Health Law
Authors:
Furrow, Barry R. / Greaney, Thomas L. / Johnson, Sandra H. / Jost, Timothy Stoltzfus / Schwartz, Robert L.
Edition:
3rd
Copyright Date:
2015
31 chapters
have results for insurance
Chapter 3. The Liability of Health Care Professionals 49 results (showing 5 best matches)
- Liability insurers use several mechanisms to assess physician insurance risks, and physicians are in fact likely to feel the effects of increased malpractice litigation in terms of insurance availability and pricing. Private insurance operates as a mode of regulation in liability insurance as well as other lines of insurance.
- Most health care providers buy insurance to protect themselves from medical malpractice claims. Medical malpractice insurance is sold by several types of insurers—commercial insurance companies, health care provider owned companies, and joint underwriting associations. Many large hospitals self-insure for medical malpractice losses rather than purchasing insurance, and a few physicians practice without insurance.
- Any serious analysis of a malpractice “crisis” begins with the insurance industry. The increase in the frequency of litigation against health care professionals and institutions coincided in the 1970s with a crisis of malpractice insurance availability. The most visible manifestation of the malpractice crisis in the 1970s and again in the 1980s was the size of increase in premiums for malpractice insurance purchased by health care professionals and institutions. Several insurance carriers dropped out of the malpractice market during the 1970s, while others raised their malpractice premiums precipitously to compensate for investment losses. The insurance market shrank, rates rose, and physicians and hospitals felt the pinch.
- In the mid-1970s state legislatures passed a first wave of reform legislation, and new insurance entities, such as physician-owned insurance companies, were created. The malpractice problem, as measured by the rate of increase of insurance premiums, seemed to stabilize. Then in the 1980s a new round of premium increases and large visible jury verdicts reignited the debate. The insurance “crisis” thus began with a rapid escalation in the costs to physicians and health care providers generally of malpractice insurance, as well as costs to product manufacturers, municipalities, and anyone who carried liability insurance.
- The market for malpractice insurance fails to satisfy many of the economist’s conditions for an ideal insurance market. The ideal market consists of a pooling by the insurer of a large number of homogeneous but independent random events. The auto accident insurance market is perhaps closest to fulfilling this condition, since the large numbers of events involved make outcomes for the insurance pool actuarially predictable. Malpractice lacks these desirable qualities of “… large numbers, independence, and risk beyond the control of the insured.” The pool of potential policyholders is small, as is the pool of claims, and a few states have most of the claims. The awards vary tremendously, with 50% of the dollars paid out on 3% of the claims. In small insurance programs, a single multimillion dollar claim can have a tremendous effect on total losses and therefore average loss per insured doctor.
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Chapter 6. Regulation of Private Health Care Financing 103 results (showing 5 best matches)
- Federal law makes Medicare and Medicaid secondary payers to private insurance to conserve the resources of the federal government. State legislation often attempts to make no-fault policies secondary to group health insurance to reduce the cost of no-fault insurance. Liability under worker’s compensation statutes tends to be primary to health insurance obligations.
- In 2012, 198.1 million Americans were covered by some form of private health insurance. 170.1 million Americans were covered under employment-related health insurance, and 30.6 million by other forms of private health insurance. In that same year private health insurance paid out $917 billion for health care, accounting for about 33 percent of national health expenditures. Fifty-five percent of Americans had health insurance coverage through their employers in 2012, but many employers, particularly small employers, do not offer health insurance as a benefit, and many employees who are offered employment-related coverage decline coverage because of the cost or because they are covered by a spouse’s policy.
- Offers of health insurance coverage as an employment benefit expanded rapidly after World War II as unions fought for employee benefits, which had become recognized as a subject of collective bargaining. During the 1950s employment-related health insurance continued to expand rapidly, driven by employee benefit tax exclusions and deductions in the 1954 Internal Revenue Code. By 1965, private health insurance covered 156 million Americans, 80 percent of the population. Health insurance coverage
- Health insurance is usually subject to some form of cost-sharing, under which the insured pays a share of medical costs. Cost-sharing is in part intended to diminish the incidence of “moral hazard”—the excessive use of services because the service is paid for by the insurer rather than the insured—but it also reduces the cost of insurance directly by shifting some of the cost of services to the insured. Employees commonly pay some part of the premium for employment-related health insurance. Insurance is also often subject to a deductible (e.g. the first $1000 of covered expenses) that the insured must pay each year before expenses begin to be covered. Separate deductibles may apply for particular services (such as hospitalization) or for individual family members. After the deductible is met, most insurance plans impose either a percentage coinsurance (e.g. 20% of covered expenses) or a flat per-service copayment (e.g. $20 per doctor visit) on the insured.
- Health insurance coverage is based in the first instance on a contract between the insurer and the insured individual or group. Therefore, questions of insurance coverage initially depend on contract interpretation (see § 6–2). An insurer’s denial of a benefit in breach of the insurance contract may also under some circumstances result in a suit in tort (see § 6–3).
