Health Law and Policy Commons^™

Mediation And Medicare Part A Provider Appeals: A Useful Alternative, Kathleen Scully-Hayes

Journal of Health Care Law and Policy

No abstract provided.

Health Plan Internal Consumer Dispute Resolution Practices: Highlights From A National Study, Naomi Karp, Erica Wood

Journal of Health Care Law and Policy

No abstract provided.

Racial Profiling In Health Care: An Institutional Analysis Of Medical Treatment Disparities, René Bowser

Michigan Journal of Race and Law

This Article links unscientific, race-based medical research to a broader, institutionalized pattern of racial profiling of Blacks in clinical decision-making. Far from providing a solution to the problem of racial health disparities, this Article shows that race-based health research fuels a collection of dubious background assumptions, creates a negative profile of Black patients, and reinforces taken-for-granted knowledge that leads to inferior medical treatment. This form of racial profiling is unjust, and also causes countless unnecessary deaths in the Black population.

Routine Patient Care In Clinical Trials: Whose Cost Is It Anyway?, Dina Berlyn

Journal of Law and Health

This article examines the issue of coverage for routine medical expenses for clinical trial patients by third party payers from both a medical and political policy perspective. It is critical for patients, investigators, and sponsors to know who is responsible for paying these costs. This issue affects the willingness of patients to enter clinical trials and has the potential to affect which diseases will be the subjects of clinical trials. This presentation first summarizes the basics of clinical trials and then explores the definition of routine care in clinical trials. Medicare reimbursement, an issue that has been the subject of …

Punishment Of Health Care Fraud , Yvette M. Mastin

Journal of Law and Health

Although the definition of "health care fraud" is only one of the numerous issues of concern to health law practitioners and health care providers, the language that defines the conduct in question is the foundation of all other concerns related to "health care fraud." This Article will demonstrate the need for a narrowly construed definition of "health care fraud." The Article begins by providing a scenario to explain how a situation involving potential "health care fraud" can arise in the delivery of health care services. The Article then addresses how "health care fraud" is defined through a discussion of the …

The Tortuous History Of The Kyl Amendment, Marilou M. King

Health Matrix: The Journal of Law-Medicine

No abstract provided.

Section 4507 And The Importance Of Private Contracts, Thomas W. Greeson, Heather L. Gunas

Health Matrix: The Journal of Law-Medicine

No abstract provided.

The First Fifty Years: Health Law's Greatest Hit, Thomas Wm. Mayo

Faculty Journal Articles and Book Chapters

In honor of the Syracuse Law Review's 50th Anniversary, this article considers various developments in health law and concludes that the passage of the Medicare amendments to the Social Security Act has had the most significant impact on the field. The article discusses the impact of Medicare on the culture of hospitals and their medical staffs, on the development and dissemination of new technologies, and on restructuring and reforming the industry in key areas, including fraud and abuse, patient dumping, organ donation, advance directives, patients' rights, and other agencies' regulation of health care providers.

Increasing Consumer Power In The Grievance And Appeal Process For Medicare Hmo Enrollees, Kenneth J. Pippin

University of Michigan Journal of Law Reform

Federal law requires that Health Maintenance Organizations (HMOs) and Managed Care Organizations (MCOs) provide Medicare beneficiaries with specific grievance and appeal rights for challenging adverse decisions of these organizations. The Health Care Financing Administration (HCFA) is charged with enforcing these regulations. Currently, however, HCFA contracts with HMOs, allowing them to enroll Medicare beneficiaries despite the fact that many of the statutory and regulatory requirements are ignored by the Medicare HMOs. This is problematic because the elderly Medicare population may not be able to independently and adequately challenge the HMO's denial of care or reimbursement. Because HCFA has been reluctant and …

Health Care Marketing Under The Anti-Kickback Statute, Eric S. Tower

University of Miami Business Law Review

No abstract provided.

Is Managed Care Good For What Ails You - Ruminations On Race, Age And Class, Frank M. Mcclellan

Villanova Law Review (1956 - )

No abstract provided.

Introduction - Kyl Amendment Symposium, Maxwell J. Mehlman

Faculty Publications

Introduction to the Symposium: Medicare Private Contracting (The KYL Amendment), Cleveland, Ohio, 2000.

