Question

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) Description, prohibitions, and applications of the statute

B) Remuneration in the context of the statute - explain in your own words

C) Identifiers of violations of the statute

D) 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

a)Applications

b)Penalties

- Clayton Act

a)Section 7 prohibitions

b) Investigation procedures under the Clayton Act

Answer 1

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.