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Chapter 13. Antitrust Law Part 2 9 results (showing 5 best matches)
- Perhaps the most significant manifestation of market imperfections associated with information problems occurs in health insurance. Two phenomena, moral hazard and biased selection, have a significant effect on the allocative efficiency of insurance markets. Biased selection occurs in two ways. Adverse selection describes the tendency of persons who expect to need health services to purchase insurance and to seek coverage for the specific coverage they need. At the same time, insurers make efforts to attract healthy consumers who will have less costly claims, a phenomenon called “favorable selection.” These biases in the selection process tend to cause competition to unravel, decrease the social benefits of insurance and ultimately undermine the risk-spreading function of insurance. Moral hazard refers to the tendency of insurance to reduce the insured’s incentives to arrest the hazard. In the case of health insurance, some claim that moral hazard interferes to some extent with...
- This statutory exemption provides that the Sherman, Clayton and FTC Acts are only “applicable to the business of insurance to the extent that such business is not regulated by State law.” Thus as long as an activity that would otherwise violate the antitrust laws (e.g. price fixing) is part of the “business of insurance” and authorized and regulated by the state, it is immune from attack. The Supreme Court has interpreted the “business of insurance” requirement strictly, holding that insurers’ provider contracts that did not involve “spreading and underwriting of a policyholder’s risk” were not exempt.
- monopsony power by insurance companies,
- ...is fully applicable to the health industry and has left very little room for consideration of factors other than competitive effect, the peculiarities and distortions of health care markets often necessitate more sophisticated analyses in order to reach economically sound results in antitrust cases. Moreover, widespread regulatory interventions by state and federal governments frequently call for difficult judgments about when conduct is truly private and hence within antitrust’s purview. Finally, antitrust law has sometimes been used by private plaintiffs for strategic purposes to accomplish selfish economic objectives that actually thwart the competitive process. This section sets out the statutory and doctrinal framework that guides antitrust analysis and discusses the unique issues posed by the economics of health care insurance and delivery. Subsequent sections examine the application of antitrust principles in five contexts: issues pertaining to the concept of “...
- Trade associations operating under not-for-profit organizational structures are nevertheless subject to the jurisdiction of the FTC when they engage in activities that confer economic benefits on their members, such as providing advantageous insurance and financing for members, or that engage in lobbying, litigation, marketing and public relations for their benefit.
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Chapter 4. Liability and Quality Improvement of Health Care Institutions Part 3 10 results (showing 5 best matches)
- The liability risks are certainly predictable in the short term as providers adjust to a new payment design with its regulatory demands. ACOs however have access to a range of insurance tools to offset these risks. The first is Directors and Officers liability (D&O) insurance, which covers many of the risks that ACOs may face, including litigation filed by shareholders and others for any number of business decisions. Second, Managed Care Errors and Omissions (E&O) insurance protects the health plan or network coordinator from claims brought by patients, competitors, and regulators, covering a much broader range of litigation risks. Many health care providers currently do not purchase such insurance coverage, but any organization that is forming or joining an ACO should consider purchasing it. Third, Provider Excess Loss Insurance protects the financial stability of a health care provider by limiting its exposure to catastrophic individual health claims from services it has...
- a. The Health Insurance Portability and Accountability Act (HIPAA)
- The goals of an effective risk management program are to eliminate the causes of loss experienced by the hospital and its patients, employees, and visitors. Risk management is thus concerned not only with the quality of patient care delivered by a hospital, but also with the safety and security of the hospital’s employees, visitors, and property. The risk manager also administers claims against the hospital if injuries occur and oversees the hospital’s insurance programs, determining which risks the hospital ought to insure against and which it ought to retain through self-insurance or high deductible reinsurance. Finally, the risk manager manages public and patient relations, as dissatisfied patients are more likely to sue for medical errors.
- Risk managers by contrast focus more on financial losses from medical malpractice claims and other forms of organizational liability, with the goal of insurance cost management and litigation risk reduction. The incident report has been the central tool of the risk manager. Hospitals require incident reports on occurrences that have resulted or could result in hospital liability or patient dissatisfaction; reportable events range from falls and sudden deaths to injuries from drug errors or equipment failures. Nurses typically prepare the reports and the risk manager investigates them, compiles data, and reports on hospital problem areas. Incident reports are central to claim management, allowing for payment when liability is clear and allowing coordination of defense.
- Managed care rapidly supplanted fee-for-service medicine during the 1990s and after. By 2012 employment-based insurance covered 155 million members. Fewer than one percent of the employees in all firms are enrolled in fee-for-service indemnity plans. Preferred Provider Plans (PPOs) now cover 56 percent of insured workers, and Health Maintenance Organization (HMOs) plans cover 16 percent, Point of Service (POS) plans 9 percent, and High Deductible Plans cover 19 percent, having risen from just 8 percent
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Chapter 7. Health Insurance Regulation Under the Affordable Care Act 94 results (showing 5 best matches)
- This chapter first reviews briefly the problems of access and cost to which the ACA responds. It then analyzes the provisions of the ACA intended to expand access to insurance coverage. Finally, it discusses ACA provisions designed to reform insurance and insurance markets, including the exchange marketplaces.
- Between 2000 and 2012, the number of Americans not covered by health insurance grew from 38.7 million to 48 million. An estimated 15.7 percent of the population lacked health insurance in 2012, up from 14.0 percent in 2000. Much larger numbers of Americans lacked health insurance at some point in time if one looks at periods spanning several years.
