members had financial interest

Qui Tam Provisions

• Pt sues providers for fraudulent activity against the federal government

Due to ACA Antifraud Intitiatives

• More than 15,000 Medicare providers were expelled from the system for fraudulent activity

The Cost Conundrum 

Healthcare Cost Drivers

Overutilization/$$$

• Technology

Legal

• Defensive medicien

• Malpractice insurance

• Provider consolidation & antitrust issues

Administrative Costs

• Multiple payers with different coverages → Fragmentation

• Facility costs

Labor

Carrots & Sticks

• Incentives

  • Provider bonus

  • Provider discount

• Penalties

  • Withhold payment

  • Inc premiums

Law

• Body of rules for the conduct of individuals & organizations 

• Often interpreted & may change over time 

• Created so there is a minimal standard of action required 

Federal Laws

State laws

Local government laws

Common law

• When judiciary system interprets previous legal decisions regarding a case 

Statutes

• Laws created by legislature

Rules & Regulations

• Created from interpretation from both common law & statutes by administrative agencies

Civil Law

• Focuses on the wrongful acts against individuals & organizations based on contractual violations

Torts

• Category of wrongful acts, in civil law, which may not have a preexisting contract

Criminal Law

• Actions that are illegal based on court decisions

  • Must prove without a reasonable doubt of guilt

  • Criminal law infractions: Medicare & Medicaid fraud