MAG Overview of Key Federal Health Care Laws

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Kimberly Ramseur

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The Medical Association of Georgia (MAG) prepared the following summary of some of the key federal laws that apply to the medical profession as a resource for its member physicians. It is not a complete or exhaustive resource, and it is not intended to serve as legal advice – so physicians should contact their medical malpractice insurance provider and/or their health care attorney for specific guidance.

Americans with Disabilities Act (ADA)

The Americans with Disabilities Act gives civil rights protections to individuals who have disabilities that are similar to the ones that are provided to Americans on the basis of race, color, sex, national origin, age and religion. It guarantees equal opportunity for individuals with disabilities in public accommodations, employment, transportation, state and local government services and telecommunications. The ADA dictates how physicians treat patients with disabilities, including those with hearing impairments.

Anti-Kickback Statute

The Anti-Kickback Law was designed to protect patients and the federal health care programs from fraud and abuse. It provides that anyone who knowingly or willfully receives or pays anything of value to influence the referral of federal health care program business – including Medicare and Medicaid – can be charged with a felony. This law contains several safe harbor provisions (specific exceptions deemed not to violate the law), so compliance is fact-sensitive. Click here for an article on "How to comply with the Anti-Kickback Statute." Click here for a detailed list of safe harbor provisions and click here to watch the “Anti-Kickback Statute” informational video. Click here for MAG Legal Counsel Trish Yeatt's article "How to comply with the Anti-Kickback Statute."

Antitrust Laws

Antitrust laws address conduct that reduces or eliminates competition, including monopolies or price-fixing practices. It is imperative for physicians to be familiar with federal antitrust provisions. For example, it is illegal for physicians to share information about their employment compensation, reimbursement or discounts with other physicians. Under federal antitrust laws, physicians also cannot conspire or collaborate on payer contracts.

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)

COBRA gives employees the right to pay premiums to keep the group health insurance that they would otherwise lose after they reduce their work hours or quit their jobs or lose their jobs (i.e., “qualifying events”). Most people qualify for COBRA benefits for up to 18 months. Click here for COBRA FAQs.

Emergency Medical Treatment and Active Labor Act (EMTALA)

EMTALA is effectively a non-discrimination statute that requires hospitals and physicians to treat patients who arrive at an emergency department in an unstable condition without considering their ability to pay for the care or their health insurance coverage. EMTALA also addresses emergency room physician on-call requirements.

Employee Retirement Income Security Act (ERISA)

ERISA was enacted to prevent fraud and the mismanagement of employee pension and benefits funds by plan administrators (i.e., insurance companies). Under ERISA, an employee’s benefits cannot be wrongfully withheld and plan administrators must uphold certain fiduciary duties. ERISA does not apply to 1) government-sponsored insurance or 2) insurance for individuals, including insurance for people who are self-insured or 3) workers compensation or 4) automobile plans that include medical benefits or 5) some church plans. ERISA preempts state laws and lawsuits that “relate to” employee benefits plans. ERISA is designed to limit an employer’s liability related to the provision of health insurance benefits and to provide an incentive for an employer to provide health insurance benefits by freeing employers from state insurance regulation. Click here for more information.

False Claims Act

The False Claims Act makes it illegal for any person or entity to receive improper payments or avoid making payments to the federal government (e.g., Medicare or Medicaid). It also rewards “whistleblowers” who have information about false claims that have been submitted that are related to a government program for coming forward (and filing an action). Click here to watch the “False Claims Act” informational video.

Family Medical Leave Act (FMLA)

FMLA requires that any employer that has at least 50 employees must grant eligible employees up to 12 weeks of unpaid leave during any 12-month period for one or more or the following reasons: 1) the birth and care of the employee’s newborn child or 2) the employee’s efforts to adopt a child or become a foster parent or 3) caring for an immediate family member who has a serious health condition or (4) medical leave (i.e., the employee is unable to work) that is associated with a serious health condition.

Food Drug and Cosmetic Act (FD&C Act)

One of the main provisions of the FD&C Act is to establish the quality and safety standards for drugs and medical devices that are distributed to U.S. consumers. Physicians who use or import drugs or devices that fail to meet these standards or aren’t FDA-approved face increasing scrutiny. Click here for an article detailing a specific incident regarding the FD&C Act and the fines for violations.

Health Care Quality Improvement Act of 1986 (HCQIA)

HCQIA (aka as the “federal peer review law”) establishes peer review committees that are responsible for evaluating 1) the qualifications of professional health care providers 2)  patient care and 3) complaints that are filed against health care providers. Peer review committees that meet HCQIA standards and act on a good faith basis are immune from civil liability. Under HCQIA, practitioners must receive due process before any substantive action is taken against them. It is also worth noting that a peer review committee’s communications are confidential under HCQIA.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. These AS provisions also address the security and privacy of health data. The HIPAA Privacy Rule implemented in 2003 regulates the use and disclosure of Protected Health Information (PHI) held by "covered entities" (e.g., health care clearinghouses, employer sponsored health plans, health insurers, and medical service providers that engage in certain transactions). In January 2013, HIPAA was updated via the Final Omnibus Rule. The greatest changes relate to the expansion of requirements to include business associates, where only covered entities had originally been held to uphold these sections of the law. Click here for more information about the recent changes.

The Patient Protection and Affordable Care Act (PPACA)

PPACA includes numerous provisions that regulate the health insurance industry. These provisions will take effect between 2010 and 2020. Policies issued before 2010 are exempted by a grandfather clause from many of the changes to insurance standards, but they are affected by other provisions. 

Stark Law

Also known as the Physician Self-Referral Law, the Stark Law prohibits physicians from referring Medicare and Medicaid patients for “designated health services” to an entity with which they or an immediate family member has a financial relationship. The Stark Law contains approximately 35 exceptions, so the guidance for and compliance with the law is extremely fact-sensitive. Click here to watch the “Physician Self-Referral Law” informational video.