- general, individuals who can afford health insurance and who are not otherwise insured will need to purchase insurance or pay a penalty. Employers are not required to offer health insurance to their employees, but are required to enroll their employees in offered coverage automatically unless the individual employee affirmatively opts out. Employers will also be required to pay a penalty if they fail to offer their employees coverage, or if they offer inadequate or unaffordable coverage and their employees end up purchasing insurance through the exchanges funded by public subsidies. The exchanges and other insurance market reforms are examined below.
- At the heart of the health care reform is the concept of the health insurance exchange. An exchange (now generally referred to as “marketplace”) is a consumer-friendly market for health insurance, resembling a farmer’s market, stock market, or online travel service. It is a place where consumers can go, browse through the range of available insurance options, and choose the insurance plan that is best for themselves and their families. Small business health options (SHOP) exchanges will offer the same opportunities to small businesses. Given the range of understandable and transparent information that consumers will have available under the provisions examined in the previous section, consumers should be able to make intelligent choices when purchasing insurance.
- Nevertheless, the ACA dramatically expands the scope of federal insurance regulation. The ACA extends to an unprecedented extent federal regulation over the nongroup (individual) market, which was previously regulated almost exclusively by the states. The ACA also applies many more federal requirements to group health insurance plans, including self-insured plans. Sections 1563(e) and (f) of the ACA create §§ 715 of ERISA and 9815 of the Internal Revenue Code, applying all but two of the insurance regulation provisions of Part A of Title XXVII of the Public Health Services Act (PHSA), as amended by the ACA, to ERISA plans. However, each of the insurance reform provisions in the ACA has its own scope. Some cover all nongroup and group plans, some only insured plans, and some only nongroup and small group insured plans. In any event, federal regulation of health insurance will be much more extensive after the legislation is fully implemented than before.
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- The ADA includes important provisions regarding insurance. including in employer-provided health insurance. The Affordable Care Act brought entities that receive federal subsidies within the definition of federal funding for § 504, and this provision may allow claims against private insurers that receive payment in the form of federal insurance subsidies under the ACA.
- The ACA adopted several measures favorable to the provision of emergency medical care. The ACA’s greatest contribution to decreasing the pressure on emergency departments, however, is its extension of health insurance coverage and improved access to primary care.
- regulation where a hospital refused to accept a patient being transported in a non-hospital-owned ambulance after inquiring about whether she had insurance.
- The Affordable Care Act adopted a broadened definition of “federal financial assistance” to make clear that it includes “credits, subsidies, or contracts of insurance”
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Chapter 13. Antitrust Law 14 results (showing 5 best matches)
- For purposes of this discussion, HMOs may be defined as entities combining both the insurance (or “financing”) and service delivery functions in a single entity and usually entailing integration of physicians’ practices. IPAs are organizations comprised of physicians in independent practice who contract through the IPA with an HMO. IPA physicians share risk to some extent by virtue of their reimbursement arrangements with the HMO but do not perform the insurance function and do not integrate their practices. PPOs typically do not perform any insurance function or integrate their practices and physicians are paid on a fee-for-service basis and rarely assume risk. Both IPA and PPO physicians continue to compete for patients who are enrolled in insurance plans not served by their IPA or PPO.
- Group Life & Health Insurance Co. v. Royal Drug Co., 440 U.S. 205, 99 S.Ct. 1067, 59 L.Ed.2d 261 (1979); Arroyo-Melecio v. Puerto Rican American Insurance Co., 398 F.3d 56,67 (1st Cir. 2005)(immunity depends on “whether [defendant’s] activity constitutes the business of insurance”).
- The Supreme Court has defined the “business of insurance” to require that the activity involve (1) spreading or transferring risk and (2) the relationship between insurer and insured and not parties outside the insurance industry. Although state regulation must be present, this requirement has been broadly construed so that a general regulatory scheme is covering the unfair or anticompetitive.
- Group Life & Health Insurance Co. v. Royal Drug Co., 440 U.S. 205, 221, 99 S.Ct. 1067, 1078, 59 L.Ed.2d 261 (1979). In re Workers’ Compensation Ins., 867 F.2d 1552 (8th Cir.1989) (1989). , Virginia Academy of Clinical Psychologists v. Blue Shield, 624 F.2d 476, 484 (4th Cir.1980) (refusal to underwrite risk might constitute business or insurance).
- UNUM Life Insurance Co. v. Ward, 526 U.S. 358, 119 S.Ct. 1380 (1999) (interpreting “business of insurance” broadly in ERISA context).
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Chapter 3. The Liability of Health Care Professionals Part 2 6 results (showing 5 best matches)
- An analogous line of case law can also be found in the insurance benefit cases, where a plaintiff is denied insurance coverage because a physician neglected to complete benefit forms. Courts note that a treating physician is in a unique position to comply with insurance requirements and must do so. On the other hand, a physician who simply examines a person for purposes of employment by a third party and not treatment is generally not obligated to complete insurance forms.
