Health Care Compliance Regulations in the U.S.

Prone to timely amendments, The U.S. health care industry falls amidst the most scrutinized industries in the entire country. It is consistently experiencing a surging growth leading to a significant increase in the requirement of compliance officers across the 50 states.

The role of such compliance professionals is to assist health care facilities in maintaining compliance against the ever-growing regulations issued by the government. Let us take a look at some of the major laws and acts that help health care facilities in navigating through compliance procedures issued by The U.S. health care industry.

The department of Health and Human Services (HHS) in collaboration with the distinguished Office of the Inspector General (OIG) is the pivotal wing responsible for ensuring quality care and safeguarding the privacy of electronic health records (EHR).

A. Granting public access to emergency services, the EMTALA (Emergency Medical Treatment and Labor Act) mandates hospitals to render emergency services without considering the financial stability or insurance policy coverage of a patient.
This act is specifically applicable to all hospitals that participate in Medicare.

B. The importance of the Patient Protection and Affordable Care Act (PPACA) has had a huge contribution to bringing subsidized health care to the country. The law further requires providers to reimburse every patient (enrolled through federally funded programs) according to a specially designed ethics and compliance program.

C. CMS (Centers for Medicare and Medicaid Services) lays out EHR incentive programs to motivate health care facilities to protect and regulate electronic health records according to standards set by HITECH (Health Information Technology for Economic and Clinical Health). The HITECH Act is instrumental in improving the quality of health care delivered by providers. It further grants patients the legal right to extract their own records from doctors, hospitals, and other health care facilities.

According to CMS, in the year of 2016, U.S. health care reflected spending of $ 3.3 trillion and between 3% to 10% of this staggering amount is lost to fraud [1]. Figures on this colossal loss were generated by the Federal Bureau of Investigation and National Health Care Anti-Fraud Association.
With the sole intention of curbing the number of frauds, the government has also set-up various statutes, laws, and dedicated units.

A. Every state needs to have its own Medicaid Fraud Control Units (MCFU) which are meant to investigate frauds committed by Medicaid providers.
This unit also keeps a thorough check on issues related to patient abuse or neglect at the hands of health care facilities.

B. In addition to MCFU, The False Claims Act keeps a check on claims presented by facilities. The function of this act is to determine civil liability in case of a provider presenting a fraudulent claim to the government.

C. According to the Federal Anti-Kickback Statute, health care professionals are strictly prohibited from accepting money or products termed as rewards for referrals. This is concerning patients who are availing health care benefits under programs like Medicaid and Medicare.

Registered under the Occupational Safety and Health Act of 1970, the Occupational Safety and Health Administration (OSHA) defines workplace safety standards.

A. There is a multistep compliance process in place which helps in safeguarding health care workers whilst they handle x-ray machines and deal with infectious agents at the facility.

B. The Federal Emergency Management Agency (FEMA), is government agency which is responsible for setting up a systematic approach wherein government entities along with public and private sector organizations work in coherence to render a diligent response in case of catastrophic or large-scale epidemics or bioterrorism incidents.


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