Question

Discuss which health care law- EMTALA, HIPAA, STARK or Anti-kickback- is most challenging for health care organizations to monitor and/or prevent. Explain your position.

Answer 1

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay.

The Health Insurance Portability And Accountability Act (HIPAA) was signed into law in the year 1996, by President Bill Clinton. It is a legislation which provides security provisions and data privacy, in order to keep patients’ medical information safe. The act contains five titles, or sections, in total:

• HIPAA Title I aims to protect coverage of health insurance for those who have changed or lost their jobs. It prevents group health plans from refusing to cover individuals who have pre-existing diseases or conditions, and prohibits them from setting limits for lifetime coverage.
• HIPAA Title II aims to direct the United States Department Of Human Services and Health in order to standardize the processing of electronic healthcare transactions nation-wide. It requires the organizations to implement safe electronic access to the patients’ health data, remaining in compliance with the privacy regulations which were set by the HHS.
• HIPAA Title III is related to provisions which are tax-related, as well as general medical care guidelines.
• HIPAA Title IV defines a further reform in health insurance, including provisions for those who have pre-existing diseases or conditions, and individuals who are seeking continued coverage.
• HIPAA Title V includes provisions associated with company-owned insurance, and treatment of those who lost their citizenship for income tax reasons.

The Stark Law is a healthcare fraud and abuse law that prohibits physicians from referring patients for certain designated health services paid for by Medicare to any entity in which they have a “financial relationship.” The federal government interprets the term “financial relationship” broadly to include any direct or indirect ownership or investment interest by the referring physician, as well as any financial interests held by any of the physician’s immediate family members. Unlike the federal Anti-Kickback Statute, the Stark Law is not a criminal statute. However, the Office of the Inspector General (OIG) for the Department of Health and Human Services (“HHS”) can pursue a civil action against Stark Law violators under the civil monetary penalties law. Stark Law violations can result in penalties of up to $15,000 for each billed service that is based on a prohibited referral, plus three times the amount of the government overpayment.

The federal Anti-Kickback Statute is a healthcare fraud and abuse statute that prohibits the exchange of remuneration—which the statute defines broadly as anything of value—for referrals for services that are payable by a federal program, which, in the context of healthcare providers, is Medicare. Anti-Kickback violations also usually constitute violations of the False Claims Act, meaning that Anti-Kickback investigations can likewise result in fraud liability. However, there are far more criminal prosecutions of individual physicians under the Anti-Kickback Statute than the False Claims Act.

As you begin your career, it is crucial to understand these laws not only because following them is the right thing to do, but also because violating them could result in criminal penalties, civil fines, exclusion from the Federal health care programs, or loss of your medical license from your State medical board.