Health law is the federal, state, and local law, rules, regulations and other jurisprudence among providers, payers and vendors to the healthcare industry and its patient and delivery of health care services; all with an emphasis on operations, regulatory and transactional legal issues.
Healthcare laws exist to ensure that patients have the best care possible. If they don’t get the treatments they expect, these patients can lean on legislative acts to get relief. And regulatory agencies can step in and close down those groups that don’t follow healthcare acts, so no future patients are harmed.
Multiple healthcare acts exist, but in this piece, we’ll focus on those devoted to protecting the rights of patients.
4 Healthcare Laws to Know
Healthcare acts protecting patient privacy are likely well-known to most consumers and professionals. These are the laws we talk about in common conversations about the care we get when we visit the doctor.
This list of healthcare laws isn’t comprehensive, but it can give you an idea of the landscape regarding patient rights.
These are four healthcare laws to know:
ACA: The Affordable Care Act is commonly associated with insurance. Under the legislation, consumers can tap into programs to help them pay for medical expenses. But the law also includes regulations regarding preexisting conditions and covered care.
EMTALA: The Emergency Medical Treatment and Labor Act allows patients to head to the emergency room to get care even if they can’t pay the bill that comes when treatment is complete.
GINA: The Genetic Information Nondiscrimination Act ensures that people won’t face discrimination based on the results of genetic testing. If patients participate in a test and some issue is revealed, they can fight back if their employers penalize them for the results.
Again, this list of healthcare laws isn’t meant to be comprehensive. Instead, think of it as a research starting point.
Moving Beyond Healthcare Laws
Medical professionals must comply with applicable healthcare acts and laws. But they’re also guided by their ethics, including some versions crafted by oversight agencies.
For example, the American Medical Association has a formal Code of Medical Ethics that all physicians commit to. These rules cover how doctors relate to their patients, how they communicate medical news, and more.
Also, some healthcare professionals are guided by rules that originate at the state level. A hospital, for example, might have state laws regarding patient care. They can’t take in more cases than staffing rules allow even if they want to help more people.
If you’re confused about the legal landscape in your area, let us help. We have a skilled team that can help you understand your local laws. Contact us to find out more.
Healthcare officials often chuckle when they see questions like, “Who regulates health care?” If only one law or organization oversaw every aspect of healthcare in this country, life would be a lot simpler for medical professionals and the organizations in which they work.
In reality, many different organizations are involved with regulating healthcare. And they enforce rules and regulations that may appear at the federal, state, or local level.
Who Regulates Health Care at the Federal Level?
The largest and most complex healthcare laws originate at the federal level. They are enforced by a variety of different agencies.
These three main federal agencies oversee healthcare organizations:
The U.S. Inspector General: Seated within the DHS, the Office of the Inspector General creates compliance documents to help hospitals and doctors comply with a bevy of federal laws.
The United States Department of Labor: The Occupational Safety and Health Administration creates rules that ensure a safe workplace. Since so many people work in healthcare, the rules are critical.
All of these groups offer guidance to help organizations comply with their rules and regulations. But compliance means paperwork. Hospitals and other care organizations must prove that they both understand and comply with the rules.
Who Else Is Involved in Regulating Health Care?
Healthcare providers are also required to abide by laws that originate from outside the federal system. The landscape varies from organization to organization.
A provider might have rules that originate in:
State agencies. Some states have rules regarding workers’ rights, patient access, and payment caps.
Federal payors, like Medicare. Some organizations must follow rules about payment options.
Private payors. Some companies like Blue Cross have rules about payments and access.
Nonprofit boards. Some hospitals and other care organizations are ruled by a board of directors. That group may also have compliance rules.
The landscape can be complex. An organization may face competing or conflicting rules regarding patient care and payments.
Navigate Health Care Industry Regulations
Healthcare providers need to focus on patient care, not paperwork. As one of the largest healthcare law firms in the nation, we can help. Let us assess your regulatory environment and help you come up with a comprehensive compliance plan. We can help you craft appropriate reports too, so you can prove you’re doing your job. Contact us to find out more.
Diagnosis. A doctor misses a critical point and fails to issue a diagnosis, or the doctor interprets results improperly and misdiagnoses a patient.
Procedures. The doctor offers a treatment that isn’t needed, or the patient has a surgery performed on the wrong site.
Care. The patient is forced to leave the facility too quickly, or the patient doesn’t get proper instructions to help prevent complications.
This is a short, non-exhaustive list. In general, tort laws in healthcare are made to help patients fight back when something goes wrong with their care. Almost any complication you can think of could be part of tort law.
