Module 3: Healthcare Consumer, Fraud, and Antitrust Legislation

Hill-Burton Act of 1946 (Hospital Survey and Construction Act)

Provided federal grants to fund hospital construction and modernization in exchange for hospitals providing a community service requirement of uncompensated care to low-income individuals.

Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986

An anti-patient-dumping statute under COBRA § 9121 requiring Medicare-participating hospitals with emergency departments to screen, stabilize, and treat emergency conditions or active labor regardless of insurance status or ability to pay, enforced by fines up to $50,000 per violation.

Children’s Health Insurance Program (CHIP)

Enacted under Title XXI of the Balanced Budget Act of 1997, CHIP provides federal matching funds to states to furnish health insurance coverage to children in families whose income exceeds standard Medicaid thresholds but who cannot afford commercial insurance.

False Claims Act (FCA) & Qui Tam Provisions

Originally enacted during the Civil War as the "Lincoln Law," the FCA penalizes individuals and contractors defrauding federal programs. Its qui tam provisions allow private whistleblowers to sue on behalf of the government and receive 15% to 25% of recovered proceeds.

Ethics in Patient Referral Act of 1989 (Stark Law)

Prohibits physicians from referring Medicare or Medicaid patients for designated health services (such as clinical laboratory, imaging/MRI, or physical therapy) to entities with which the clinician or an immediate family member has a financial interest.

HIPAA & HITECH Act of 2009

HIPAA (1996) created national standards via the Privacy Rule (protecting individually identifiable health information) and the Security Rule (safeguarding electronic protected health information).

The HITECH Act (2009)

increased penalties, extended compliance to business associates, and mandated breach notification within 60 days.

Antitrust Laws in Healthcare (Sherman, Clayton, Hart-Scott-Rodino)

Administered by the DOJ and FTC to ensure market competition.

The Sherman Act (1890)

bans monopolies, price fixing, market division, boycotts, and tying.

The Clayton Act (1914)

halts anticompetitive mergers.

Hart-Scott-Rodino Act (1976)

mandates pre-merger notification and review for hospital combinations exceeding specific asset thresholds