Healthcare Law Worksheet

Health care business situations

The Law and Code Section

Legal requirements and Penalties for

non-compliance with the Law

Risk Assessment

Low

Medium

High

(Give reasons to support your rating)

Role of Person who can be a resource for compliance

(Give reasons to support your choice)

A question you would ask the resource person to help you better know how to comply with the law

A managerial action you would take to comply with the law

(Give reasons to support your action)

1. Your organization just hired a physician from out of state. The physician will need to become licensed in your state of Maryland. As an administrator, you have been asked to oversee the process to ensure the physician obtains a valid Maryland license to practice medicine.

State licensing law

Maryland Code § 14-101 (2013)

The Maryland Board of Physicians can impose a fine of up to $5,000.

Low

2. You were reviewing the new physician contract and see that the physician will be paid a flat salary with bonuses from the hospital for increasing hospital admissions.

Federal Antikickback Statute (AKS)

42 U.S.C. § 1320a-7b

Maryland Code § 8-511 (2016)

Examples of prohibited kickbacks include receiving financial incentives for referrals, free or very low rent for office space, or excessive compensation for medical directorships. Possible penalties for violating the AKS include: fines of up to $25,000, up to five years in jail, and exclusion from Medicare and Medicaid care program business.

3. Your managed care organization (MCO) wants to build a new hospital and 2 new rehabilitation centers in your state of Maryland. You are asked to spearhead the project.

State Certificate of Need

19 U.S.C. 19-120

Maryland Code § 19-125 (2018)

4. You oversee the medical billing department. The billing manager responsible for day to day activities was out of the office for 6 months on a disability leave. The manager has just returned and discovered that the coders billed everything at the highest level of service whether there was documentation to support it or not during the 6 months the manager was gone.

Federal False Claims Act (FCA)

Notice of Overpayment Rules

31 U.S.C. §§ 3729 - 3733

5. Your hospital wants to expand and buy out a physician group in a nearby town. The physicians would become employees of your hospital. 75% of the physicians in your town and the nearby would be employed by your hospital when the venture is complete.

Federal

Antitrust law

Joint Venture Guidelines

6.You are responsible for the profit/loss statements for your budget area each month. The Vice President over your area just asked you to ”improve” the numbers to show a profit even though the numbers show a loss. You have been told that the VP owns 60% of the shares of stock for your public corporation.

Federal Sarbanes

Oxley

Act (SOX)

Conflict of Interest

7. You are an entrepreneur and want to open up a home health company in Maryland. You want to be incorporated under Maryland law and operate as Home Care Inc.

State Incorporation

Law

8. You work for a family practice physician clinic. Two of the physician owners are also part owners of a nearby durable medical equipment (DME) store and a clinical lab. All physicians in the organization regularly refer patients to the DME store and clinical lab.

Federal

Physician Self-Referral Law (Stark)

42 U.S.C. § 1395nn

9. Your hospital is a non-profit organization and doesn’t pay taxes. The billing company at your hospital just sent word that it sent 50 unpaid claims to collections. You wonder if this should be considered charity care instead.

Federal

Internal Revenue Service (IRS) tax law

26 U.S.C.

10. You work for a large health insurance company. The company wants to start a disease management program for its members by contracting with a national pharmaceutical to run the disease management program.

Federal

Health Insurance

Portability and

Accountability

Act (HIPAA) Business Associate Regulations

45 U.S.C. § 160.103 (2013)

Since the introduction of the Omnibus Rule, the new penalties for HIPAA violations apply to healthcare providers, health plans, healthcare clearinghouses and all other covered entities, as well as business associates (BAs) of covered entities. The penalty structure for a violation of HIPAA laws is tiered, based on the knowledge a covered entity had of the violation. Tier 1: Minimum fine of $100 per violation up to $50,000

Tier 2: Minimum fine of $1,000 per violation up to $50,000

Tier 3: Minimum fine of $10,000 per violation up to $50,000

Tier 4: Minimum fine of $50,000 per violation