What Is Healthcare Law?

Healthcare law is the legal framework for regulating the healthcare industry and medical services. Healthcare law protecting public health quality of care includes informed consent, bioethics, medical ethics, and managed care. Regulatory compliance includes HIPAA privacy, provider licensing, ERISA regulations, and insurance coverage. There are several federal healthcare fraud laws, including the False Claims Act, the Anti-Kickback statutes, and the Stark law. Doctors and hospital administrations are liable for violating patients’ rights under clinical negligence and medical malpractice claims.

A healthcare attorney is a key asset for any healthcare company. They can provide guidance for complying with existing regulations and legal aspects of the healthcare industry. They can also represent you in a licensing or other healthcare system-related issue.

An Overview of Healthcare Law: What You Need To Know

• The healthcare industry is among the most regulated in the United States, and for good reason
• Legislators have passed numerous laws designed to protect patient well-being and privacy
• Violating these laws can result in fines, license revocation, and jail time
• Many practitioners turn to healthcare lawyers to help create compliance programs for their practices

Assert Your Rights to Health Care

Health laws are complex. Use the Super Lawyers directory to find a healthcare lawyer near you who can protect your rights and access to the care you need.

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Healthcare Fraud and Abuse

According to estimates, healthcare fraud costs the government tens of billions of dollars each year. Since the government is the largest health insurance provider, any fraud can drain the public treasury.

Consequently, the government has passed numerous laws to protect against fraud and abuse.

False Claims Act

It is against the law to submit a false claim to the federal government for reimbursement. Many prosecutions are brought under the False Claims Act for various activities, such as submitting fraudulent bills to Medicare or retaining overpayments.

A civil penalty is assessed for each false claim, and they can rack up. Adjusted for inflation, each penalty is approximately $25,000. You will also need to pay back the amount you obtained from the government illegally, then multiply it by three. For example, if you submit $500,000 in false claims, you will have to pay back $1.5 million.

Anti-Kickback Statute

The federal Anti-Kickback Statute prohibits offering or accepting anything of value in exchange for a referral for a service paid by the government.

Kickbacks take many forms. The most obvious is someone offering you a fee for referring one of your patients to them. Kickback investigations involve doctors, hospitals, nursing homes, hospice services, ambulance services, and at-home healthcare providers.

Any violation can result in severe criminal penalties: up to 5 years in prison and fines up to $25,000. You might also face civil fines and loss of your license.

Stark Law

The Stark Law prohibits doctors from referring Medicare or Medicaid patients to an entity in which the doctor (or an immediate family member) is an owner. For example, a doctor cannot refer a patient to a nursing home he partially owns.

The Stark Law is designed to remove the incentives for making unnecessary referrals. A healthcare attorney can help you analyze if a referral would violate the law. The Stark Law also has some exceptions that might apply, so meeting with an attorney can help immensely.

An experienced healthcare attorney provides essential representation to any medical provider facing civil or criminal sanctions for violations.

Healthcare Audits

To uncover fraud, government regulators and private payors increasingly rely on audits. Very few healthcare providers will escape an audit, which is time-consuming and potentially invasive. Many investigators will request more documents than they are entitled to. A healthcare attorney can protect your business by negotiating the scope of the audit and reviewing documents before you hand them over. An attorney can also defend you and your practice in a hearing or in court.

The audit process is burdensome, and the appeals process is confusing. They require attorneys with the experience to marshal evidence, coordinate expert witnesses, and streamline the audit process. If you accidentally submitted inaccurate bills, an attorney could defend you against any allegation of fraud.

Healthcare Compliance

Compliance and regulatory violations pose serious risks to hospitals and other healthcare providers. To manage that risk, you should hire a healthcare attorney to help create a compliance program for your practice. These programs are essential because they foster a culture of compliance and inform your employees of the steps they must take.

Compliance programs also show that your hospital or practice is making a good-faith effort to comply with all regulations, which matters if the government investigates you.

If you suspect your practice has committed compliance violations, an internal investigation can help you get ahead of any regulatory or criminal proceedings. A healthcare attorney can perform a confidential investigation to help you root out the source of regulatory violations.

Patient Privacy

Numerous laws protect patient privacy and severely penalize doctors who violate them. The Health Insurance Portability and Accountability Act (HIPAA) is the primary federal law in this space. HIPAA led to national standards to protect sensitive health information from disclosure unless a patient gave consent.

HIPAA also led to the creation of security rules, which require that covered healthcare providers develop safeguards for patient privacy. A company cannot comply with HIPAA unless it makes serious efforts to train employees to handle sensitive patient information.

The Department of Health and Human Services (HHS) Office for Civil Rights reviews HIPAA violations. Penalties are steep. The severity will depend on whether you knew of the violation and whether you could have prevented it with due diligence. The most severe offenses are for willful neglect of the rules.

Adjusted for inflation, minor violations currently carry a minimum fine of $127, up to approximately $64,00 for severe offenses. It’s also possible to receive multiple violations per year, up to a certain limit. Criminal penalties are also possible, with serious violations resulting in 10 years in prison.

If you are a healthcare provider or other covered entity, you should hire a healthcare attorney to ensure your practice complies with HIPAA. This compliance can help you avoid potentially devastating fines.

Professional Licensing and Credentialing

Medical boards in each state regulate medical professionals such as doctors and dentists. They investigate complaints and impose discipline, including suspension or permanent debarment. If you are a healthcare professional, you’ll need a license from your state before accepting patients and providing medical treatment. Any prior criminal convictions or malpractice claims can slow down the process.

A healthcare attorney can advise you on the application process or defend you in front of the licensing board if you are facing a complaint.

Healthcare Litigation

Lawsuits are common in the healthcare industry. Many high-stakes disputes could potentially force your practice into liquidation, and even minor disputes can damage your reputation in the community. A seasoned healthcare attorney can represent you in various sorts of litigation:

• Government investigations
• HIPAA violations
• Insurance laws and private insurance company litigation
• False Claims Act
• Facility construction disputes
• Commercial disputes
• Medical malpractice claims
• Investor and partnership disputes
• Intellectual property litigation
• Shareholder lawsuits
• Breach of contracts
• Unfair competition claims
• Mergers and acquisitions of healthcare organizations
• Bioethics disputes

Reputation management is a key part of all healthcare representation. To protect a company’s reputation, healthcare attorneys can launch internal investigations, which show that you are taking allegations of misconduct seriously and have taken steps to ensure they don’t happen again.

A healthcare attorney can help reduce litigation costs. Disputes brought as class actions can cost millions of dollars. In some situations, settling early can save you money and avoid admitting to liability. An attorney should carefully review all possible resolutions and help you identify the best one for your situation.

Healthcare Attorney FAQs

When meeting with healthcare lawyers, ask any questions you have in mind, such as:

1. Should I talk to government agencies without an attorney?
2. Should I automatically turn over any patient or billing records, or are there situations where I can limit what I disclose?
3. What kinds of penalties do you think I face?
4. If my practice is sued, will I need a different attorney to represent me? Or do you represent both me and my practice?

Finding the Right Attorney for Your Needs

It is essential to approach the right type of attorney — someone from a reputable law firm who can help you through your entire case. Visit the Super Lawyers directory to find a lawyer who practices healthcare law.