Description
Discussion Questions
What kinds of fraudulent or abusive behavior relating to health care services can occur in hospital operations? How does the role of the compliance committee help to monitor and prevent these?
You are a hospital administrator, and you receive a call from a colleague at another hospital. Your colleague, who is a friend, informs you that he has received a demand for a stipend from the ophthalmologists who take ED calls at his hospital, and they want a sizeable raise. He asks you what you pay for that type of call, and suggests that you could both benefit by coming up with a standard rate of pay over which neither of you will go in response to physician demands. It could save your hospitals $300,000 to do this. What is your response, and what is the rationale for it?
Do you think that hospitals who engage in group purchasing organizations are engaging in a form of price-fixing? If yes, then why? If no, then why not?
EMTALA Scenario Analysis
Write a 1,000-1,250 word paper in which you analyze a scenario using the Emergency Medical Treatment and Active Labor Act (EMTALA).
You are the administrator on call for Hospital A and are responsible for accepting and rejecting patients. You receive a call at 2:00 a.m. from Health Hospital B regarding a patient with a severed ear.
The ED physician is calling to arrange an EMTALA-qualified transfer from his hospital to yours, but the ENT physician on call at your hospital is refusing to accept the transfer, stating that the patient does not need a higher level of care.
You call your ENT on call, and he admits he has just had three glasses of wine and will not be available for about 6 hours. You electronically send him the record that Health Hospital B would send with the patient. The ENT physician advises that the ear looks salvageable and could easily be sutured in any ED. The ED physician at Health Hospital B is very nervous about the possibility of an EMTALA violation.
- If you decide to reject the patient, is this a violation of EMTALA? Explain.
- What decision will you make as the administrator? Explain.
- Based on this scenario, what could be implemented to prevent this type of situation from occurring in the future?
- Under what scenario would the Hospital A physician be concerned about an EMTALA situation?
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.
Read "Feds Increase EMTALA Penalties against Physician and Hospitals," by Bitterman, from Emergency Physicians Monthly (2017), to complete the topic assignment.
URL:
http://epmonthly.com/article/feds-increase-emtala-penalties-physicians-hospitals/
Access the Primary Law page of the Emergency Medical Treatment and Active Labor Act (EMTALA) website. Click on "2008 amendments." Read pages 48654-48657.
URL:
http://www.emtala.com/law/index.html
Antitrust Case Analysis
Using the Health Care page of the U.S. Department of Justice Antitrust Division website, locate three antitrust law cases. Write a 500-750 word analysis of each case that describes the following:
- A brief overview of the particulars of the case.
- The impact of the case on the law and powerbrokers.
- Concerns regarding the case in the role of a health care leader.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.
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Running head: ANSWERS TO DISCUSSION QUESTIONS
Answers to Discussion Questions
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ANSWERS TO DISCUSSION QUESTIONS
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Answers to Discussion Questions
Question 1
Health care organizations engage in fraudulent practices and behavior through the pricing
and billing systems of the organizations and other operational procedures, which are designed to
give the organization financial benefits despite the failure to provide the services to patients.
According to Joudaki et al. (2015), medical providers tend to submit claim forms to the
insurance companies or government agencies for services that they may not have provided or
even for services not covered as done with matching patient files that may not have
documentation. Also, there are cases of misrepresentation of provider services through acts like
an impersonation of the physician in the billing systems. An additional example is the cases of
false reporting of diagnosis to seem so severe to bill for extra services. The final pattern of
fraudulent practices and behavior is the assurance of prescription drugs falsely for recreational
use or the provision of prohibited referrals.
Meanwhile, the compliance committee is an essential aspect of any healthcare organization,
which is responsible for ensuring adherence to its compliance requirements. Also, the committee
has oversight on legal and regulatory requirements especially those that might have adverse
impacts on the company due to any mismanagement of the patients. Thornton, Mueller,
Schoutsen, and Van Hillegersberg (2013) stated that committee has an obligation to know about
the compliance issues in the facility and develop the measures for dealing with them including
the cases of fraud and personnel involved in them. Finally, the committee provides for
communication among all staff that will curb cases of impersonation as health physicians and
allows monitoring to avoid unprofessional.
ANSWERS TO DISCUSSION QUESTIONS
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References
Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab,
M. (2015). Using data mining to detect health care fraud and abuse: a review of
literature. Global Journal of Health Science, 7(1), 194.
Thornton, D., Mueller, R. M., Schoutsen, P., & Van Hillegersberg, J. (2013). Predicting
healthcare fraud in Medicaid: A multidimensional data model and analysis techniques for
fraud detection. Procedia technology, 9, 1252-1264.
Question 2
My response to the proposition from the hospital administrator is that we are not
interested in the cost-saving benefits because it is illegal since the decision to use a standard rate
of pay for the physicians who work at our hospitals is price fixing. According to the Federal
Trade Commission (2018), price fixing is an agreement among competitors to raise, lower, or
stabilize prices or use competitive terms (para 1). Also, the antitrust laws that are used to regulate
the establishment of prices for commodities and services stipulate that a company must establish
rates and other terms independently and without going into agreement with a competitor. When
these provisions are used to examine the scenario, the proposition by the hospital administrator is
illegal despite its potential to save the organization an estimated $300,000.
Expressly, a hospital is not permitted to the fix prices of the healthcare prices through an
agreement with other providers regardless of whether the fixed costs are lower, higher, or the
same amount without any legitimate justification for the decision. An additional aspect of the
illegitimate nature of the proposal is that the emergency department ophthalmologists are not
allowed by law to negotiate a pay raise collectively and use it as a condition to determine the cost
ANSWERS TO DISCUSSION QUESTIONS
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of their services or their availability to the patients (Kaplow, 2013). Finally, the proposal would
limit the option of patients to obtain better care services that could be available to them if both
hospitals decide to enter an agreement to fix their prices.
References
Federal Trade Commission (2019). Price fixing. Retrieved from https://www.ftc.gov/tipsadvice/competition-guidance/guide-antitrust-laws/dealings-competitors/price-fixing
Kaplow, L. (2013). Competition policy and price fixing. Princeton University Press
Question 3
Group purchasing organization engage in the form of price fixing because part of their
responsibility entails the negotiation of prices for healthcare services such as the supply of
medical products or drugs on behalf of the healthcare providers. The hospitals that engage in the
group purchasing organizations do not negotiate with the suppliers as it is done on their behalf
for good discounts on the products (Blair & Durrance 2014). Therefore, they need to agree on the
prices for retail that are in line with the purchase prices.
Hospitals that are members of the group purchasing organizations monitor it with a bid to ensure
exposure on the dealings and that they do not restrain the trade. Both of them engage in the
assessment of administrative fees, and contracts durations with those supplying, Also, the
breakthrough of policies that are related to what their impacts may be on product innovation can
lead to anti-competition that can only be achieved through the fixing of prices to attain their
targets (Feldman, 2015). The engagement in the group purchasing organizations allows the
healthcare providers, taxpayers and also patients to save money, the presence of a variety to
choose from promotes competition from the procurement companies and also the existence of
ANSWERS TO DISCUSSION QUESTIONS
the funding model help in supporting completion and also lowering cost for the receiving end,
this therefore seeks for fixing the prices so as to benefit the health care providers.
References
Blair, R. D., & Durrance, C. P. (2014). Group purchasing organizations, monopsony, and
antitrust P...
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