Running head: Financial Laws and Regulation

Financial Laws and Regulations

Margarita Perez
5/6/16
Essential of Health Care Finance
Professor: John Jabbour
DeVry University

Financial Laws and Regulations

Five elements pertaining to the false claim under the False Claims Act?
The False Claim Act is a federal law that forbids transferring deceitful claim or making
an untrue statement or representation in connection with an application. Five essential elements
of liability and damages under the False Claim Act. Prove that a health care provider knowingly
submitted a false claim, in deliberate, reckless and disregard, of the claim's truth or falsity. The
FCA is not intended to apply to honest mistakes and negligence. Doing business with the
government one is obligated to make at least limited inquiries as to the accuracy of the claims.
(Scott, P., D., nd).
A false claim under the false claim act will permit the courts to provide triple the amount
of the actual settlement to be awarded against companies and individuals for falsely billing the
government, false representation in regards to some delivered goods & services. False
documentation of the performance of a contract or a false progress report to avoid payment to the
government or to receive payment from the government. In fact, the False Claims Act has several
other provisions, but they all follow the same organizing fundamental truth, the persecution of
operations that attempt to defraud the governmental finances at the federal level. (Scott, P., D.,
nd).
What three broad objectives HIPPA Privacy Standards were designed to accomplish?
The Health Insurance Portability and Accountability Act, (HIPAA) law signed on April
21, 1996 is to ensure the use of rules for electronic transactions of healthcare information as a
way to align the accurateness and effectiveness of the healthcare system. HIPAA included Title II
the portion of the HIPAA law known as administrative simplification. The rules in this section
were designed to protect the privacy of healthcare data, information, and security. Administrative
simplification provisions required DHS to acknowledge the national standards for electronic

Financial Laws and Regulations

healthcare issues. At the same time, Congress realized that advances in electronic technology
could compromise the privacy of health information. Therefore, Congress decided to implement
into HIPAA provisions that mandated federal privacy protections for certain individually
identifiable health information. (HIPAA Privacy Rule and Public Health, 2003).
According to our text book (Essential of Health Care Finance, 2011, Pg. 95), HIPAA
prevents the exposure of any individual health information that is transferred or maintained
electronically such as computers, emails, fax, telephones, and hand held devices. HIPAA privacy
also ensures that individuals have the right of deciding which information should not be
disclosed under any circumstances. Finally, HIPAA privacy standards ensure that CEs implement
safeguard in the protection of ePHI from unapproved access, adjustments, deletion, and
transmission, while at the same time, providing data or information is accessible and usable on
demand by authorized individuals. This includes healthcare operations for disclosures to business
associates, payments, and treatments. (Essential of Health Care Finance, 2011, Pg. 95)
Stark II laws 10 designated health services (DHS) that are prohibited?
Stark II laws prohibit physician to refer patients to entities in which the physician has any
financial relationship that provides DHS. Ten distinct health services (DHS) not permitted under
these laws. These include clinical laboratory services, inpatient and outpatient hospital services,
physical therapy, and outpatient prescription drugs. Also occupational therapy and speechlanguage, home health services, and durable medical equipment and supplies. Pathology
services, radiology and certain other imaging services, and radiation therapy services and
supplies are forbidden. Other DHS health services that fall under this law are prohibited are
parenteral and enteral nutrients, equipment and supplies such as prosthetics, orthotics, and
prosthetic devices and supplies. (Hamilton, P., LLP, Attorney at Law, 2016).

