FACHE Flash Cards - Laws & Regulations

EEOC (Equal Employment Opportunity Commission)

INDEPENDENT agency created in 1964-works to eliminate employment discrimination based on race, color, religion, gender, disability, age or other criteria unrelated to job performance.

ERISA (Employee Retirement Income Security Act of 1974)

Provides standards for funding, vesting, fiduciary responsibilities of pension and 401(K) plans.

HIPAA (Health Insurance Portability and Accountability Act)

1996 federal law that addresses the sharing of patient information among healthcare organizations.

3 internal reasons PHI may be released without authorization of patient?


3 Main categories of HIPAA provisions:

1. Transaction Code Sets
2. Privacy Rule
3. Security Rule

4 distinct areas of the HIPAA Security Rule

1. Administrative procedures
2. Physical safeguards
3. Technical security services
4. Technical security mechanisms

HIPAA civil penalties

$100 per incident for "innocent mistakes"
$10,000 per incident for "willful neglect"
$50,000 per incident for "uncorrected willful neglect

HIPAA criminal penalties

- Up to $50K and 1 year in prison for knowingly and improperly obtaining and disclosing PHI;
- Up to $100K and 5 years in prison if the offense is under false pretenses;
- Up to $250K and 10 years in prison for obtaining or disclosing PHI with the intenti

7 Minimum objectives of Corporate Compliance

1. Establish standards and procedures
2. High-level personnel have overall responsibility
3. Diligence in not involving with people "with propensity to engage in illegal activities"
4. Effectively communicate standards (educate staff)
5. Reasonable steps

Corporate compliance risk areas

- substandard care
- HIPAA Privacy
- billing MCR or MCD substantially in excess of usual charges

Hill-Burton Act

Provided federal funds for the construction of private hospitals during the 1960s

501(c)(3) exemption standards

- organized exclusively for charitable purposes
- cannot have any noncharitable purposes
- may not benefit private interests
- does no prohibit payment of reasonable compensation for management
- Community Board
- Open medical staff
- 24-hour ER
- Provisi

What is the 2-Prong test for hospital joint ventures (Revenue Ruling 98-5)?

1st Prong: Is the Primary Purpose of the JV to pay dividends to the owners or to accomplish a charitable purpose?
2nd Prong: The tax-exempt entity retain enough control of the JV to guarantee the operations are exclusively for public purposes

Sarbanes-Oxley Act (SOA)

2002 Act that imposes obligations on companies to disclose and certify the accuracy of their financial condition.
- document destruction and whistleblower policies
- exposure of CEOs, CFOs and Board Members
- effective compliance programs
- code

Stark Law

Prohibits physicians from referring designated healthcare services (DHS) for Medicare patients to any entity with which they or an immediate family member has a financial relationship.

Stark Exceptions

- "arms length negotiation"
- must be commercially reasonable
- must have a signed written agreement
- set a fair market value

Definition of Fraud

The INTENTIONAL deception or misrepresentation that and individual KNOWS to be false or does not believe t be true and KNOWS that the deception could result in an unauthorized benefit

Definition of Abuse

Incidents that are consistent with sound practices, directly or indirectly resulting in unnecessary costs to the government (can be an honest mistake)

Definition of Kickback

- any inducement, payment, solicitation, offer or payment of any kind
- in return for referrals for recommending, ordering, leasing or purchasing a service or item
- that may be at least partially paid for through a federal program

List of Designated Health Services (DHS)

- IP and OP services
- OP prescription drugs
- PT and OT
- Imaging (except Nuc Med or PET)
- Prosthetics
- Parenteral and Enteral Nutrients

What services are NOT part of DHS?

- Lithotripsy
- Ambulatory Surgery
- Nuc Med / PET
- Cardiac Cath
- Neurological Testing

Anti-Kickback Penalties

$25K and up to 5 years prison for each offense; subject to exclusion from Medicare; Government may collect treble damages plus $50K for each violation

False Claims Act of 1986

- Qui Tam provision to encourage whistleblowers
- Whistleblower may recover between 15% and 25% of what the government recovers
- Government may collect up to 3 times the amount of false claim
- provider may be excluded from MCR and MCD


Emergency Medical Treatment and Active Labor Act

EMTALA requirments

Hospital EDs must provide medical screening to any individual and requires EDs to examine and treat anyone with an emergency medical condition
Civil monetary penalties may be assessed against hospitals and/or physicians
Also includes an "anti-dumping" pro

Office of the Inspector General (OIG)

government agency that investigates and prosecutes fraud


a private insurance policy that pays the difference between the medical charge and the amount that Medicare pays

Medicare Part A

The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.

Medicare Part B

The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.

Medicare Part C

managed care health plans offered to medicare beneficiaries under the medicare advantage program

Medicare Part D

Medicare prescription drug reimbursement plans

Secondary Payor Rule

Medicare does not pay for services of which MCR is not the primary payor


A federal and state assistance program that pays for health care services for people who cannot afford them.

Healthcare Quality Improvement Act (HQIA) of 1986

Established the National Practitioner Data Bank;
Immunity for certain peer review activities

4-part test for HQIA immunity

1. Must be taken under the reasonable belief that the action was in furtherance of the quality of healthcare
2. Reasonable effort to obtain the facts
3. Physician afforded notice and hearing procedures
4. Reasonable belief the peer review action was warra

Patient rights under HIPAA

1. receive a copy of Notice of Privacy Practices
2. request restriction of use for treatment payment options
3. request confidential communication
4. access and copy information
5. requests for amendments
6. an accounting of disclosures
7. right to notifi


wrongful acts for which an injured party has the right to sue

Respondeat superior

Let the master answer" an employer is vicariously liable for the behavior of an employee working within his or her scope of employment

Res ipsa loquitur

A doctrine under which negligence may be inferred simply because an event occurred, if it is the type of event that would not occur in the absence of negligence. Literally, the term means "the facts speak for themselves.


Failure of consent - an intentional tort

Negligent Credentialing

Occurs if a hospital has retained a physician that the governing body of the hospital knew or should have known was incompetent.


Failure by a health professional to meet accepted standards

False imprisonment

Failure to release a patient from a facility (usually mental health)

ACGME (Accreditation Council for Graduate Medical Education)

Established in 1981, evaluates and accredits medical residency programs in the US