Di Giovanni L, Gibofsky A
Fordham University School of Law, USA.
Leg Med. 1995:279-303.
The broad language and the broad application of the antifraud and Stark statutes has created uncertainty in the developing trend toward prepaid health plans and other systems (such as joint ventures) which are designed to deliver high quality services at reasonable costs. The motivation behind the statutes and the need for statutes that prosecute exploitation of the federal health care systems are needed. However, a reactive prosecutorial system may be inappropriate. A proactive administrative regulatory system where parties contemplating such ventures can receive quick, reliable approval or disapproval (with an explanation) would reduce the uncertainty in the current system. Such a system can be developed using the Stark reporting requirements and can be based on the model of certificate-of-need applications. Such models are being discussed in national health reform proposals, but in the area of antitrust. These proposals should consider such mechanisms for health care fraud that is of a more subtle nature. A serious longterm drawback is the lack of a preemption provision in the current laws and the proposals for national health reform relating to health care fraud and prohibited referrals. A preemption provision would reduce uncertainty that will develop as health care ventures cross state lines.
反欺诈法规和《斯塔克法案》宽泛的措辞及广泛的适用范围，给预付费健康计划及其他旨在以合理成本提供高质量服务的体系（如合资企业）的发展趋势带来了不确定性。这些法规背后的动机以及惩治对联邦医疗保健系统的剥削行为的法规是必要的。然而，被动的检察系统可能并不合适。一个积极主动的行政监管系统，在此系统中，考虑此类合资企业的各方能够迅速获得可靠的批准或不批准（并附带解释），将会减少当前系统中的不确定性。这样一个系统可以利用《斯塔克法案》的报告要求来开发，并且可以基于需求证明申请的模式。此类模式正在国家医疗改革提案中进行讨论，但却是在反垄断领域。这些提案应考虑针对性质更为微妙的医疗保健欺诈的此类机制。一个严重的长期缺陷是现行法律以及国家医疗改革中有关医疗保健欺诈和禁止转诊的提案中缺乏优先适用条款。优先适用条款将减少随着医疗保健企业跨越州界而产生的不确定性。
