What are five elements pertaining to the establishment of a false claim under th

Question

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

Explanation / Answer

Answer:-

FINANCIAL LAW AND REGULATION:-

As stated in our book, the five elements relating to the establishment of a false claim under the False Claims Act are the government must determine that the claim was submitted falsely and that it was submitted with knowledge. The government must establish the claim was false and submitted knowingly, establish submitted claim to the person with actual knowledge, in considered ignorance, or with reckless disregard for the claim’s falsity, or truth . One of the other elements is that the element must be proven beyond a rational uncertainty to safeguard conviction is false, fictitious or fraudulent claim was material. Also, the false claim is founded of individual possession of property or money used by government and intending to deceive the government.

Objective of HIPPA privacy standards :-

There are three main objective HIPPA privacy standards that were considered to accomplish. Firstly, maintain the privacy of patient health information via fax, emails, and letters by using the right procedure in transferring or maintaining electronically records. Second main objective was to limit the circumstance in which individual disclose and use patient health information, establish every patient’s right regarding their medical information, and require protected individual to adopt administrative safeguards to protect the confidentiality and privacy of patient medical information. The third and last main objective of HIPPA privacy standards is to make sure that required entities adopt administrative safeguard by all the employees are following the rules and regulation along with security standards in order to protect personal health information of the patients .

Stark Law :-

As stated in our book, The Stark Law is a designated health services to an entity with which the physician has a financial relationship that prohibits a physician from referring a patient. Also, the physician may not bill Medicare patients for a claim based on a prohibited referral. The Stark Law only relates to referral made by physician and it does not include an intent requirement like the AKS (Cleverly, pg 93).According to our book, “Designated health services” is specifically defined to include the following:

1.Clinical laboratory services

2.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 and supplies

6.Parenteral and enteral nutrients, equipment, and supplies

7.Prosthetics, orthotics, and prosthetic devices

8.Home health services and supplies

9.Outpatient prescription drugs

10.Inpatient and outpatient hospital

Qui Tam:-

FINANCIAL LAW AND REGULATION4Qui tam is an Latin phrase that means “he who as well for the king as for himself sues in this matter.” The Federal False Claim has the legal term mechanisms for Qui Tam that permits person and entities to sue the wrongdoer on behalf of the government w with evidence of fraud against federal programs contracts .The actions of Qui Tam are also known as “whistleblower” suits. A relater in the qui tam action with personal knowledge of fraud brings the suit against a defendant on behalf of the government. The actions of qui tam should not be public, the known with which the realtor bring but the information that would not otherwise be available without the qui tam suit. The relator does not need to have a personally harmed by the alleged false claim. Although, a percentage of any award or settlement amount can, be received by the relator. The government has the option of joining the action of a plaintiff once a relator files a qui tam action. A person can receive a portion of 15- 25 percent of any recovered damages if the government does not decides to join. A successful qui tam action is when granting a relator a percentage, the FCA provides individual with incentive to assist government in identifying fraud especially the knowledge of an inside is required to identify such acts .

HIPAA Privacy Rule:-

In 1996, the Health Insurance Portability and Accountability Act or the HIPAA was endorsed by the U.S. Congress. The HIPAA Privacy Rule, also called the Standards for Privacy of Individually Identifiable Health Information, provided the first nationally-recognizable regulations for the use/disclosure of an individual's health information. Essentially, the Privacy Rule defines how covered entities use individually-identifiable health information or the PHI (Personal Health Information). 'Covered entities' is a term often used in HIPAA-compliant guidelines. This definition of a covered entity is specified by [45 CFR § 160.102] of the Privacy Rule. A covered entity can be a:

Health plan

Healthcare clearinghouse

Healthcare provider

Overview of the Privacy Rule

Gives patients control over the use of their health information

Defines boundaries for the use/disclosure of health records by covered entities

Establishes national-level standards that healthcare providers must comply with

Helps to limit the use of PHI and minimizes chances of its inappropriate disclosure

Strictly investigates compliance-related issues and holds violators accountable with civil or criminal penalties for violating the privacy of an individual's PHI

Supports the cause of disclosing PHI without individual consent for individual healthcare needs, public benefit and national interests

EMTALA:-

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented

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