In the constantly evolving climate of health care enforcement, maintaining a strong and effective internal compliance program has taken on added significance in the past few years. The Centers for Medicare and Medicaid Services and the Office of Inspector General of the U.S. Department of Health & Human Services, along with various other federal and state enforcement agencies, have increasingly focused on self-regulation of health care providers’ compliance as one of their top priorities.
Every hospital and medical staff will occasionally have to conduct a professional review concerning one of its physicians, and sometimes that review will lead to a hearing. Happily, no hospital does this very often, but, consequently, no hospital does it often enough to be really familiar with the process.
What This is and How to Protect It
State law purports to make the proceedings of a medical review or quality assurance committee confidential and privileged. This protection applies to the materials the committee reviews, the records it produces, and the recollections of the people who were at its meetings. N.C. Gen. Stat. § 90- 21.22A(c); N.C. Gen. Stat. § 131E-95(b). However, the protection is not as solid as you might imagine.
When the Government Comes Knocking:
False Claims Act Investigations
The primary federal and state enforcement agencies handling Criminal or Civil False Claims Act government investigations include the U.S. Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), the Office of Inspector General for the U.S. Department of Health & Human Services (OIG), the Department of Defense (Tricare Health Program), the United States Postal Inspection Services, State Medicaid Fraud Control Units, and task forces comprised from these agencies.
Regulatory Requirements for Nonprofit Hospitals in Financial Assistance and Debt Collection
Roughly 60% of hospitals nationwide have either obtained or are seeking tax-exempt status under the Internal Revenue Code (Code) and applicable rules. Rules adopted by the Treasury Department and the IRS impose upon nonprofit hospitals (referred to in the Federal Register as charitable hospitals) a number of additional requirements when attempting to collect debts owed for patient care and have imposed additional mandates related to financial assistance policies (FAP) and qualification of low-income patients for financial assistance.
Self-Referral and Anti-Kickback Statutes 101 For Hospitals
Hospital decision makers must understand the basics of the federal self-referral and anti-kickback statutes in structuring business arrangements with physicians and others in a position to refer, including medical director and other physician contracts, service agreements with other parties who generate referrals, management contracts, and joint ventures.
Best Practices for Dealing With Difficult Discharges
Fortunately, most people think of hospitals as places to go for treatment and healing, and then cannot wait to go home. Now and then, however, a hospital encounters the patient who just won’t leave, despite being medically able to do so. Imagine this scenario – a patient with recurring abdominal pain has presented to the hospital emergency department numerous times, often requiring a short term inpatient admission to stabilize and treat his or her acute medical need.
Honoring Patients End of Life Wishes:
Avoiding the Pitfalls of Advance Directives
All patients have the right to direct the course of their medical care. This includes the right to decline care, even life sustaining care. So says the United States Supreme Court, the U.S. Congress and the N.C. General Assembly. Through an array of Supreme Court decisions and federal and state laws, patients are guaranteed the right to create advance directives, such as living wills and health care powers of attorney, that either describe the care they want, or name a third party to make such decisions, when the patient is no longer able to make or communicate their own health care decisions.
Top 10 Certificate of Need FAQS
North Carolina’s Certificate of Need Law, codified in N.C. Gen. Stat. Ch. 131E, Article 9, outlines the types of services that require a CON and the requirements for filing, opposing, and ultimately appealing a decision of the N.C. Department of Health and Human Services, Division of Health Service Regulation, Healthcare Planning and Certificate of Need Section (the CON Section) regarding an application.
Document Retention in The Hospital Setting
Every hospital needs a comprehensive and consistently applied record retention policy that covers all forms of hard copy and electronic data. The reasons for adopting and implementing such a policy include, among others, ensuring compliance with statutory and regulatory requirements, maintaining control of records during litigation, improving efficiency in complying with records requests, and avoiding the disclosure of unnecessary or obsolete records.