Ftc Settlement Order Bars Texas Doctors ' Group From Joint Price Negotiations

The customers, Charles Ellison and Susan Bresler represented by the Atlanta law firm Strickland Brockington & Lewis sued the Natural Gas Company “under a private right of action in the Gas Act.” The plaintiffs sought to recoup their overpayments charged through the defendant’s violations of the Natural Gas Competition and Deregulation Act (Natural Gas Act). The defendant asked the court to dismiss the case due to the plaintiff’s failure to establish a reasonable claim on which repayment should be given. A trial court granted a motion to dismiss the case, but an

The Iron triangle for healthcare consists of cost, quality, and access; these three characteristics when balanced create great healthcare. Managed Care Organizations combine the three to offer consumers with care that is appropriate for their individual needs. Our book describes managed care organizations as “the cost management of healthcare services by controlling who the consumer sees and how much the service cost” (Basics of the U.S Healthcare System, Niles). Taking a look at the history prior to the Health Maintenance Organization Act of 1973 (HMO ACT of 1973) the implementation has been significant in balancing cost, and quality control. Before this Act was signed in to law by President Nixon healthcare costs were determined by fee for service. A fee for service or indemnity plan is a plan that allows the provider to determine the cost of service, this fee for service plan caused for healthcare costs to increase rapidly. An example of this would be going to the doctor with neck pain, being told to stretch then receiving a bill for 25,000 dollars. As could be understood the cost of healthcare had became a problem.

The PHO served as a vehicle through which competing hospitals and physicians could bargain collectively with health plans to obtain higher fees for themselves. The owner PHOs, member hospitals, and member physicians canceled contracts with payors and informed them that the PHO would be the sole entity through which they would enter into payor contracts. To contract with the PHO, payors allegedly have had to accept the fixed physician fee schedule and fixed discount of no more than 10 percent off hospital list prices.

Managed care organizations should have arrangement with both the medical insurers and providers to provide treatment for a contracted rate. Hospital should advertise the services they offer to members of healthcare plans through their healthcare provider by emphasizing on the technology, staff, and other quality of care they provide. Worker compensation plans are similar to commercial plans but treats injured employees. Hospital must contract with all workers compensation plans and must also negotiate coordination of benefits with other insurance carriers of the injured person to full compensate services. For Self pay patients hospital can reach out to them by having pre negotiate rates for treatment when payments are made in advance for certain procedures. Hospital should have system to accept payments when made in any

The pharmacist submitted claims for reimbursement on brand name medications rather than on the less expensive generic drugs that were actually dispensed. This is a result of health care fraud on Medicare part D, which is in violation of the False Claims Acts (FCA) and anti-kickback statues. "The FCA protects the government from being overcharged or sold substandard goods or services" (CMS, 2015). The federal Anti-Kickback Statue is designed to protect patients and federal health care programs from fraud and abuse. It states "that anyone knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward referrals of items or services reimbursable by a Federal health care program" (CMS, 2015)."The

To conclude this report, there are four considerations of a legal and valid insurance contracts that patients may present at the provider’s office or clinic. The guide to understand and remember are as follows: (a) the patient or person insured must be a mentally competent adult and should not be under the influence of drugs or alcohol; (b) the insurance company must have a signed application and offer the policy to the patient, then the patient or person should accept the issuance of the policy without misrepresentation of facts on the application of the person being insured; (c) the services produced and sold or the exchange of value and the first premium payment should be submitted with the application considered must be presented together; and (d) there should be a legal purpose which is an insurable interest in the case of a person’s healthcare insurance policy. These are good guidelines to know and understand for the success of an administrative life cycle of a physician-based claim (CMS

The Roaring Fork Valley Physicians, IPA, Inc., a Corporation violated Federal Trade Commission (FTC) Act’s Section 5. This Roaring Fork Valley Physicians, IPA, Inc., a Corporation was connected to approximately 80 percent of the doctors of the Garfield County, Colorado. The Federal Trade Commission (FTC) Act’s Section 5 stands for 15 USC 45. This act prohibits any unfair or deceptive act in practice in or affective commerce. This law is applicable to all the individuals who are related to the commerce and includes banks too. (1)

Making horizontal unofficial agreements with other competing physicians by acting through respondent to fix prices for treatment process which is usually high.

Securities and Exchange Commission v. NutraCea et al., United States District of Arizona, Civil Action No. CV 11-0092-PHX-DGC

BARBARA J. O'NEIL et al., Plaintiffs and Appellants, v. CRANE CO. et al., Defendants and Respondents.

Section 5 of the FTC Act provides the FTC and DOJ enforcement powers when unfair methods or acts which prohibit competition occur (Pozgar, 2012, p. 98). In general, joint pricing agreements among competitors are treated as per se illegal under Section 1 of the Sherman Act. The Clayton Act includes sections that “prohibit discrimination (e. g., in price), exclusive dealings and similar arrangements”, among corporations (anitrustlaws.org, 2015). The Sherman Antitrust Act makes illegal “every contract, combination in the form of trust or otherwise, or conspiracy in restraint of trade or commerce among the several states is declared to be illegal”. Areas of concern for healthcare organizations include reduced market competition, price fixing, actions that bar or limit new entrants to the field and preferred provider arrangements (Pozgar, 2012, p. 98).

Healthcare services have been on the rise for over 10 years now. According to a 2012 consumer alert, the industry provided $2.26 trillion in payments for more than four billion health insurance benefit claims in the year 2011(Fraud in Health Care). The bulk of the claims and the mainstream of fraud and abuse stem from the Medicare system professionals, who are knowledgeable about the process and persuade new clients into handing over their pertinent information in hopes of deception and illegitimate claims. Multiple and double billing, fraudulent prescriptions, are some of the major flaws in this organization that has made the healthcare services industry curdle. (AGHAEGBUNA, 2011) This is a non-violet crime and is often committed by very

Medicare is the nation’s largest health insurance program which benefits to more than 40 milliion Americans. However, billing and administrative fee overly cost that Medicare will soon can not handle the fee which leads to the disruption of health care in the U.S. The Medicare reform, various choices for Medicare and reduce fee-for-service plan are proposed to ensure Medicare program to continue. Medicare reform must be contained by injecting economic efficiency into the program, realigning the economic incentives of those who demand medical goods and services and those who provide them. Reduce fee-for service seems to be easy but not since there are many fees and charges should be taken care of in the form of insurance providers. While Medicare

In addition, this multi-payer system allows health care prices be set though the private marketplace of the country driving high costs for everyone. This health care system is the only one in the world that gives the freedom of setting their fees and prices, as they see convenient, to the large number of independent providers of health care services and marketers of pharmaceutical and medical supplies that exists. By doing so, the system has become unaffordable for the uninsured because of its excessive costs, and health insurance companies have been forced to accept whatever prices they set since they need to have them included in their networks.

Read Case 1.9, "ZZZZ Best Company, Inc." in your text. Answer questions #1, 2, and 4 found at the end of the case.