Skip to main content

Arkansas State University

Healthcare Law in the United States: What You Need to Know

Keeping up with the ever-changing healthcare laws can be a daunting task for nurse administrators. From pricing to privacy, legislative changes can affect every aspect of healthcare delivery and operations.

Luckily, an advanced degree with a focus on nursing administration can prepare healthcare professionals for the legal elements of the modern health industry. Here are several federal healthcare laws every nurse administrator needs to know to protect their patients and institutions:  

Stark Law Reform

As healthcare costs continue to rise, there has been a renewed focus on reducing fraud and abuse. The Centers for Medicare & Medicaid Services (CMS) enacted the Physician Self-Referral Law, commonly referred to as “Stark Law,” in 1989. According to CMS, the law “prohibits a physician from making referrals to an entity for certain healthcare services, if the physician has a financial relationship with the entity.”

However, CMS updated these anti-kickback regulations in November 2020. The new guidelines create permanent exceptions to the law that will encourage greater collaboration among providers without fear of violating the self-referral statute. They shift toward a value-based reimbursement model instead of a volume-based one. It also reduces the administrative burden associated with documenting compliance.

Consumer Pricing Transparency  

For decades, patients have been unable to access accurate pricing for hospital services and procedures before receiving them. Beginning January 1, 2021, every U.S. hospital must offer “clear, accessible pricing information online,” including self-pay and negotiated rates for items and services, says CMS. Institutions must supply information in two ways: a “comprehensive machine-readable file” of all items and services and a consumer-friendly format of at least 300 “shoppable services.”

Hospitals are subject to compliance audits, and those that do not comply face corrective active and monetary penalties. Similarly, beginning January 1, 2022, all uninsured and self-pay patients receiving scheduled care must receive good faith estimates from facilities and providers as part of the No Surprises Act.  

Patient Privacy and Substance Abuse Treatment  

Patient privacy remains a prominent concern, especially for patients seeking treatment for substance abuse and opioid use disorders. Previously, the receiving party’s information had to be explicitly listed for these records to be released. Revised guidelines, known as Part 2 under the Confidentiality of Substance Use Disorder Patient Records regulation, no longer require this information when releasing records.

The change will facilitate coordination of care and allow providers “to more easily conduct … quality improvement, claims management, patient safety, training and program integrity efforts,” notes the Substance Abuse and Mental Health Services Administration, the organization that oversees the legislation.

Expansion of Telehealth Billing

Telehealth services experienced rapid growth during the pandemic, and the trend will likely continue. However, insurance companies will no longer cover some telehealth services once the public health emergency ends. According to the American Health Law Association, the 2021 Physician Fee Schedule resulted in the following changes to telehealth coverage:

  • Expanded the list of covered telehealth providers
  • Classified audio-only telehealth services as billable under Medicare
  • Made nine telehealth services permanent for Medicare reimbursement
  • Included 13 telehealth billing codes that will remain temporarily through the end of 2023
  • Listed 74 billing codes that will expire alongside the official end of the public health emergency order

Physician and Emergency Room Access

Patients want to choose where they receive healthcare services, and the Affordable Care Act preserved those rights after passage in March 2010. Patients with health plans created or purchased after that date can choose any available in-network primary care physician or pediatrician, says Patients also do not need a referral for OB-GYN services, nor can they be charged a penalty for using out-of-network emergency room services.

Healthcare laws are constantly changing. Nurse administrators must stay abreast of these updates to ensure their patients’ rights are protected and their facilities remain in compliance.

Learn more about Arkansas State University’s online MSN – Nurse Administrator program.

Request Information

Submit the form below, and an Enrollment Specialist will contact you to answer your questions.

  • This field is for validation purposes and should be left unchanged.

Or call 866-621-8096

Ready to go?

Start your application today!
Or call 866-621-8096 866-621-8096
for help with any questions you have.
  • Choose All That Apply