Volume 2 Issue 7
VOLUME 3 | ISSUE 2
Laws, Regulations (& You) in Healthcare
There is a large body of laws and regulations that advocate for patients in healthcare. Unfortunately, patients either do not often know of or understand these legal mandates or requirements or why they exist and how they should be effectively applied to ensure patients receive healthcare in a manner they deserve and
the way the laws and regulations were intended.
With 2024 just on the horizon, and as you consider your healthcare insurance options in the new year and begin to schedule appointments for preventive care, elective surgeries, and the like, it may be a good idea to review how certain laws and regulations in healthcare work for you.
Here is a short list:
Emergency Medical Treatment and Active Labor Act (EMTALA)
This federal law prohibits questions about payment until emergency department patients have been medically screened. Patients are typically required to provide insurance and payment information before being seen by a physician. However, emergency departments are unique in that any person who has an emergency must be treated or stabilized, regardless of their ability to pay or insurance coverage. Learn more about EMTALA here: Emergency Medical Treatment & Labor Act (EMTALA) | CMS.
False Claims Act
This federal law prohibits making false records or claims to get a claim or false record paid or attempting to retain monies paid by making false statements. It allows for the imposition of liability on any person who submits a claim to the federal government that he or she knows (or should know) is false. Examples could include a physician who submits a bill to Medicare for medical services she knows she has not provided; a government contractor who submits records that he knows (or should know) is false and that indicate compliance with certain contractual or regulatory requirements; or what is known as “reverse false claims” that may include a hospital who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare program. To learn more about the False Claims Act, click here: Civil Division | The False Claims Act (justice.gov).
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA or The Privacy Rule allows for information sharing in a healthcare setting that does not violate a covered entity’s rights or protected health information (PHI) at any point while receiving medical care. PHI refers to demographic data personally identifiable to the patient such as name, address, date of birth, and social security number, and others. Learn more about HIPAA here: HIPAA Home | HHS.gov.
Patient Protection and Affordable Care Act (PPACA)
The PPACA, also known as “Obamacare,” seeks to: reduce healthcare costs while also reducing wasteful spending; to decrease the number of uninsured Americans through shared responsibility amongst government, individuals, and employers; to expand Medicaid for people with incomes less than 138% of the federal poverty level (FPL) while bringing about longer-term changes in the availability of primary and preventive health care; and finally, to invest in the public's health through both an expansion of clinical preventive care and community investments. To learn more about the PPACA, click here: Patient Protection and Affordable Care Act - Glossary | HealthCare.gov.
Patient Self-Determination Act (PSDA)
This law requires all providers, which includes hospitals, long-term care facilities, and other institutional providers, excluding individual physicians, must provide written information that advises adult patients of their right "to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at the individual's option, advance directives" (42 CFR § 489.102ai). Providers must also advise patients of their policies on advance directives, including any restrictions on the provision of care. Learn more about PSDA here: eCFR :: 42 CFR 489.102 -- Requirements for providers.
Hopefully, this information was helpful. If there are others you’d like to understand or know more about, reach out at firstname.lastname@example.org. Always happy to help as your partner in “All Things Healthcare.”