The Medicare And Medicaid Anti-Kickback Statute: Safe Harbors Eradicate Ambiguity, Durin B. Rogers

Journal of Law and Health

This Note will briefly explore the history of the Medicare and Medicaid programs including the introduction of the PPS. Next, the Note will detail the legislative history surrounding the adoption of the MMAKS and the judicial interpretation applied to its elements. The Note will follow with an analysis of the purpose, goals, and disagreements relating to the MMPPPA's "Safe Harbor" regulations, resolving their alleged ambiguity against the medical profession. Finally, the Note will advocate support of the recently proposed Health Care Cost Containment and Reform Act of 1992 with emphasis on increasing the budget and size of the staff within …

Machiavelli And The Politics Of Welfare, National Health, And Old Age: A Comparative Perspective Of The Policies Of The United States And Canada, Camilla Watson

Scholarly Works

This Article maintains that in order to fully comprehend the politics of welfare, retirement security, and national health coverage, it is necessary to examine Machiavellian principles in relation to the variables of economic development and inter-party competition. If the principles of Machiavelli are applied in a slightly different and more constructive manner, they may facilitate reform of the American welfare, retirement, and national health systems. Now that the political balance in the United States has shifted from the conservative to the liberal, the time is ripe to consider reforming the entire Social Security system and instituting a comprehensive national health …

Rethinking The Health Care Delivery Crisis: The Need For A Therapeutic Jurisprudence, Bruce J. Winick

Journal of Law and Health

In designing a sensible system of national health insurance we need to avoid a repetition of the built-in inflationary pressures that followed the adoption of Medicaid and Medicare. Medicaid and Medicare eligibility encouraged many to increase their use of health care services, in part because they no longer needed to bear the costs (or full costs) or services. This increased demand, exceeding the supply of health care services, predictably produced price hikes. Other factors undoubtedly have contributed to the escalation of health care costs, including the tendency of some doctors to order unnecessary diagnostic tests, over-reliance on high technology, and …

The Economics And Politics Of Emergency Health Care For The Poor: The Patient Dumping Dilemma, Maria O'Brien

Faculty Scholarship

As the numbers of uninsured mount⁴ because of job dislocations, exhaustion of benefits, and unaffordably high premiums, the incidence of "dumping" by private hospitals is, predictably, on the rise. Dumping occurs when a hospital, in violation of federal or state law, transfers an emergency patient to another (usually public) hospital or simply refuses any treatment based on the patient's inability to pay.5 In addition to the completely uninsured, favorite dumping targets include Medicare and Medicaid patients, AIDS patients, and cancer patients whose therapy may cost more than the maximum reimbursement under private insurance.

Dumping is merely a part of …

Securities Funding Of Long-Term Care: A Step Toward A Private Sector Solution, Dana Schilling

Fordham Urban Law Journal

This Article proposes a new system of fudning long-term care that contemplates the issuing of securities. This mechanism is designed to supplement or supplant private insurance and to enable the private sector to play a more significant role. This Article considers the current funding alternatives for nursing home care, and specifically explores the types of facilities already in existence to serve the elderly in need of nursing home services. This article proceeds to explore the concept of a health care consortium, and discusses the various legal implications of the plan.

Medicare's Prospective Payment System At Age Eight: Mature Success Or Midlife Crisis?, Bruce C. Vladeck

Seattle University Law Review

This Article is necessarily a rather selective (for reasons of brevity and reader tolerance) and even subjective attempt to summarize the experience under PPS to date and to suggest some lessons that might be drawn from that experience for the future reform of PPS itself and of payment systems generally. No attempt will be made here to be comprehensive, to explain all the technical details of an inherently and increasingly complex system, nor even to systematically survey the rapidly growing body of literature. But the few issues and themes that clearly stand out will be the focus of most of …

Policing Cost Containment: The Medicare Peer Review Organization Program, Timothy Stoltzfus Jost

Seattle University Law Review

This Article will first examine the problem of health care cost inflation and the payment strategies the Medicare program has adopted to address that problem. It will then discuss the perverse incentives that these payment strategies create, and the role of the PRO program in addressing harmful provider behavior encouraged by those perverse incentives. The Article examines evidence on whether the PRO program is succeeding or failing in this mission, and suggests possible means of improving the effectiveness of the PRO program in policing cost containment. Specifically, it recommends clarifying and strengthening the deterrent role of the PROs, crafting PRO …