- § 3–21. The Nature of the Insurance Industry
- a. Improving Insurance Availability
- A physician-patient relationship is normally a prerequisite to a professional malpractice suit against a doctor. When for example a doctor employed by an insurance company examines an individual for the purpose of qualifying him for insurance coverage, the usual rule has been that a doctor owes no duty to the individual to treat or
- Some physicians—such as obstetricians and emergency physicians—have curtailed their services in response to liability insurance concerns. Indigent patients create a special problem, since these patients create a liability risk, yet physicians cannot recover their liability insurance costs because there is no compensation for their services. They cannot also ask the patients to waive their common law rights to sue for negligence, following cases like
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Chapter 8. Medicare 20 results (showing 5 best matches)
- Between 1993 and 1997, Medicare experienced cost increases in excess of those experienced by the private insurance market (7.5 percent as compared to 3.5 percent). The private insurance market had by the mid-1990s turned to managed care, and conservative critics, who had always disliked Medicare’s administered price approach, argued that this disparity proved that the use of administered prices is inferior to managed care as a strategy for controlling costs. Some went further, contending that Medicare should merely provide vouchers to its recipients, who could then purchase insurance in the private insurance and managed care markets. The Republican Balanced Budget Act of 1995 would have turned Medicare into a voucher-based managed competition program, but it was vetoed by President Clinton. The more moderate Balanced Budget Act of 1997, created a new Medicare Part C, the Medicare+Choice managed care program, and attempted to woo, rather than drive, Medicare patients into
- set at $1216 for 2014. For the 60th through the 90th day of inpatient hospital services the beneficiary must also pay a co-insurance amount equal to one quarter of the deductible, and for the 91st through the 150th lifetime reserve days, a co-insurance amount equal to half the deductible. A beneficiary must also pay co-insurance for drugs and biologicals and The deductible and co-insurance obligations of Medicare recipients eligible for Medicaid qualified Medicare beneficiary coverage are covered by Medicaid.
- Unlike virtually every other industrialized nation, the United States has not developed a program for making health care available to all of its citizens. Rather, it has depended largely on employment-related group health insurance for financing health care, supplemented by individual insurance policies for those who can afford them and a variety of federal, state and local programs aimed at specific populations. The 2010 Affordable Care Act expanded coverage through advance premium tax credits that will help lower- and middle-income Americans purchase health insurance.
- The Medicare Program is really four programs, Parts A, B, C, and D. Part A, the Hospital Insurance program, covers inpatient hospital, post-hospital skilled nursing, home health, and hospice services. Part A is funded (much like the social insurance programs of central European nations) by payroll taxes assessed against employers, employees, and the self-employed, General revenues may not be used to fund the Part A program, although Part A may borrow from other federal social insurance trust funds.
- The conceptual bases of Medicare Part A and Part B were initially quite different. Part A was established as a social insurance program; Part B as a voluntary supplemental insurance program. Correspondingly, Medicare beneficiaries had full appeal rights under Part A like they had under Social Security. Part B beneficiaries denied services, however, could only ask the private Medicare contractor to reconsider.
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Chapter 9. Medicaid 26 results (showing 5 best matches)
- Though one of the primary functions of Medicaid in recent years has been to provide health insurance for children, many children have remained uninsured. Even after Medicaid eligibility expansions in the late 1980s and early 1990s, over 10 million children, many of them in low-income families, were still without health insurance. In response to this continuing problem, Congress created, as part of the 1997 Balanced Budget Act, the Children’s Health Insurance Program (CHIP), title XXI of the Social Security Act.
- F. THE STATE CHILDREN’S HEALTH INSURANCE PROGRAM
- § 9–14. The State Children’s Health Insurance Program (CHIP)
- Medicare is generally perceived to be a social insurance program like Social Security and the national health insurance programs of central European countries. Part A is funded by payroll taxes paid by employed persons, while Part B and D are financed by general revenue funds and by premiums paid by beneficiaries. Eligibility is not means-tested, although wealthy beneficiaries pay higher premiums and low-income beneficiaries receive assistance with Part D coverage. No stigma is attached to receiving benefits, which are considered to be an earned entitlement. Medicare is entirely a federal program and receives broad-based political support.
- and as long-term care insurance for the elderly is very costly, many elderly persons end up on Medicaid, our country’s catastrophic insurance program of last resort. In 2011, 12.5 percent of Medicaid funds were spent on nursing facility care, 3.3 percent on intermediate care facilities for the mentally retarded, and 13.5 percent on home health care.
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Chapter 13. Antitrust Law Part 3 10 results (showing 5 best matches)
- falling within its protection. The exemption applies solely to the “business of insurance,” not to insurance companies and only to parties in the insurance industry. In general, insurer services that do not directly involve the function of risk-spreading such as providing administrative services for a self-insured plan or offering an HMO product (which combines delivery of health services with the insurance function) are not exempt. On the other hand, providers offering group insurance policies that included prescription drug benefits,
- Ball Memorial Hospital, Inc. v. Mutual Hospital Insurance, Inc.,
- Travelers Insurance Company v. Blue Cross of Western Pennsylvania,
- The court upheld the government’s contentions as to relevant product market of commercial insurance product and geographic markets consisting of 15 regional markets. It also found the government had adequately alleged harm to consumers in the of higher insurance costs and creation of barriers to entry by rival insurance plans. Although Delta Dental had only a 35–45 per cent share of the market for dental insurance, the Justice Department contended that its contracts with over 90 per cent of Rhode Island dentists gave it power to foreclose competition by rivals. Finally, in a twist on the situations described above, the Department challenged and settled by consent decree a case involving a dominant hospital system’s insistence on steeply higher reimbursements from insurers if they contacted with its smaller rival hospitals.
