Question from: Essentials of Health Care Finance By William Cleverley and James Cleverly
Describe billing compliance and methods of private, public and government audit laws (Chapter 4)
1 Effect of Healthcare Reform - Five ACA contained payment reforms
2 The Stark Law - Description and prohibitions of the law - Designated Health Services inclusions and exclusions - Results of Violation of the Stark law - Exceptions to the Stark Law
3 The Anti-Kickback Statute - Description, prohibitions, and applications of the statute - Remuneration in the context of the statute - explain in your own words - Identifiers of violations of the statute - Description of Statutory exceptions and safe harbors of the statute
4 The False Claims Act and Qui Tam Actions - Describe FCA and Whistleblower Actions
5 Anti-trust Acts in Healthcare - Sherman Act * Applications * Penalties - Clayton Act * Section 7 prohibitions * Investigation procedures under the Clayton Act
As per HOMEWORKLIB RULES fourth question is answered
4 The False Claims Act and Qui Tam Actions
Qui Tam- an abbreviation of a Latin phrase that has the meaning he
who as well for the king as for himself sue in this manner. Qui Tam
is a technical legal term for the mechanism in the federal false
claims act that allows for person and entities with evidence of
fraud against federal programs or contracts to sue the wrongdoer on
behalf of the govt.
Describe FCA and Whistleblower Actions
A providers good faith submission of its payment claim may provide
a partial or complete defense if the government attempts recovery
under the FCA . But it does not negate criminal liability under the
criminal disclosure provisions of the social security act.
5) Anti-trust Acts in Healthcare
Sherman Act
a)Applications of Sherman Act
The Sherman act applies to virtually all businesses in the country
, including health care providers it condemns any conduct that
causes inefficiencies resulting higher prices or lower quality of
services to the ultimate consumer. Most business practices that are
condemned under the Sherman act are justified from a business
standpoint, but deemed illegal because they are unreasonably
restrain Trade.
CLAYTON ACT
a) Section 7 Prohibition : Section 7 of the CLAYTON ACT Prohibits
all mergers and acquisition of stocks or assets that may
substantially lessen competition or that tend to create monopoly '
in any line of commerce in any section of the country enacted in
1914. the Clayton act made price discrimination ,tying ang
exclusive dealing contracts mergers of competing companies and
interlocking directorates illegal but not criminal.
b)Investigation procedures under the Clayton Act
Enforcement of Clayton act involves only civil remedies. Where as
the DOJ directly enforces the actions of the sherman act. Both the
DOJ and FTC enforces the Clayton act.The DOJ can bring equitable
actions in federal district courts to prevent and hinder acts
limiting competition and the FTC may enforce its action through
both its own agency , administrative hearings and the federal
district courts.
Question from: Essentials of Health Care Finance By William Cleverley and James Cleverly Describe billing compliance...
Question from: Essentials of Health Care Finance By William Cleverley and James Cleverly (the title of the book and author) Describe billing compliance and methods of private, public and government audit laws 1 Effect of Healthcare Reform A) Five ACA contained payment reforms 2 The Stark Law A) Description and prohibitions of the law B) Designated Health Services inclusions and exclusions C) Results of Violation of the Stark law - Exceptions to the Stark Law 3 The Anti-Kickback Statute A)...
Question from: Essentials of Health Care Finance By William Cleverley and James Cleverly Describe/Explain the requirements for Medicare benefits and Medicare payments (pages 40-41) 1 Four Basic Medicare Benefit Programs - Part A - Part B - Part C - Part D 2 Medicare Payments - Hospital Inpatient * PPS and five exclusions * Medicare subpayment split * Modifiers (6) * Primary Diagnosis and Secondary Diagnosis - Physicians * Participating physician and Nonparticipatign physician - Hospital Outpatient * Ambulatory payment...
Question from: Essentials of Health Care Finance By William Cleverley and James Cleverly (the title of the book and author) Describe/Explain the requirements for Medicare benefits and Medicare payments 1 Four Basic Medicare Benefit Programs - Part A - Part B - Part C - Part D
1. Which of the following is PROBABLY a case of medical malpractice? I. A doctor neither monitors nor diagnoses cerebral bleeding in a patient with a head injury, resulting in the patient's death. II. A doctor does not examine a person with an eye injury, resulting in vision loss. II. An incorrect diagnosis of cancer on a biopsy (pathology) inspection, leading to unnecessary surgery. A. III only B. I only C. II only D. I, II, III 2. Margaret was...