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What is case law? Case law are decisions that has been instituted by a judicial determination and some are placed into action by the body of legislators. Several case law events deals with the critical regulatory healthcare issues. This paper will inform the reader of how the issues relates to the nature, sources, and functions of the law.

Issues related to the nature, sources, and functions

“The Affordable Care Act was passed by Congress and then signed into law by the President on March 23; 2010. On June 28, 2012 the Supreme Court rendered a final decision to uphold the health care law”. (Healthcare.gov, 2012) The Affordable Healthcare Act affords new means to hold insurance companies responsible and offers strong selections for customers. The Medical Loss Ratio (MLR) is known as a percentage that healthcare insurers must meet or better known as the MLR requirement. Healthcare insurers are required by the Affordable Care Act to produce a reimbursement to its consumers. The Medical Loss Ratio financial measurement used in the Affordable Care Act to help ensure that health plans provide significant value to users. The following is an example of how insurers use the MLR “if an insurer uses 80 cents out of every premium dollar to pay its customers’ medical claims and activities that improve the quality of care; the company has a medical loss ratio of 80%.

A medical loss ratio of 80% indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs, and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws.” (Healthcare.gov, 2012) The Affordable Care Act Law forces payer insurance policies for persons or groups to devote at least 80% of payments of medical care directly paid on behalf of the patient, that are meant to improve their quality of care. Payers marketing to big groups are required to spend 85% of those payments made for care and quality enhancement. The Affordable Care Act rule will not apply to companies that function as self-insured plans. Payer companies are required to report each year to the Human Services department regarding payments spent on quality improvement and health care services and any rebates applied to consumer accounts. The first report, was in 2011, and the newest in June of 2012. Payers are obligated to make the first of rebates to consumers in August of 2012. (Healthcare.gov, 2012)

This Act has good and bad ramifications. First the Act which is source law from the legislator, which not only creates new rules of law it also sweeps away existing inconvenient rules. The act has potential for ensuring that quality of care continues to improve, however companies that do not meet these standards are required to give a premium rebate to the consumer. What the law doesn’t say is how much of a rebate is required to give. The 20% is for overhead and quality improvements. The overhead of the company could be more than 20% therefore the consumer is left with no rebate. That rebate really only works out to be very small 10-15 dollars per consumer. Companies like large insurance payers spend 10 times those figures on quality improvements. I have worked in Healthcare for several years and in early 2005 legislation went through that required all Healthcare organizations adopt some sort of meaningful use Electronic Health Record by 2014.

This is a massive under taking for most healthcare institutions and the government was only offering up to $40,000 per healthcare organization to assist with this implementation. For a lot of smaller provider organizations this was a good deal, however the larger insurance companies and healthcare organizations would be spending millions on Electronic Health Records. According to the Centers for Medicaid and Medicare (CMS) only about 25% of healthcare organizations as of 2011 are up and running on a meaningful use EHR. (Centers for Medicare and Medicaid Services, 2012) These improvements the healthcare organizations are making with regards to EHRs are far surpassing the required 20% a year even if you break it down each year.

“October 1, 2013, medical coding in U.S. health care will be modified from ICD-9 to version 10. All healthcare related systems that is protected by the Health Insurance Portability and Accountability Act (HIPAA) are required to make the transition, not just those healthcare institutions that submit Federal Medicare or State Medicaid claims.” (Centers for Medicare and Medicaid Services, 2012) This is yet another quality improvement mandated by the source law of the Legislator that will cost healthcare organizations millions to implement.


Do the current process improvements that are currently mandated for all healthcare organizations count toward the 20% of profits made from premiums and services or do healthcare organizations still need to utilize the 20% for quality improvements on top of the already mandated improvements that the government requires to implement in the next few years? Healthcare all over the world often sometimes face many obstacles which includes different law cases. This paper has informed the reader of how the issues related to the nature, sources, and functions of the law.

Centers for Medicare and Medicaid Services. (2012) Retrieved from
Healthcare.gov. (2012). Retrieved from

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