- a case involving a challenge to a “most favored nations” (MFN) clause in the provider contracts of Blue Cross/Blue Shield, which controlled 80% of the Rhode Island private health insurance market. When Ocean State, a new HMO, began to make significant inroads, the Blues responded by imposing a requirement that participating physicians grant the Blues the same discount they granted to Ocean State. The First Circuit affirmed a judgment notwithstanding the verdict, finding that the “most favored nations” clause was a legitimate competitive strategy to assure that the Blues could get the lowest price for services rather than an attempt to monopolize the health insurance market. As such, it held the conduct was not “exclusionary” as a matter of law and did not violate Section 2.
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- Compare Tesar v. Anderson, 789 N.W.2d 351 (Wis. App. 2010) (cause of action against mother’s automobile insurance company recognized on behalf of fetus when the mother’s pregnancy was terminated as a result of the mother’s allegedly negligent driving) and Grodin v. Grodin, 102 Mich.App. 396, 301 N.W.2d 869 (1980) (cause of action recognized against mother’s homeowner insurance company on behalf of child whose mother took tetracycline during pregnancy, resulting in discoloration of child’s teeth) with Chenault v. Huie, 989 S.W.2d 474 (Tex.Civ.App.1999) (no tort action permitted against mother by child allegedly injured by mother’s illegal drug use during pregnancy). In one New Hampshire case, a child injured in utero collected $100,000 from a motorist’s insurer and $850,000 from the child’s mother’s uninsured/underinsured motorist insurer. The child also sought $300,000 more from the mother’s homeowner’s insurer (and more from the mother’s employer, as well as the lessee of the...
- For an updated summary, see Edward L. Raymond, Jr., Annotation, Coverage of Artificial Insemination Procedures Or Other Infertility Treatments By Health, Sickness Or Hospitalization Insurance, 80 A.L.R.4th 1058 (1990).
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Chapter 8. Medicare Part 2 2 results
- , Ezekiel J. Emanuel & Jeffrey B. Liebman, The End of Health Insurance Companies, N.Y. TIMES OPINION PAGES (Jan. 30, 2012, 9:00 PM), http://opinionator.blogs.nytimes.com/2012/01/30/the-end-of-health-insurance-companies/ (predicting that “by 2020, the American health insurance will be extinct” because ACOs will replace private health insurance companies); Stephen M. Shortell et al.,
- Ezekiel J. Emanuel & Jeffrey B. Liebman, The End of Health Insurance Companies, N.Y Times Opinion Pages (Jan. 30, 2012).
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Chapter 12. Medicare and Medicaid Fraud and Abuse 11 results (showing 5 best matches)
- The OIG is quite concerned that routine waiver of cost-sharing by providers and practitioners may result in increased utilization and other abuses. The coinsurance and deductible waiver safe harbor is very narrow in scope, therefore, and does not protect providers other than hospitals or charge-reimbursed physicians and suppliers. It must be read in tandem with the Fraud Alert on waiver of the Part B deductible and coinsurance issued in January of 1991. That fraud alert identified as suspect practices advertisements that stated “Medicare accepted as payment in full” or that promised discounts to Medicare beneficiaries, routine use of “financial hardship” forms, collection of coinsurance and deductibles only where the beneficiary has Medigap insurance, charges to Medicare beneficiaries that are higher than those made to others for similar services or items, failure to collect deductibles or coinsurance for reasons unrelated to indigency, or “insurance programs” that cover coinsurance...
- Waivers of coinsurance and deductibles may result in civil penalties as well. Section 231(h) of the Health Insurance Portability and Accountability Act of 1996 imposes sanctions against “individuals or entities that offer remuneration to a program beneficiary that they know, or should know, will influence the beneficiary’s decision to order or receive items or services from a particular provider, practitioner or supplier reimbursable by Medicare or the State health care program.” The provision exempts deductible and coinsurance waivers that meet certain conditions, cost-sharing provision as part of a benefit plan design, and incentives to promote primary care.
- ...for participating in a federal health care program. Others police Medicare cost-control initiatives—punishing overservice or improper coding by providers paid on a fee-for-service or cost basis or underservice by providers paid through risk-sharing contracts. A few cases have been brought against providers who have violated their obligations to Medicare or Medicaid by providing poor quality items or services. A complex and confusing body of law prohibits under the rubric “bribes and kickbacks” a variety of rebates, discounts, and profit-sharing arrangements that in other industries might pass as a permissible division of the proceeds of collective activity. The parallel Stark legislation prohibits self-referrals. Finally, a long list of specific prohibitions promotes various federal policies, including improving the quality of nursing home care, assuring emergency treatment regardless of ability to pay, and protecting persons who purchase Medicare supplement insurance...
- Congress backed off this legislation in 1998, when the DOJ and OIG issued guidelines to constrain their enforcement initiatives. Yet, aggressive enforcement continues to play an important role in a system where the utilization review and claims auditing systems found in private health insurance are largely absent.
- In the Medicare and Medicaid Patient and Program Protection Act of 1987, however, Congress authorized HHS to issue “safe harbor” regulations, delineating conduct that HHS determined should not be subject to prosecution or exclusion under the anti-kickback statute. The Health Insurance Portability and Accountability Act of 1996 further required HHS to annually solicit additional safe harbors or modifications of existing safe harbors, as well as advisory opinions and special fraud alerts.