4 Legal Elements in Medical Torts
To win a case, the patient must show that the professional or organization was negligent when providing care, and that negligence caused an injury that deserves compensation.
Skim through social media posts and blogs, and you might believe that there’s a new healthcare law in the books. Otherwise, why would so many people ask questions like, “When does the new healthcare law take effect?” and “What is the new healthcare reform law?”
It’s critical for healthcare professionals to know how reform laws work and when they take effect. But it’s also very easy to get overwhelmed and confused by the ever-changing landscape.
Let’s break things down.
What Is the Affordable Care Act?
The health care reform law enacted in March 2010 is the Affordable Care Act (ACA). It’s also commonly known as Obamacare and the new healthcare law.
The ACA is far from new. Chances are, you’ve heard of it or billed patients using this form of insurance within the last decade. Key benefits of the legislation include:
Subsidies. People with lower incomes get help with premiums.
Penalties. Those who don’t get health insurance are dinged for that decision.
Expansions. Some states lowered Medicaid eligibility rules.
Marketplaces. People can sign up for health insurance through programs run at the state or federal level.
The bill contains many more provisions, including some involving preexisting conditions and others involving covered services. There’s a lot to unpack, and sometimes, consumers get lost in the details.
What Is the New Healthcare Law?
When people ask questions like, “When does the new healthcare law take effect?,” they’re reading news articles about changes.
The short answer: There is no new healthcare law.
The longer answer: The older legislation is changing. For example:
Premiums decreased. Cost-sharing programs announced by the Biden administration reduced costs, allowing some people to buy plans for about $10 per month.
Legislation could change things. A lawsuit filed in late 2020 asks the Supreme Court to consider whether the Affordable Care Act is unconstitutional.
In an environment like this, it pays to watch the news carefully and monitor how coverage and eligibility may change.
But it’s also wise to take the long view. Tiny shifts and ongoing legislative battles are unlikely to change your day-to-day work as a healthcare administrator. Don’t panic about the headlines.
Make Sense of the Affordable Care Act
As a boutique, full-service law firm focused exclusively on healthcare, we know the ins and outs of the ACA from the perspective of consumers, providers, and payers. We’d love to help you understand what the law means and how you should react to it. Contact us to find out more.
Healthcare fraud law should be easy to understand. If you don’t set out to lie, cheat, or steal to make money, you should be safe, right?
Unfortunately, the laws can be incredibly complex. Add in partnerships and sophisticated work-sharing agreements, and untangling the mess of responsibility could be even more difficult.
We’ll explain a few examples of healthcare law and fraud to make the problem easier to understand. But know that it’s always wise to contact a lawyer when you think you’re engaged in activity that could be considered fraudulent.
Inadvertent Healthcare Fraud Cases
Sometimes, the decisions you make as a healthcare professional break the laws, even if you never intended to do so.
Consider the Stark Law. Under that statute, you’re not allowed to refer a Medicare patient to any entity with which you have a financial relationship. In theory, you could break that law by:
Referring patients for tests and accepting a portion of the fees billed for those tests.
Giving your doctors an incentive for some kinds of tests.
Improperly paying your physicians
Making an arrangement with a medical center and promising to refer patients for some kinds of tests.
Inadvertent fraud is real, and these cases are complex. It’s wise to work with a lawyer, especially if healthcare arrangements are involved.
What About the Healthcare Fraud Law False Claims Act?
Typically, healthcare professionals know that they’re breaking this particular fraud law. They doctor the paperwork and hope to make money before anyone notices. But sloppy bookkeeping could also play a role. If you’re not absolutely sure that you’re submitting everything properly, wait and think before you take action.
Healthcare Fraud Law: Criminal Statutes
Sometimes, your mistakes aren’t inadvertent or paperwork related. If you intend to break the law and you know your conduct is wrong, you could be liable for criminal charges.
Two main criminal statutes apply to medical professionals, and they involve:
Kickbacks. If you get something in return for Medicare or Medicaid business, you’re involved in an illegal scheme.
Fraud. If you intend to falsify records or documents for your financial gain, you could face legal challenges.
Criminal charges could end your career. And they could also put you in jail for long periods of time.
What Should You Do When You Suspect Fraud?
If you’ve been reading this list with a growing suspicion that you’re engaged in something unethical, take action.
There might be times when Medicare denies coverage for an item, service, or test that you or your company provided. In the event this occurs you have the right to formally disagree wit the decision and encourage Medicare to change it. Therefore, understanding the appeals process for Medicare claims is vital for all providers. The aim of this article is to give providers a better understanding of the five (5) levels of the Medicare Appeal process, and what must occur at each level.
