Health law and regulations

Health Law and Regulations

In America, the health care industry is highly regulated. This is because there are certain aspects of the law which are designed to improve quality and offer everyone with a variety of treatment options. To fully understand this relationship requires carefully examining a specific government agency, the laws impacting the industry, the effects on a health care provider and how this is affecting communities. Together, these elements will highlight the way they are influencing how health care services are delivered across the country.

Explain the role of one specific governmental regulatory agency that has a significant effect on the health care industry.

One government agency which is responsible for the regulation of health care is the Centers for Medicare and Medicaid Services (CMS). Their responsibility is to ensure quality and the efficient delivery of health care services for older adults, the disabled, children and low income families. At the same time, they establish reimbursement levels, standards of care and are working to modernize the industry. They also provide coding for treatments / diseases and determine if a procedure is medically necessary. ("Better Care," 2013)

Provide at least two examples of specific laws (and corresponding regulations) currently faced by the health care industry and enforced by the specific governmental regulatory agency you are examining

The first law enforced by the CMS is the Affordable Care Act. Under these guidelines, they have the power to create health exchanges through the Medicaid programs (via the states) to cover 100 million Americans, who have trouble paying for the costs of health insurance. This means that they are regulating the practices of insurance companies by requiring them to keep their costs down and preventing them from engaging in certain procedures (such as: excluding preexisting conditions). (Lewis, 2013)

For instance, under Section 1104, it is establishing rules creating a unique system for the identifier and electronic transfer of funds. This is designed to ensure that the health exchanges can function more effectively and deal with the new challenges from patients who want to sign up for insurance. For the industry, this means that they will have greater costs for following these standards and implementing a new platform in the process. (Lewis, 2013)

The second law is the Health Insurance Portability and Accountability Act (HIPAA). Under these guidelines, the CMS has been pushing health care providers to begin enacting various kinds of privacy reporting standards in order to provide patients with more privacy, control and determining who has access to their medical records. (McGraw, 2013)

For example, a corresponding regulation which is enforced under these provisions is the Administrative Simplification Compliance Act. This requires that all forms which are submitted to Medicare (starting in October 2003) must be done so electronically. The basic objectives were to increase the practices of the health care sector by making them more responsive to stakeholders utilizing electronic-based medical records in the process. What the CMS is doing, is forcing these organizations to become efficient through implementing these guidelines for health professionals and providers. (McGraw, 2013)

Include in analysis the effect of these laws on at least one specific health care provider (such as: a specific hospital or clinic) that you select.

The impact of the Affordable Care Act on Coventry Health Systems is that their cost structure will begin changing towards the end of this year and into 2014. This means that they will have more structured policies in place. That are designed to reduce how much they are changing for different services. At the same time, the insurance companies will be reimbursing them for more of the costs of different people who are using their facilities. ("A Summary of Fees and Taxes," 2013)

For example, one area where this will occur is with the implementation of the Patient Centered Outcomes Research Institute. Under this new program, health care providers will have to pay a $.08 cent fee for every dollar they are charging to help patients make more informed decisions about their treatment options and services available. This is having an effect on their different hospitals by causing the cost structures to increase dramatically. ("A Summary of Fees and Taxes," 2013)

HIPAA is having an effect on Coventry Healthcare by requiring the provider to have greater protections in place to ensure that they are in compliance with these provisions. This means that they will see increasing costs from implementing different polices. That are requiring them to change how they are submitting paperwork to the CMS. At the same time, they must continue to engage in practices that will update these standards and follow them over the long-term. This will result in continuous training and monitoring to ensure that staff members are in compliance with these provisions. ("Health Care Law / Legislation," 2013)

For instance, a study that was conducted by the AMA found that many of these procedures were often very complex. This is because health care providers (such as: Coventry) were forced to follow a long list of requirements in order to be in accordance with these provisions. The problem is that there was a slowdown in the payments and the claims they were receiving. This is because a central clearinghouse was used in the process and there were times when something was completed. Yet, it would come back as requiring more information to be in compliance with these guidelines. For Coventry, if there was a streamlining of these guidelines, they could save $200 billion every year. At the same time, their cost structures and operating environment would become more efficient utilizing them. ("Standardization of the Claims Process," 2009)

Include ways that you have seen this effect in your own life or community.

The way that these laws have taken effect inside the community is to create a change in the kinds of services health care providers are offering. This is occurring through them having to adjust the fees they are charging. It is at this point, when they are seeking out more guidelines from the CMS about possible policy changes and if there will be shifts in the way they are reimbursing Medicare or Medicaid for these services. ("A Summary of Fees and Taxes," 2013)