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Chapter 11. Health Care Organizations: Business Structures and Tax Exemption Part 2 7 results (showing 5 best matches)
- See P.L.R. 200724034 (2007) (income received by a tax-exempt organization from administering health insurance plans for federal agency’s trainees and other workers who did not qualify for federal insurance did not generate unrelated business tax income because its administration was substantially related to the organization’s tax exempt purpose of supporting that federal agency’s research programs); TAMS 200218037 (2002) (fees received by exempt general partner for administrative and management services provided to limited partnership operating MRI facility were unrelated business tax income).
- treatment will be accorded to … members-subscribers” in violation of the prohibition against private benefit and because the prepayment of medical services was a “form of insurance,” and so not exempt under § 501(c)(3). The Tax Court reversed, holding that rendering medical care was a charitable purpose and that the HMO could satisfy the qualifications to which hospitals were held, relying on the availability of emergency treatment and the fee waiver program. The Tax Court held that “[i]f the charitable hospital can, except for emergency cases, restrict its treatment to paying patients, the Association should be able to restrict itself to paying members.” The Court was not persuaded by the IRS’ claim that the HMO offered a “form of insurance” through spreading the risk of the costs of treatment among subscribers, because this risk-spreading benefit was a public benefit available to a large number of potential subscribers. In 1981, the Service “acquiesced” in Sound Health Association,
- , West’s Colo. Rev. Stat. Ann. § 12–36–134(1)(g) (joint and several liability for all shareholders except when corporation carries professional liability insurance meeting state requirements); S.D. Codified Laws §§ 47–11A–8 to 47–11A–12, §§ 47–11B–17 to 47–11B–21, §§ 47–11C–17 to 47–11C–21; Kan. Stat. Ann. § 40–3403(h); Cady v. Schroll 23 HLR 177 (Issue No. 5, Jan. 2014) (where the court found no liability for negligence of professional healthcare employee who is covered by state’s malpractice insurance fund).
- , Ala. Code § 10–12–3; Official Code Ga. Ann. § 14–11–201; Md. Code Corps. & Ass’ns § 4A–201 (excluding business of insurers); Wyo. Stat. § 17–15–103 (excluding banking and insurance).
- In rejecting a the conversion transaction involving Blue Cross & Blue Shield of Maryland based on failure to comply with statutory standards, the insurance commissioner also found breaches of the duty of care and loyalty in that the purchase price did not reflect the fair value of Carefirst, due diligence was not exercised in negotiating the terms of the acquisition, and that it would ultimately result in unjust bonuses to directors.
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Chapter 11. Health Care Organizations: Business Structures and Tax Exemption 11 results (showing 5 best matches)
- The fully integrated system is one that combines comprehensive, integrated service delivery with the insurance function. Prototypical examples are those HMOs, which employ staff physicians (staff model HMOs) or contract with group practice physicians (group model HMOs) and own their own hospital for provision of acute care services. ...integrated in several respects. First, individuals must obtain all covered health services from the HMO; any services received from non-HMO providers are paid for out-of-pocket. Thus, patients are closely bound to the HMO for their care. Second, physicians are employees or are paid through capitated payments and other financial incentives that serve to align their incentives with those of the HMO. Essentially, both the HMO and its providers are at risk for overutilization. Finally, internalization of the insurance function within the entity enables the HMO to design and market to employers and individuals a single and complete package that...
- However, given the need for capital and the incentives for expansion and integration under health reform, many predict that for profit health systems will expand at the expense of standalone nonprofit hospitals. In other sectors, such as skilled nursing facilities and health insurance, there has been a decided movement to the for profit corporate form.
- Public benefit corporations under state law usually qualify as 501(c)(3) charitable entities, have self-perpetuating boards of directors and do not have members to whom they may distribute assets on dissolution; some state laws also apply a higher standard of conduct to directors of these entities. Mutual benefit corporations such as trade associations and certain mutual insurance companies have members who may be entitled to receive distributions of assets upon dissolution.
- Consequently, the court held that the company could merge with Illinois Blue Cross-Blue Shield (an Illinois mutual insurance company) without dedicating any of its assets to charitable purposes. In reaching its decision, the Texas court relied on a variety of factors that indicated how BCBST actually operated, such as that it was regulated as an insurance company; provided no charity care or other traditionally charitable services; did not receive charitable gifts or contributions; charged competitive market prices for its product; and operated for the benefit of its policy holders, not the public at large.
- Hospitals enter into shared services agreements with each other to share costs of everything from laundry services to acquisitions of complex equipment. Physicians and hospitals frequently jointly own and operate entities offering ancillary services as well as medical office buildings and equipment. Hospitals and physicians often integrate to form entities that negotiate for provider contracts with payers, or in the case of HMOs, actually perform the insurance function themselves. In anticipation of negotiating with health alliances, hospitals, insurers and physicians have begun to form integrated delivery systems to link most primary and acute care provider services into a single business unit.
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Chapter 15. Determination of Death and Procurement and Distribution of Organs for Transplantation 3 results
- Many legal consequences are triggered by the determination that death has occurred. These include the creation and distribution of an estate, the distribution of life insurance proceeds, the distribution of government and privately funded benefits, the termination of certain kinds of legal actions, and the termination of contractual interests such as health insurance coverage, among others.
