What are five elements pertaining to the establishment of a false claim under the False Claims Act?

HIPAA privacy standards were designed to accomplish what three broad objectives? Explain each.

Stark II laws prohibit physician referrals to entities in which the physician has a financial relationship. What are 10 specific designated health services (DHS) for which referrals by physicians who have financial relationships with the entity providing the DHS are prohibited?
Discuss the following: Qui tam HIPAA Privacy Rule
EMTALA Compliance programs

 

Answer

The False Claims Act

The False Claims Act statute establishes the following five elements, which the prosecution has to prove beyond a reasonable doubt in order to secure a conviction: the first element is if a claim for property or money is made. Secondly, if the claim is against or to an agency or department of the United States. Third, if the claim was false, fraudulent or fictitious. Forth, if the person must have known that the claim was false, fraudulent or fictitious at the time, and finally, if the false, fictitious or fraudulent claim was material.

Privacy standards of HIPAA were designed to achieve three broad objectives. The first is to define the conditions in which the protected health information could be used and disclosed. Second objective is to establish certain rights of individuals concerning protected health information, and the final objective requires adoption of administrative safeguards to ensure the protected health information remains private.

Stark II laws prohibit certain Designated Health Services clinical laboratory services listed hereby. (1) physical therapy, occupational therapy, and speech language pathology services, (3) radiology and certain other imaging services, (4) radiation therapy services and supplies, (5) durable medical equipment (DME) and supplies, (6) parenteral and enteral nutrients, equipment and supplies, (7) prosthetics, orthotics and prosthetic devices and supplies, (8) home health services, (9) outpatient prescription drugs, and (10) inpatient and outpatient hospital services.

Qui tam is a lawful provision in the US under the False Claims Act that allows for a private citizen, also called ‘whistleblower’, with past or present knowledge of fraud committed against the government of the US to bring suit on the behalf of the government. This provision permits a private citizen, referred to as a “relator,” to file a complaint on behalf of the US government, where the private citizen has information that the mentioned defendant has deliberately submitted or otherwise caused the submission of fraudulent or false claims to the US government. If the relator succeeds in his suit, he is entitled to a percentage, usually between 15 to 25 percent of the funds recovered by the government.

The HIPAA Privacy Rule is a set of regulations that offers federal protections from unauthorized disclosure of personal health information, known as protected health information (PHI), carried by entities. It gives patients a range of rights concerning their health information, including rights to inspect and obtain a duplicate of their health records, and rights to request corrections. At the same time, the HIPAA Privacy Rule is balanced in the sense that it permits disclosure of PHI to public health authorities that are approved by the law to collect information for purposes of controlling or preventing disease, disability or injury without necessarily seeking the individual’s authorization.

The Emergency Medical Treatment & Labor Act (EMTALA) is a statue passed in the year 1986 as an element of the COBRA. It requires participating hospitals to provide an examination and care to anyone who needs emergency healthcare treatment, irrespective of their ability to pay or insurance coverage. If a participating hospital is not able to stabilize a patient in its capacity, or if the patient makes a request, a suitable transfer should be implemented.

Compliance programs are systematic procedures instituted by any organization to ensure that the provisions of regulations being imposed by a government agency are being met. Examples are training of staff, establishing policies and procedures, internal monitoring among others. Setting up a compliance program is critical to protecting an organization. For example, in the event the organization is ever charged with violating rules and regulations, U.S. Sentencing Guidelines assert that the existence of an effective compliance program within an organization will be regarded favorably.

 

References

Boese. (2010). Civil False Claims and Qui Tam Actions 4e (2 Volumes) (Vol. 1). Aspen Publishers.

Kohn, A. M. (2002). HIPAA Privacy Rule. Applied Clinical Trials11(6), 60-63.

Lee, T. M. (2004). EMTALA Primer: The Impact of Changes in the Emergency Medicine Landscape on EMTALA Compliance and Enforcement, An. Annals Health L.13, 145.

Robertson, J. P. (1994). False Claims Act, The. Ariz. St. LJ26, 873.

Snyder, A. G. (1996). False Claims Act Applied to Health Care Institutions: Gearing Up for          Corporate Compliance, The. DePaul J. Health Care L.1, 1.

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