The American healthcare system is subject to fraud and record-setting amounts charged for normally affordable care. To combat this issue, the United States government implemented a number of statutes, regulations, programs, and compliance obligations on pharmaceutical companies and healthcare providers. For example, the Federal False Claims Act, the Stark Law, and the requirements in Obamacare. These pieces of legislation decrease the risk of fraud and protect stakeholders’ rights and financial security, such as nurses, doctors, and, most importantly, patients.
The Federal False Claims Act was a response to massive fraud in the healthcare system. It was passed in 1863 “to protect the federal government from fraud perpetrated by unscrupulous Civil War contractors” (Stowell, 2020, p. 387). The law imposes the investigation of suspicious activity, such as false records or statements aimed to avoid paying or transmitting healthcare services to the United States government. Medical associations have an obligation to report and record documents and agreements made between practitioners and patients for full transparency and elimination of the risk of tax avoidance. The Federal False Claims Act protects that obligation and enforces penalties for its unfulfillment. It coordinates its efforts with HHS-OIG to obligate compliance with its legal standards. For example, if the provider requested payment for more expensive categories of care than were provided or services that were never provided, the Federal Government stepped in to intervene. American citizens who have been wronged by the healthcare system can sue their providers on behalf of the government because of this act. It emphasizes the importance of protecting patients rights to affordable and high-quality services by giving them the opportunity to receive adequate retribution.
After the passage of the Affordable Care Act, the Federal False Claims Act improved its efficiency in dealing with fraudulent behavior in the healthcare sphere. According to Stowell (2020), after the Affordable Care Act, Congress lowered the disclosure bar for information that could be considered in a lawsuit. It made it so that the plaintiff in the case could use information that was specifically and privately available to them as evidence for false claims.
In terms of regulations imposed by the United States government, the Stark Law requires certain standards that health professionals have to meet to be able to provide their services to citizens. It was passed in 1989 and prohibited physicians with a financial relationship with a lab from meeting standards for referral for clinical lab services under Medicare (Stowell, 2020). After the passage of Medicaid, the Stark Law was expanded to include Designated Health Services in its regulations. These services incorporate physical therapy, occupational therapy, radiological and therapy services, and medical supplies. Its main goal is to ensure quality control measures within the healthcare sphere. It also restricts requesting referrals and government assistance from the government with fraudulent intent.
The government requires healthcare organizations to provide quality services and insurance to American citizens by Obamacare or the Affordable Care Act. It is both legislation and a guidance document for public healthcare providers. The American healthcare system has been criticized because of its cost, which does not always equate to its quality. These criticisms highlight the problem of low rates of health insurance among the population, especially those who are especially in need of care but refuse it because of their financial situation.
The 2010 legislation imposes compliance obligations on workplaces and healthcare providers to ensure sick people. The specific services included in the obligations are emergency, rehabilitative, mental health, laboratory, ambulatory services, hospitalization, maternity and newborn care, pediatric services, oral and vision care, and medication. The requirements that need to be met for affordable care are the patient’s monetary situation, meaning if they are below the poverty line, they have access to federally subsidized care (Center et al., 2017). It is very important for poor people to receive adequate care because they are significantly more vulnerable to health risks, such as poor urban environments, high work ethic, and financial stress.
Healthcare organizations are required, under Obamacare, to provide affordable healthcare to people in need. However, such a promise made by President Obama was not completed in its entirety. According to Center et al. (2020), after the act’s passage, “premiums continue to increase, worker participation in insurance is reduced, and out-of-pocket expenses continue to increase, specifically in some categories of vulnerable populations” (p. 129). The focus on healthcare provision and payment methods has contributed to additional costs of care and regulatory burden on medical companies. One aspect of this issue is explained by the rising costs of healthcare around the globe, meaning it is very difficult to measure the impact of the Affordable Care Act on American healthcare.
In conclusion, the American government has multiple laws in place to ensure healthcare affordability and eliminate possible fraud within the system. The Federal False Claims Act allows citizens to investigate and prosecute healthcare providers that have falsely administered care or payments. The Starks Law regulates designated healthcare service spheres to ensure that practitioners with financial ties to their medical institutions are charged for referrals. The Affordable Care Act, or Obamacare, is government legislation also used as a compliance program for health insurance. All of these government interventions in the healthcare system were passed with the intent to protect patients and vulnerable groups from exploitation and inadequate care.
Center, H., Woods, C. A., Manchikanti, L., & Purdue Pharma, L. P. (2017). A critical analysis of Obamacare: Affordable care or insurance for many and coverage for few. Pain Physician, 20(3), 111-138. Web.
Stowell, N. F. (2020). A forensic accountant’s guide to the most potent federal laws used against healthcare fraud. Journal of Forensic and Investigative Accounting, 12(3). Web.