- Melissa Wong, Coverage for Kidneys: The Intersection of Insurance and Organ Transplantation, 16 Comm. Ins. L. J. 536 (2010); C.K. Argo et al., Regional Variability in Symptom-Based MELD Exceptions: A Response to Organ Shortage?, 11 Am. J. Transplant. 2353 (2011).
- Organ transplantation is available only to those individuals who have the ability to pay, usually through Medicare, Medicaid, or private insurance. A candidate ordinarily is not placed on the active waiting list unless there is a reliable source of payment for the transplant and for the rather expensive lifelong post-transplant care required. Organ transplants raise the same coverage issues as do other medical treatments in terms of definition of benefits in the policy or program; determinations as to whether a treatment is experimental; and assessments of medical necessity, including concerns over effectiveness.
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Table of Cases Part 2 7 results (showing 5 best matches)
- Massachusetts Mutual Life Insurance Co. v. Russell ……………………………. 335, 343, 348
- Metropolitan Life Insurance Company v. Glenn ……………………………………………. 340
- Pilot Life Insurance Co. v. Dedeaux ……. 314, 328, 330, 335
- Pilot Life Insurance Company v. Dedeaux ………………………………………… 268
- Taylor v. Prudential Insurance Co………. 264
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Table of Contents 15 results (showing 5 best matches)
- Ted Acosta & Howard J. Young, The Health Insurance Portability and Accountability Act of 1996 and the Evolution of the Government’s Anti-Fraud and Abuse Agenda, 30 J. Health & Hosp. L. 37 (1997).
- GAO, Health Care Fraud, Types of Providers Involved in Medicare, Medicaid, and the Children’s Health Insurance Program Cases, 3, 8 (GAO–12–820, Sep. 2012).
- GAO, Health Care Fraud, Types of Providers Involved in Medicare, Medicaid, and the Children’s Health Insurance Program Cases, 29 (GAO–12–820, Sep. 2012).
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Summary of Contents 5 results
Chapter 4. Liability and Quality Improvement of Health Care Institutions 8 results (showing 5 best matches)
- , Michael Nathanson, Hospital’s Corporate Negligence: Enforcing the Hospital’s Role of Administrator, 28 Tort and Insurance L.J. 575 (1993).
- http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf. Ariele Yaffee, Financing the Pulp to Digital Phenomenon, 7 J. Health & Biomed L. 325, 340–41 (2011). “Health plan” is defined in § 1171 as “an individual plan or group health plan that provides, or pays the cost of, medical care.” This includes group health plans, health insurance issuers, health maintenance organizations, Part A or B of the Medicare program, Medicaid, Medicare supplemental policies, long-term care policies, employer welfare benefit plans, health care programs for active military personnel, veterans health care programs, CHAMPUS, the Indian Health Service program, Federal Employees Health Insurance Benefits Program, state child health plans, Medicare Plus Choice organization, and any other individual plan or group health plan that provides or pays for the cost of health care.
- J. Gabel, et al., The Changing World of Group Health Insurance, 7 Health Affairs 48, 52 (1988) (defined in study as HMOs, PPOs, or conventional plans with preadmission certification review).
- , Taylor v. Prudential Insurance Co., 775 F.2d 1457 (11th Cir.1985).
- Katie Siegel, Risks: Accountability in the ACO Structure, Risk and Insurance, (April 7, 2014), www.riskandinsurance.com.
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Chapter 14. Reproduction and Birth 9 results (showing 5 best matches)
- Under the Affordable Care Act, most group health plans and health insurance issuers must provide preventive services to their enrollees and insured without requiring any copay, deductible, or other form of cost-sharing. ...of which had jurisdiction over some aspects of this requirement) issued an interim final rule that adopted the Health Resources and Services Administration guidelines, based on recommendations made by the independent Institute of Medicine, that such preventive services include all forms of contraception that are approved by the Food and Drug Administration (FDA). Thus, most health plans and health insurance policies would cover hormonal methods of contraception (i.e., birth control pills and post-intercourse emergency contraception like Plan B and ella), IUDs, sterilization, and patient education and counseling. Notably, neither condoms nor vasectomies must be covered because those do not require FDA approval. This interim final rule did not come as a surprise...
- Finally, some women who have delayed child-bearing for economic reasons or to establish careers are discovering the negative impact of age on their ability to conceive. Many potential parents are simultaneously discovering that their health insurance refuses coverage on infertility procedures such as assisted reproduction and that the cost is beyond their means, raising societal issues of access to such procedures and whether only those with substantial financial resources will have meaningful access to remedy their infertility problems.
- Indeed, such actions commonly are commenced by the parents on the child’s behalf. It is to avoid exactly this kind of potential collusion that states previously applied doctrines of family immunity. The judicial abrogation of that defense amounts to a determination that the value of the risk spreading function of insurance (which cannot be served if plaintiffs are kept out of court by arbitrary defenses like that of family immunity) outweighs the adverse consequences of such potentially collusive lawsuits.
- More recently, the types of limitations imposed by states have included attempts to push forward the last permissible date for an abortion from the point of viability to some earlier point of fetal development, the regulation of health plan and insurance coverage of abortion, the requirement that abortions be performed at licensed facilities, like surgery centers, and by physicians with admitting privileges at nearby hospitals, and the regulation of tort law and damage principles to discourage abortion.
