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.
On January 1, 2021, every hospital in the United States (with very few exceptions) will be required to post clear, accessible pricing information online about the items and services they provide. These “standard charges” must be provided in two ways: first, as a comprehensive list of all items and services offered by the hospital in a machine readable format; and second, as a display of “shoppable services” in a consumer friendly format. According to CMS, the stated goal of the new rule is to empower patients “with the necessary information to make informed health care decisions.”
With the first requirement, the list must include gross charges, discounted cash prices, payor-specific negotiated charges, and de-identified minimum and maximum negotiated charges. The items and services covered are basically anything for which the hospital has established a standard charge, regardless of location or whether the item or service is provided on an inpatient or outpatient basis. These include, but are not limited to, supplies, surgical implants, procedures, room and board, and professional charges.
Out of network physician owned specialty hospitals are unique in that there are less stringent legal requirements on the facility, but patient care obligations remain the same. This means that patient care must be prioritized over profits and all actions taken by the hospital and any physician investor must showcase that order of priority.
Given the amount of scrutiny placed in physician owned specialty hospitals in the past two decades, these facilities are well served to identify and implement a process to remedy compliance concerns. Even when a facility does not submit claims to any Federal health insurance provider and is out of network with all commercial insurance companies, it is still required to follow the laws of the state where it is located.
The best plan for surviving scrutiny in such situations is to have a plan. Proactively seek out applicable laws and regulations, and determine how your hospital will abide by them. Compliance can be tailored to fit your facility.
Overutilization and Self-Referrals
A physician who shares ownership in a hospital may have a financial incentive to refer patients for services if he or she receives a percentage of the revenue generated. Laws including the Federal Stark Law and Anti-Kickback Statute were promulgated to combat unnecessary referrals. A 2003 study by the Department of Health and Human Services concluded that physician-investor referrals to hospitals in which they have an investment interest are similar to those physicians without investment interests. Nevertheless, the fear of overutilization and unnecessary self referral remains at the forefront of the regulators’ minds at both the State and Federal level. read more
The debate over the pro’s and con’s of physician-owned hospitals has been raging for decades. Physician-owners say their hospitals are more patient-focused, provide higher quality care, obtain better outcomes and therefore receive higher patient satisfaction scores. They also point out their convenience and efficiency.
Opponents argue that physician-ownership leads to overutilization and cherry-picking of only the best patients. The less-desirable patients (both clinically and financially) are then left to be taken care of by the community hospitals. For those reasons, both the American Hospital Association and the Federation of American Hospitals remain strongly opposed to physician-owned hospitals.
Federally, the Stark Law includes an exception which allows a physician to refer patients to a hospital in which the physician has an ownership interest, so long as the ownership interest is in the entire hospital, and not just a subdivision of the hospital. However, in 2010, the federal government weighed in again on the issue, and passed the Affordable Care Act (ACA), which includes provisions which (i) restrict physician referrals to hospitals in which they hold an ownership interest; (ii) restrict any increases in physician-ownership of a hospital; and (iii) restrict expansion of physician-owned hospital facilities. CMS has granted exceptions to these restrictions, but those have been limited to rural hospitals and high Medicaid hospitals, and attempts to amend the law have failed. read more
With the opioid epidemic in South Florida at crisis levels, there is an increasing demand on local hospital emergency departments for screening and evaluations of drug overdoses, considered a medical emergency. Addiction treatment law evolves with EMTALA updates. Many patients receiving substance abuse treatment in this community are coming from out-of-state. Many are young, under 35 years and a majority receive outpatient services. Overdoses are occurring more frequently as patients deliberately misuse opioid prescriptions such as Fentanyl or an illicit drugs such as heroin. If the patient possesses and or uses an illicit drug while in treatment, the policy in many facilities is to terminate treatment and discharge the patient. But if the patient has overdosed, the facility will place a call to 911 and that patient will end up with a visit to a local emergency department. A discharged patient will often continue using and end up in the emergency department, taken there by paramedics or some other individual.
Evolution of EMTALA
Local emergency departments now play a pivotal role in the next steps that an overdosed patient may take. Is the patient receiving their EMTALA rights (Emergency Medical Treatment and Labor Act), a federal law requiring anyone coming to a hospital emergency department to be screened and examined? If an emergency medical condition exists, treatment is provided to relieve or eliminate the emergency medical condition within the service capability of the hospital, a difficult task with substance abuse. read more
In 1986 President Ronald Reagan signed the Emergency Medical Treatment and Active Labor Act (EMTALA) into law. Since then, the application of the law has been expanded and refined. It was one of the first laws giving the government the authority to dictate certain operations of a hospital. While other laws and regulations such as the Anti-Kickback Statute and the Stark Law have become more of a focus for health care providers, EMTALA remains an area of active enforcement. All providers with hospital privileges should therefore be aware of its application.
The policy behind the law is fairly straightforward. Hospitals with emergency departments should not be able to turn away patients needing care because of their inability to pay (no more “wallet biopsies” as part of triage). Likewise, hospitals should not be able to “dump” patients on other facilities for reasons other than for advanced care.
The requirements of the law are also very basic. If a patient comes to an emergency department and requests an examination or treatment for a medical condition, the hospital must provide an appropriate medical screening exam, within its capability, to determine whether or not the patient has an emergency medical condition. The screening provided goes beyond simple triage, and must be performed by a clinical provider such as a physician, nurse practitioner, or physician’s assistant. read more