Medicare/Medicaid Reimbursement Issues - A Provider's Perspective, Deborah M. Naglak

Journal of Law and Health

In 1965, Congress took its first historical step towards the ideal of universally accessible health care services with the enactment of the Medicare and Medicaid programs. These programs are federally subsidized health insurance programs administered by the Health Care Financing Administration within the Department of Health and Human Services. Under the Medicare statute, the federal government reimburses providers of medical services for care rendered to elderly or disabled patients, subject to guidelines and limitations. The Medicare Act establishes the costs allowed for reimbursement for services and authorizes the Secretary of the Department of Health and Human Services (HHS) to promulgate …

Financing Uncompensated Care: An Approach To The Issues, James F. Blumstein

Journal of Legal Education

No abstract provided.

Medical Peer Review, John D. Blum

Journal of Legal Education

No abstract provided.

When Must A Hospital Challenge The Medicare Reimbursement Policy?, Robert L. Schwartz

Faculty Scholarship

The Issue for the Court is whether the Medicare statute permits hospitals that do not formally request Medicare reimbursement for particular items in the cost reports filed with their fiscal intermediaries (who audit the reports) to seek reimbursement for those items when they appeal the fiscal intermediary's decision to the appropriate administrative board or court.

When Can The Government Issue A Retroactive Medicare Reimbursement Rule? A Preview Of Bowen V. Georgetown University Hospital, Robert L. Schwartz

Faculty Scholarship

The only issue before the Court is whether the Secretary of Health and Human Services can issue a regulation with entirely retroactive effect governing Medicare reimbursement for healthcare providers. The Court must decide whether such a retroactive rule is permitted by the Administrative Procedures Act (the "APA"), which defines a rule as "an agency statement of either general or particular applicability and future effect," or by the Medicare statute, which authorizes the Secretary to issue regulations to provide for the reimbursement of the "reasonable costs" of hospitals providing Medicare services.

United States V. Greber And Its Effect On The Medicare And Medicaid Programs, Stephen C. Pierce

Kentucky Law Journal

No abstract provided.

Abusing The Patient: Medicare Fraud And Abuse And Hospital-Physician Incentive Plans, Kathryn A. Krecke

University of Michigan Journal of Law Reform

Part I provides a background discussion of the PPS, DRGs, and incentive plans. Part II focuses on the fraud and abuse provisions of the Medicare statute and argues that incentive plans violate the plain language · of the statute, which prohibits any knowing and willful remuneration for the inducement of referrals. Part III concentrates on the fraudulent and abusive practices that incentive plans encourage. The plans frustrate legislative intent because they encourage practices that subvert the cost-containment purposes of the PPS and have an adverse effect on patient care.

The Medicare Rx: Prospective Pricing To Effect Cost Containment, H. Lynda Kugel

University of Michigan Journal of Law Reform

This Note analyzes the impact of changing hospital reimbursement while maintaining charge-based reimbursement for physicians on hospital-physician relationships and on cost and quality of care. This Note contends that if the stated goals of redirecting incentives and containing costs are to be realized, physicians must be drawn into the revised reimbursement scheme. An indirect, aggregate approach is advocated to maintain the integrity of the physician-patient relationship and to avoid a direct financial impact upon the physician regarding patient care decisions. Part I will briefly examine the reasons for changing hospital reimbursement from retrospective cost-based reimbursement to prospective fixed rates. Part …

Redefining Government's Role In Health Care: Is A Dose Of Competition What The Doctor Should Order?, James F. Blumstein, Frank A. Sloan

Vanderbilt Law Review

Throughout the 1970s, the two major political parties espoused some form of national health insurance. Faced with a fiscal squeeze, however, the Carter Administration gave national health insurance a relatively low priority.The political movement for comprehensive national health insurance rests on an ideological commitment that the federal government should underwrite the cost of providing universal access to medical services. The objective is essentially redistributive in nature: equitable concerns for the disadvantaged loom as the major focus. The selective expansion of coverage to encompass those identified as needy and worthy, but only those so identified, is anathema to those who traditionally …