- It generally applies principles derived from the Hyde Amendment, described above. The ACA requires each health insurance exchange to offer at least one plan that does not include abortion coverage (although there is no requirement that there be one that does offer such coverage), and it allows the states to promulgate statutes that forbid coverage sold through the exchanges from including abortion coverage (again, except in cases of rape or incest, or where the life of the mother is at risk).
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Index 30 results (showing 5 best matches)
- Insurance regulation to increase, 6–4
- See also Accountable Care Organizations; Effectiveness Research; Health Insurance; Medicaid; Medicare; Premium Tax Credits
- Access to insurance coverage expansions, 7–3, 7–4
- Application for insurance affordability programs, 7–3.
- Insurance reforms, 7–4, 7–6
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Chapter 4. Liability and Quality Improvement of Health Care Institutions Part 2 12 results (showing 5 best matches)
- a. The Health Insurance Portability and Accountability Act (HIPAA)
- Most medical records contain the same categories of information, including patient identification data, a medical history, reports of tests or procedures, informed consent documents, diagnostic and therapeutic orders, and clinical observations by physicians and nurses. Financial information will also typically be included—including information regarding patients’ employers, insurance companies, and other responsible parties.
- The Health Insurance Portability and Accountability Act of 1996 was enacted to establish a uniform standard for the transmission of health information data between payers and providers.
- the court noted that the prevalence of liability insurance has calmed fears that a charity would be devastated by an adverse negligence judgment. Since that case, over 30 jurisdictions have abrogated charitable immunity, while the rest retain immunity to the extent of statutory ceilings on recoverable damages, or only up to available coverage, or only as to charity care. Partial immunity exists in some states, for example, beyond the coverage limits of liability insurance held by the hospital,
- It makes sense to focus liability on the hospital, whether the negligent acts are done by staff employees or independent contractor physicians. The hospital is arguably in the best position to monitor conduct within its walls, to enforce adherence to policies, and to provide a source of compensation to injured patients. Expanded liability also pushes hospitals to insure their staff and physicians on the medical staff under the same insurance carrier, to reduce their costs, and to turn independent contractor physicians into employees for some hospital functions.
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- ...to collect information on physician assisted suicide, and in early 2014 the Oregon Department of Health published a report that summarized the first fifteen years of the operation of that statute. During that period over 1000 patients received prescriptions for lethal doses, and about 750 of them actually took the lethal dose. In other words, about a quarter of those who received the prescription never used the medication; it may be that the security that came with having the prescription (in case the illness were to become unbearable) was more important for many patients than actually using it. About the same number of men and women used lethal prescriptions written under the Act, and most were older (mean age, 71) and non-minority (98%). The highly educated and urban were much more likely to take advantage of the statute than the poorly educated or rural. Virtually all of those who used the lethal dose had health coverage (mostly private insurance), and 90% were enrolled...
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Table of Cases 7 results (showing 5 best matches)
- Aetna Health Insurance v. Davila ………. 333
- American Manufacturers Mutual Insurance Co. v. Sullivan ……………………………….. 451
- Arroyo-Melecio v. Puerto Rican American Insurance Co………………………………….. 766
- Ball Memorial Hospital, Inc. v. Mutual Hospital Insurance, Inc……. 770, 772, 791
- Bonte v. American Global Insurance Company ………………………………………. 863
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- The UHCDA includes the normal raft of recordkeeping provisions, limitations on the reach of the criminal law, assurances regarding the insurance rights of those who execute the documents (actions taken under the statute do not constitute “suicide”), and restrictions on the liability of those who act under the statute in good faith. A provision for $500 in liquidated damages in actions for breach of the act may not encourage litigation when the statute is ignored, but the provision for attorney’s fees in those cases
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Preface 1 result
- The second part of the text (Chapters 5 through 9) broadly addresses the issues of access to health care and control of health care costs. These chapters address both private and public financing mechanisms in the many varieties that have been formed and reformed over the past few years, including Medicare and Medicaid and private health insurance. These chapters have been completely rewritten in this edition in response to the Affordable Care Act. In these chapters we also examine the continued evolution of managed care as well as the emergence of the consumer-driven health care movement. Finally, this material also addresses legal obligations to provide medical services under the Emergency Treatment and Labor Act and the common law.
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- Publication Date: November 14th, 2014
- ISBN: 9780314289070
- Subject: Health Law
- Series: Hornbooks
- Type: Hornbook Treatises
- Description: Expert authors present an up-to-date overview of health law as it affects the professionals, institutions, and entities that deliver and finance health care in the United States. Considers the law's response to quality and error through institutional and professional regulation, and malpractice litigation against professionals, hospitals, and managed care organizations. Surveys tax, corporate, and organizational issues. Explores the government's efforts to control costs and expand access through Medicare and Medicaid. Examines government attempts to police anticompetitive activities, fraud, and abuse. And considers the legal and ethical issues involving death, human reproduction, medical treatment decision making, and medical research. The Affordable Care Act, HIPAA, HITECH, and other new statutory and regulatory changes of the past few years are thoroughly incorporated in all aspects of the legal discussion.
