Serving the Insurance Needs of Physicians, Medical Groups and Hospitals Across the USA


Compliance Definitions

HIPAA: HIPAA is by definition the Health Information Portability and Accountability Act and was enacted in 1996. It is enforced by the Office of Civil Rights of the United States Government. It is a set of federal guidelines created to allow employees to take their medical insurance with them if they leave an employer, allow people access to medical insurance despite pre-existing conditions (under some conditions), and to establish privacy standards for a patient’s health information.

HITECH: The Health Information Technology for Economic and Clinical Health (HITECH) Act provides the Department of Health & Human Services (HHS) with the authority to promulgate regulations and guidance to support the development of an interoperable, private, and secure nationwide health information technology infrastructure.

EMTALA: In 1986, the U.S. federal government passed the Emergency Medical Treatment and Labor Act (EMTALA). This act requires any hospital that accepts payments from Medicare to provide care to any patient who arrives in its emergency department for treatment, regardless of the patient's citizenship, legal status in the United States or ability to pay for the services. EMTALA applies to ambulance and hospital care.

Stark Law: The Stark law named for Pete Stark is a limitation on certain physician referrals. It prohibits physician referrals of designated health services ("DHS") for Medicare and Medicaid patients if the physician (or an immediate family member) has a financial relationship with that entity. A financial relationship includes ownership, investment interest, and compensation arrangements. DHS includes clinical laboratory services as well as the following: physical-therapy services; occupational-therapy services; radiology, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation-therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices; home health services and supplies; outpatient prescription drugs; and inpatient and outpatient hospital services. The law contains several exceptions, such as, in-office ancillary services, ownership in publicly traded securities and mutual funds, rental of office space and equipment, bona fide employment relationship, etc.

RAC Audits: Recovery Audit Contractor audits are done when an allegation of improper Medicare/Medicaid payments is made.

Patient Anti-Dumping: improper transfer of a patient (“dumping”)

CMS: Centers for Medicare & Medicaid Services.

TMB: Texas Medical Board

EMR/EHR: Electronic Medical Records aka Electronic Health Records

OSHA: Occupational Safety and Health Administration. (“OSHA”) regulations pertaining to blood-borne pathogens.

ADA: Americans with Disabilities Act (“ADA”) concerning the physical accessibility or construction of medical office premises or refusal to provide professional services to a disabled person.