Please see attachedAnti-Trust
You are a manager with five years of experience and need to write a report for senior
management on how your firm can avoid the threat of a Federal Trade Commission
investigation if you were to merge with other health care organizations. Research on
your own to select a health care organization in the United States that has been charged
with an antitrust action within the last five years and use this information as the basis for
your paper. In your report

● Summarize the charges and rebuttal or mitigation of charges used by the
health care organization you researched.

● Discuss lessons learned and propose actions that can be taken by your
management to avoid similar anti- trust actions in your proposed merger.Chapter 4

The Legal and Regulatory
Environment of Health Care

Learning Objectives

1. Understand how legal and regulatory issues shape
and define good financial management of a health
care organization.

2. Appreciate the consequences of failing to manage the
finances of a health care organization without regard
for the complex and ever-changing array of laws and
regulations that are unique to this industry.


Learning Objectives
3.  Recognize when and how to involve legal counsel

on a Medicare or Medicaid reimbursement issue or
other financial matter that has regulatory
compliance implications or would otherwise require
you to seek legal advice before making a decision.

4.  Identify the most common federal regulatory issues
such as fraud and abuse, Stark, HIPAA privacy and
security, EMTALA, and IRS requirements for tax-
exempt organizations, as well as less common
concerns that arise under the antitrust laws, Red
Flag Rules, and state insurance regulations.

Learning Objectives
5. Identify the major components of a corporate compliance

plan, including the establishment of internal controls
relating to the finances of an organization.

6. Be prepared to respond to a compliance audit or
investigation, particularly when the subject of that inquiry
includes financial records.

7. Be aware of the most important aspects of the Patient
Protection and Affordable Care Act of 2010 (Health
Reform Act) as it relates to financial management in the
post-Reform environment.


Law and Healthcare Financial Management

– Corporate Compliance Plans
• Office of Inspector General (OIG)


–  Internal Control and Corporate Compliance
• AICPA Elements


Primary Regulatory Issues
1.  Medicare Reimbursement

–  Parts A – Parts D
–  Certification of Providers
–  Payment to Providers

2.  Medicaid Reimbursement
–  Eligibility Determination

•  Federal Poverty Level (FPL)
•  Supplemental Security Income (SSI)

–  Coverage of Services
–  Establishment of Payment Rates
–  Medicaid DSH Payments 7

Primary Regulatory Issues

3.  Beneficiary Appeal Rights & Process
–  Medicare’s 5 Levels

4.  Fraud & Abuse
–  False Claims Act
–  Qui Team Actions
–  Kickback’s and Self-Referrals

•  Anti-Kickback Statute
•  Stark Physician Self-Referral Law

–  Safe Harbors 8

Privacy of Healthcare Information

–  HIPAA Overview

–  Privacy Standards

•  Protected Health Information (PHI)

–  Security Standards


Third Party Payor Contracts

–  State Regulator
•  “Any willing Provider”

–  Federal Law


Tax Exemption Issues
–  501 (C) (3) Organizations

–  Public Charity vs. Private Foundation

–  Charity Care

–  Unrelated Business Income

–  Form 990 11

Antitrust Issues
– Purpose of Laws

• Promote a competitive free marketplace

– Sherman Act
• Agreements that unreasonably restrain trade
• Price fixing

– IPA’s

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