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The Affordable Care Act (Aca) And Hospital Compliance

1565 words - 7 pages

The Affordable Care Act (ACA) brings a myriad of changes to the healthcare system and hospitals must adapt accordingly or face dire financial challenges. Some of the financial challenges will originate from the influx of Medicaid patients due to the Medicaid expansion. Based on these changes, there is an increased tendency for hospitals to engineer ways to reduce costs such as patient selection and staff reduction. However, for a hospital to participate in Medicare, which accounts for more than 50% of hospital budgets, certain laws and regulations must be followed. This paper discusses these laws and regulations and offers suggestions on how to adjust successfully to the upcoming ...view middle of the document...

Nonetheless, there are regulations that apply to patient selection that must be followed in order to ensure compliance with federal laws and prevent legal action against the healthcare organization. One of such regulations is the Emergency Treatment and Active Labor Act (EMTALA), which requires any hospital that participates in Medicare to provide medical treatment to all individuals that present at their emergency department with an emergency medical condition (EMC), regardless of their ability to pay (CMS, 1986). The ACA requires continued adherence to EMTALA and goes further to require non-profit hospitals to openly publish information about how individuals can receive financial assistance for their bills. Failure to comply with EMTALA’s guidelines may result in termination of the hospital’s participation in Medicare, as well as monetary penalties.
Another regulation of importance is the “Conditions of Participation” in the Medicare and Medicaid programs. Of particular importance is the rule that requires an increase in patient-centered care for all hospitals through internal assessment of quality, safety, and studying adverse events (CMS, 2003). These measures apply to all patients in the hospital with no room for selectivity and are accessed during onsite visits by Medicare officials. For instance, hospitals should not reduce the number or type of tests/treatments offered to a patient based on the type of insurance coverage they have or if they are uninsured or covered by Medicare/Medicaid. Since Medicare supplies more than 50% of the hospital’s reimbursements, it is imperative that these guidelines are strictly adhered to.
A third regulation, the False Claims Act (FCA) oversees inaccurate billing for services covered by Medicare and Medicaid (Kim, 2009). For instance, overbilling, under-billing or waiving the fee for a service covered by the government or private insurance is considered a false claim. According to Weiner (2001), the tendency to over-, under-, or not bill for a service arises mostly when providers are faced with patients that need a certain standard of care but the reimbursement from their third party payer is insufficient. Thus, physicians may opt to waive the coinsurance or copayment fees for patients who express financial difficulties (Weiner, 2001). Persistence of such practice may lead to violations of the Medicare and Medicaid anti-kickback statute, because providers who consistently waive fees for patients, may become favored by certain patients, providing unfair marketing advantage to the hospitals or practices they work for (Weiner 2001).
In order to adapt to these changes, while remaining compliant with healthcare laws and maintain quality care, the following suggestions are warranted. First, the hospital should consider developing increased affiliations with primary care physician groups, urgent care centers, and retail clinics such as the CVS pharmacy minute clinics. Affiliating with these groups will...

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