Financial Laws and Regulations

Examine the following: Qui tam, HIPAA Privacy Rule, EMTALA, Compliance programs
According to our text book (Essential of Health Care Finance, 2011, Pg. 90) states, Qui
tam is an action used by an individual who files a claim against an organization, under the false
claim act. This is also, known as a whistle blower. The individual is referred as a "relator." In
fact, in a Qui tam action a relator who has proof of fraud being committed brings suit against the
defendant in behave of the government. The government at this time has the right to join in the
action as a plaintiff. Therefore, if the government joins the action the, the realtor will be entitle to
a 15 to 25 percentage of the settlement awarded to him or her. If the government decides not to
join the action then, the realtor can be awarded up to 25% to 30% of the final settlement.
(Essential of Health Care Finance. 7th ed.).
The Health Insurance Portability and Accountability Act (HIPAA, established in 1996)
and the Health Information Technology for Economic and Clinical Health Act. (HITECH,
established in 2009). These two federal laws brought forth new major changes in regards to
medical record privacy measures required of health providers. HIPAA Privacy Rule is part of the
comprehensive legal framework implementing appropriate security safeguards to protect
electronic health data that may be at risk. To protect an individual's health information while
modifying appropriate access and use of that information. Also, provided unique health
identifiers for employers, health plans, health care providers and individual's security standards
protecting the confidentiality, morality and availability of Individually Identifiable Health
Information (IIHI). At the same time, the rule provides the protocols for the distribution of the
information in case that other health care providers require such information to provide an
accurate and reliable service taking into review the previous medical history of the patient.
(HIPAA: Impact and Actions by States, Updated 2016).

Financial Laws and Regulations

Emergency Medical Treatment & Labor Act (EMTALA). This law was first enacted in
1986, to provide public access to emergency room services regardless of the ability to pay and to
address the problem of "patient dumping". The provisions of this act are hospitals that participate
in the federal government program Medicare. These hospitals must provide a medical screening
exam to all persons who comes to the emergency room and requests examination or treatment for
a medical condition. If a hospital determines that an individual has a medical emergency, the
situation must stabilize or provide for an appropriate relocation. The hospital is compelled to
provide these services, in any case, if the individual cannot pay and without delay. (Emergency
Medical Treatment & Labor Act, EMTALA, 2012).
Compliance Program is a program about education, prevention, detection, collaboration,
and environment. A compliance program must be a commitment to an ethical way of conducting
business and a system for helping individuals to do the right thing. Also, a compliance program
must be effective to safeguards the organization, legal responsibility to abide by applicable laws
and regulations. The compliance programs is essential to reduce risk of probation, to reduce risk
of exclusion from government programs, to reduce threats of whistle blowers or qui tam law
suits, to reduce imposition of government designed programs. Reasons why an organization
should implement a compliance program? It shows a strong positive commitment to honesty
which helps to reinforce employees from right & wrong. Conforms legal duty to the government
and public, is cost efficient, accurate view of fraud abuse from staff and vendors. The quality of
care and code of conduct enhanced, prompt correction measures for misconduct, mitigate
sanctions imposed by the government, and may protect against personal liability. (Health Care
Corporate Compliance Programs, 2016).

Financial Laws and Regulations

References
Center for Medicare & Medicaid Services. (2012). Emergency Medical Treatment & Labor Act
(EMTALA). Retrieved from https://www.cms.gov/Regulations-andGuidance/Legislation/EMTALA/index.html
Cleverly, W., O. & Song, P., H. & Cleverly, J., O. (2011). Essential of Health Care Finance.
(7th ed.): Jones &Bartlett Learning, LLC. Sudbury, MA.

Hamilton, P., LLP, Attorney at Law. (2016). the 'Stark' Reality: Self-Referral Rule
Holds Risk, Opportunity for Physicians. Retrieved from
http://www.pepperlaw.com/publications/the-stark-reality-self-referral-rule-holds-riskopportunity-for-physicians-2001-02-22/
HIPAA Privacy Rule and Public Health. (2003). Guidance from CDC and the U.S. Department
of Health and Human Services. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm
National Conference of State Legislatures. (Updated 2016). HIPAA: IMPACTS AND ACTIONS
BY STATES. Retrieved from http://www.ncsl.org/research/health/hipaa-a-state-relatedoverview.aspx
Smith, Reed, LLC. (2016). Health Care Corporate Compliance Programs. Retrieved from
https://www.reedsmith.com/Corporate-Compliance-Programs-Practices/
Scott, P., D. (nd). Elements of a False Claims Act Claim. Law office. Retrieved from

Financial Laws and Regulations

http://www.lopds.com/false-claims-act/elements-of-a-claim/