The health care is the subject of a number of federal laws, regulations, directives, interpreting information and the model guidance. There is a considerable number of laws and regulations that affect the delivery of health care. The legislation of the legislative that has been signed into law. The legislation directs any person to take steps to support the authority in certain situations, or refrain from doing so. Statutes are not self-enforcing. Someone should be allowed to do in order to take action. The law may authorize the Department of Health and Human Services to take action, and it is up to the department to implement the law. Regulations or rules made administrative personnel who legislators delegated these tasks. It is a tool for developing policies, procedures and practice routines that tracks the expectations of the regulatory and organizational units. subject to judicial interpretation of laws and regulatory requirements.
A very important component of health care management to understand the key regulatory environment. A government regulations affecting the patient's health care Anti-Kickback Statute. The Medicare and Medicaid patients Protection Act of 1987 (the "Anti-Kickback Statute"), was adopted to prevent improper utilization of the health service referrals. The government in respect of any incentive for potential violation of a referral to the law because of the opportunity to reap the financial benefits to entice, to provide referrals that are medically unnecessary and thus increase health costs and potentially putting patients & # 39; and the health risk. The Anti-Kickback Statute is a penal code. Originally adopted almost 30 years ago, the law prohibits the intentional or initiate requests or adopt any type of remuneration to induce referrals to health services that are reimbursed by the federal government. For example, a service provider does not routinely waive the patient & # 39; s visit fee is not deductible. The government sees this as an incentive to the patient to choose the service provider does not benefit health reasons. Although these prohibitions initially limited to services reimbursed by Medicare or Medicaid programs, new legislation has expanded the law & # 39; and it reaches that each federal health program. Since the Anti-Kickback Statute is a penal code, a violation constitute crimes, criminal penalties up to $ 25,000 fine and five years in prison. Routinely waiving copayments and deductibles will result in violation of the law and the usual penalty. However, a safe haven has been created where the provider name as canceled on the basis of the patient & # 39; s financial needs are not penalized. The 1996 enactment of the Health Insurance Portability and Accountability Act (HIPAA) has a level of complexity that the Anti-Kickback Statute and the accompanying safe harbors. HIPAA mandated to give the OIG (Office of Inspector General) providers seeking advisory opinions that either an agreement or a planning agreement which does not correspond precisely to the law. The award, the OIG would analyze the layout and determine whether it could violate the law, and that the OIG would be the layout of sanctions. Many advisory opinions published in recent years, the OIG said it would not be sanctioned, although it found that the agreement in question violate the law. The most common reasons given to the OIG that no sanctions was that the entire layout of benefit to the community. Healthcare professionals need financial ensure that all business transactions comply with the Anti-Kickback statute.
The Anti-kickback laws affect the patient. The main objective of this legislation is intended to improve patient safety, make amends and avoid risk. The result of the acquisition doctor & # 39; s practice is intended to interfere with the physician & # 39; s subsequent judgment, what is the best treatment for the patient. It also interferes with the recipient & # 39; s freedom of choice of providers.
Doctors in direct patient care responsibilities. Any such incentive payments to physicians that are connected to or based on the total cost of patient care or the patient & # 39; residence time and reduce the patient services. Furthermore, the profit generated cost savings can induce investors to reduce medical services to patients. Health programs operating in good faith and integrity of healthcare providers. It is important to ensure that the quality of services at the hospital. The Anti-Kickback law promotes the government does not tolerate misuse of the reimbursement system for financial gain and hold those responsible accountable behavior. Such behavior is immediate patient complaints. Hospitals and doctors who are interested in structuring gainsharing measures adversely affect patient care.
The Anti-Kickback law creates a protective umbrella, the zone where the protection of the patients with the best health care is provided. This law promotes efficiency, improve quality of care, and better information for patients and doctors. The Anti-Kickback law is not only criminal prohibition payments intentionally cause or reward referrals or generation of federal health care business, but also to deal with the offer or payment of anything of value in exchange, leasing, ordering any product or service to be recovered all or part of a federal health program. It promotes quality and efficient health services, transparency of health care quality and price.
There are millions of patients without insurance who can not pay the hospital bills. Which patients benefit hospital charges not provided does not indicate a Federal anti-kickback statute. The purpose of most of the demand-based discounting policies of health care cheaper citizens do not have the millions of insured who are not in the hospital referral sources. Because these discounts are not insured patients, the anti-kickback laws simply do not apply. It fully supports the patient & # 39; s financial needs is not an obstacle to health care. In addition, OIG legal authorities permit patients or Medicaid and Medicare beneficiaries in hospitals and other bonafide discount you are not insured, who can not afford the medical bills. The Anti-kickback laws concerned about improper financial incentives, which often leads to abuses, such as overutilization, increase the cost of the program, the corruption of medical decision-making, and unfair competition.
There are risk management implications of this legislation. There are risks to the Anti-Kickback statute and its good to prevent them. Instead of an imposing and formidable challenges to our understanding, the result can be the development of risk management systems to control health care. This fact is acknowledged that the statutes of such an important feature of the risk management specialist. For example, there are potential risks arising from the hospital contacts the Anti-Kickback Statute. In the case of joint ventures between was a long-standing agreements concern in a position to refer, or generate federal health insurance program business and the products or services reimbursable federal health programs. In the context of joint ventures, the main concern is that your salary in the joint venture may pay a hidden past or future referrals to the company or one or more participants. Risk management should be made by the knowledge of the way in which the selection of the joint venture participants, and remains, the way in which the joint venture is structured and the way in which funding and allocation of profits of investments. Another area of risk in the hospital & # 39; s compensation arrangements for doctors. Although there are many legitimate compensation systems business rules, but violating the Anti-Kickback Statute, if the purpose of the arrangement is to compensate doctors for past or future referrals. Risk management is to follow the general rule is that any consideration flowing between hospitals and doctors to be fair market value of the actual and necessary items furnished or services.
Risk management entities are also required, as in cases where the source of the reference in the hospital or other service suppliers. It would be prudent to hospital to check carefully any remuneration flowing to the hospital in order to ensure compliance with the supplier or the Anti-Kickback statute. In addition, many hospitals an incentive to recruit a physician or other health professional to join the hospital & # 39; and the medical staff to provide medical services to the surrounding community. When used with the required doctors to an underserved communities, these rules can benefit patients. However, admission rules pose a significant risk of fraud and abuse. This can be prevented with the knowledge of the size and value of the admission benefit, duration of payment of the admission advantage of the existing practice of medicine and the need for recruitment. Another area where risk management should be applied when they receive the discounts. The Anti-Kickback law contains an exception for discounts offered to customers that claims the federal health care programs. The discounts must be published in the manner and accurately described. The regulation stipulates that the benefits shall be provided at the time of sale, or in some cases you have to set the time of sale. This helps in risk management. It is also necessary for medical staff credentialing and malpractice insurance subsidies.
The key areas of potential risk due to the federal Anti-Kickback law is pharmaceutical Relations Group 3: buyers, doctors or other health professionals, and sales agents. Activities that may pose a potential risk to include discounts and other terms of sale offered to customers, product transformation, as consultant payments. The drug companies and their employees and agents shall be the constraints of anti-kickback laws sites in marketing and promoting the products paid for by federal and state health care programs are aware of. To this end, it suggests drug manufacturers to ensure the draft guidelines to fit the area for such activities under one of the safe harbors anti-kickback laws. The Department of Health and Human Services announced the safe harbor regulations that protect certain rules laid down by the indictment of the Anti-Kickback Statute.
Healthcare to be one of the most regulated in all sectors of the trade, it is important that all facts and circumstances regarding the laws and regulations are evaluated.