The Medicare Fee-For-Service (FFS) has five levels in the claims appeal process:
Level 1 – Redetermination by a Medicare Administrative Contractor (MAC)
Level 2 – Reconsideration by a Qualified Independent Contractor (QIC)
Level 3 – Disposition by Office of Medicare Hearings and Appeals (OMHA)
Level 4 – Review by the Medicare Appeals Council (Council)
Level 5 – Judicial review in U.S. District Court read more
Medical professionals need a working understanding of the laws in their cities, states, and countries. In the United States, some of the most significant legal issues medical professionals face involve so-called “common law.”
Common law in healthcare covers a wide range of issues, both large and small. Let’s dig into examples and help you understand when you’ll need a lawyer’s help.
Common Law in Healthcare: A Definition
In everyday parlance, the word “common” is synonymous with known or normal. In legal terms, commonality is much different.
The common law system originated in England, and it forms the basis of the current American legal system. When patients head to court to talk about malpractice suits, they’re often citing the common law.
While common laws may originate in customs, they can change with time. Whenever a case heads to court and is decided, the reasoning enters legal records. That decision becomes a sort of precedent, and it can be cited in later cases.
Common issues in healthcare, such as a doctor’s lack of license, could be solved in court. When those issues are in the courtroom, lawyers from both sides will cite prior cases as a nod to common law.
Examples of Common Law in Healthcare
Almost anything that’s been solved in a courtroom in the past could be part of a common law proceeding. But in healthcare, common law cases tend to reference a few key elements.
What’s the relationship between law and ethics in healthcare? Medical students often get confused about these two topics. And their classes may not help. Many teachers use these terms interchangeably, and some course titles have both terms within them.
Law and ethics are two different things. And sometimes, medical professionals face situations in which the two concepts conflict.
The Role of Law and Ethics in Healthcare
Let’s start by defining our terms to make the connections and differences a little easier to unpack and understand.
Medical professionals deal with:
Laws. Government officials craft these doctrines, and they’re designed to protect citizens. Violate them and expect punishment. You’re expected to comply.
Ethics. These informal rules stem from your personal sense of right, wrong, and fairness. Ethics are infused by formal structures, including your government and your upbringing. But breaking them doesn’t typically come with an official punishment.
Both ethics and law in healthcare deal with behavior. But laws are minimum standards, and ethics are maximum standards.
How to Mediate Conflicts
While laws are influenced by ethics, the two can contradict one another in a healthcare setting.
Sometimes, your legal duties as a healthcare professional can conflict with your ethical responsibilities. The law may force you to do things your ethics just don’t condone. Or you may want to do something because it’s ethical, but the law isn’t on your side.
When you’re facing conflicts like this, working with a lawyer is crucial. Together, you can examine your options and find a path forward. Your lawyer may help you understand legal options to help you abide by your ethics. Or your lawyer may help you understand the legal implications of abiding by your ethics while breaking the law.
At Florida Healthcare Law Firm, we’re here to guide our clients into ethical, legal decisions. We can help you unpack thorny issues and make good decisions for your patients and your community. Contact us to get started.
But some cases cause disfigurement or suffering. For example, in 2020, a pediatric dentist in Nevada used a diamond bur on a child’s tooth. A spark ignited the throat pack inside the girl’s mouth, and the flames burned for a few seconds. Her family filed a claim for more than $15,000 in damages.
If you’re facing negligence in healthcare cases, you need a lawyer. Someone must defend the decisions you made while treating your patients. And that legal expert must ensure that your insurance company doesn’t pay too much to settle a case that’s just not your fault.
At Florida Healthcare Law Firm, we specialize in cases just like this. We’d like to help you. Contact us for an assessment and evaluation.
As you train your staff on the changes that were recently made regarding evaluation and management coding it is very important to ensure that your staff understands the auditor’s perspective as well. There are four distinct portions of an auditor’s tool when evaluating the documentation guidelines for office/outpatient evaluation and management (E/M) services (99202-99215). The four distinct portions are diagnoses, data, risk, and calculation of medical decision making (MDM). In order to ensure that a provider’s progress note is complete in the auditor’s eyes the provider should ask themselves the following six questions to create the best chances of successfully meeting the auditors expectations:
Does my progress note contain a medically appropriate history and examination?
Were my diagnoses addressed appropriately?
Did I document all orders and data reviewed?
Were other professionals included in my documentation that I worked with?
Was an independent historian used?
Does the documentation support the level of risk I chose?
For the remainder of the article, I am going to dive deeper into each question above so that you, as providers are able to recognize insufficient areas in a provider’s E/M documentation when you perform a self audit to better your practice. read more