When responding to at least two of your peers, consider the following:
· How does the legislation or regulations addressed by your peers help to meet a gap in healthcare?
· How do the requirements provided by the legislation or regulations provide support for the legislation you addressed in your initial post?
There are many regulations in the United States that contribute to the deterrence of Healthcare Fraud. The Anti-Kickback Statute (AKS) is a regulation that is governed by the Federal government and overseen by the Department of Health and Human Services (DHHS). “The AKS makes it a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a Federal health care program. When a provider offers, pays, solicits, or receives unlawful remuneration, the provider violates the AKS.” (CMS, 2021).
This regulation ensures that individuals are being referred to high-quality providers and services based on the individuals’ medical need and not due to the providers’ remuneration for referrals. If individuals are referred to providers solely for the reimbursable value being awarded to that provider, it is possible that the health outcome is not the focus; therefore increased cost may be associated with the visits or plan of care. The AKS creates standards for providers to focus on quality measures for their patients and hold providers accountable for poor decisions as a healthcare professional. Healthcare services should be delivered with patient-centered focus.
Centers for Medicare and Medicaid. (January 2021). Medicare Fraud and Abuse: Prevent, Detect, Report. cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf
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Medicare Conditions of Participation (CoP) and Condition of Coverage (CfC) are federal regulations that particular healthcare facilities must comply in order to receive funding from Medicare and Medicaid programs. The goals of the CoPs are to protect patient health and safety and to ensure high-quality care if provided to all patients. CoPs are published in the Code of Federal Regulations (CFR). A healthcare facility can be a hospital, ambulatory surgery centers, home health agencies, long-term care facilities, rural health clinics, clinics, rehabilitation agencies, public health agencies that provide occupational physical therapy and speech-language pathology services, etc. (CMS.gov,2019).
These CoPs and CfCs are standards used by other national accreditation organizations to inform Centers of Medicare and Medicaid Services (CMS) that each healthcare organization is meeting their requirements, a process called “deeming” or granting authority on CMS’s behalf, to accredit. One example is the Joint Commission, an independent non-profit organization that has accredited more than 20,000 healthcare organizations and programs in the United States (Roopma et al., 2021). The Joint Commission reports findings to CMS, the agency responsible for overseeing regulation. CMS is part of the Department of Health and Human Services, a cabinet-level executive branch department of the US government.
Regulations are evaluated and revised on an ongoing basis when needs arise and as technology changes. For example, with the broader implementation of electronic medical records and electronic health records, CMS guidelines changed to help facilitate the exchange of information between hospitals and healthcare provider offices to ensure patient information made care consistent across all involved healthcare settings. While this is still an ongoing process since there is not just one EMR that all facilities work from, the effort to ensure quality care for patients remains the goal.
This regulation has impacted the healthcare sector by improving quality reform and giving patients and their families better access to their information to make informed decisions about their care, address their goals of care and treatment preferences, and more actively involved in their own care.
Centers for Medicare & Medicaid Services, (5/19/2020 updated) Conditions for Coverage (CfCs) & Conditions of Participation (CoPs). Retrieved from
Roopma, W., Huynh, A. (March 8, 2021 updated). The Joint Commission
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