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This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program.
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This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program. Physician. 20711. - PowerPoint PPT Presentation
Transcript of 20711
This PowerPoint file is a supplement to the video presentation. Some of the educational content of
this program is not available solely through the PowerPoint file. Participants should use all
materials to enhance the value of this continuing education program.
20711Physician
Deborah Dabbs, MBA, CHC, MT(ASCP)SM has no relevant financial relationships to disclose.Deborah Dabbs, MBA, CHC, MT(ASCP)SM has read and signed a statement of Evidence-Based Content and a statement of Content Validation acknowledging her responsibility to disclose drug products and/or devices with investigative nature, non-FDA approved uses, or off-label uses to TTUHSC and the participants for this activity.
11/30/2013
The accreditation for this program is valid through:
Release Date:
12/01/2011
20711Physician
Stark Law: Part 2If you have any questions about the program you are about to watch, you may call us at:
(800) 424-4888 or fax (806) 743-2233.Direct your inquiries to Customer Service.
Be sure to include the program number, title and speaker.
20711Physician
Stark Law: Part 2Deborah Dabbs, MBA, CHC,
MT(ASCP)SM Corporate Compliance
CoordinatorUMC
Lubbock, Texas
20711Physician
Objectives
1. Recognize the recent changes and clarifications in the Stark law.
20711Physician
Objectives
2. Identify Stark law concerning compensation/ remuneration.
20711Physician
Objectives
3. Indicate Stark law penalties.
20711Physician
Stark Law
Stark II Phase III
Stark Law
The opinions expressed are those of Centers for
Medicare and Medicaid Services (CMS)
Objectives
• Indicate the most important changes and additions made by Phase III
Objectives
• Identify potential future changes to Stark
Objectives
• Recognize that any number of factors can affect the landscape of Stark
Entity Amended
• To include a person or entity performing or furnishing designated health services (DHS)
Entity Amended
• Must be the person or entity that performs the DHS
Entity Amended
• Must be the person or entity that presents a claim for the DHS
Services Provided Under Arrangements
Services Provided
• Physician owner of an entity providing DHS under arrangements...
Services Provided
...(but not billing for those services) may have a non qualifiable...
Services Provided
...ownership interest in that entity
Services Provided
• CMS prohibited under arrangement agreements between hospitals and physicians...
Services Provided
...unless they meet a direct compensation exception under Stark
Group Practice
• Modified definition of physician in group practice; includes independent contractors
Group Practice
• An independent contractor physician is only considered a physician in the group practice...
Group Practice
...when he/she is performing services in the group’s facilities
Group Practice
• Encompasses only members (owners or employees) and independent contractors
Group Practice
• Productivity bonuses could be based directly on incident to services
Group Practice
• Incident to services are incidental to the physician’s personally performed services
Group Practice
• Profits must be allocated in a manner that does not directly relate to DHS referrals
Stand in the Shoes
• A physician organization is defined as:
Stand in the Shoes
– a physician
– professional corporation with a single physician as the sole owner
Stand in the Shoes
– a physician practice–- a group practice
In-office Ancillary Services
In-officeAncillary Services
• Physicians sharing a DHS facility in the same building must control the facility...
In-officeAncillary Services
...and the staffing at the time the DHS is furnished to the patient
In-officeAncillary Services
• Common per-use fee arrangements are unlikely to satisfy...
In-officeAncillary Services
...the supervision requirements of the in-office ancillary services exception
In-officeAncillary Services
• These arrangements must fully comply with the in-office ancillary services...
In-officeAncillary Services
...exception in the real world and not just on paper
Personally Furnishing Durable Medical Equipment (DME)
Fair Market Value (FMV)
FMV
• CMS eliminated the voluntary safe harbor provision within the definition of FMV...
FMV
...applicable to hourly payments to physicians for their personal services
Fair Market Value (FMV)
2 Methods for Calculating
FMV
• Hourly payment to average hourly rate for emergency room (ER) physician services in the relevant market,...
FMV
...provided at least 3 hospitals with ER services were in the market
FMV
• Based on 50th percentile of national compensation level for physician in same specialty...
FMV
...using 4 of 6 specified salary surveys and dividing by 2,000 hours to establish hourly rate
FMV
• Providers are responsible for FMV calculations…
FMV
…blind acceptance of an independent appraisal could land you in the hot seat
Intra-family Rural Referrals
Consider:Patient's condition, distance
to travel, and weather conditions
Time Determination
• Distance• Posted speeds• Weather conditions
Time Determination
• Physicians choosing to rely upon the 45 minute...
Time Determination
...alternate transportation time test should maintain documentation
Personal Service Arrangements
• Personal service agreements should not be amended...
Personal Service Arrangements
...to change compensation paid to physicians
Personal Service Arrangements
• The existing agreement should be terminated and a new agreement,…
Personal Service Arrangements
...with revised compensation terms, should be entered into
Personal Service Arrangements
• Personal service arrangements are defined as...
Personal Service Arrangements
...general remuneration from an entity under an arrangement...
Personal Service Arrangements
...or multiple arrangements
Personal Service Arrangements
To:– physician– his/her immediate
family member
Personal Service Arrangements
To:– group practice
Personal Service Arrangements
• Includes remuneration for specific physician services...
Personal Service Arrangements
...furnished to a nonprofit blood center
Conditions
• Each arrangement is set out in writing, is signed by the parties,...
Conditions
...and specifies the services covered by the arrangement
Conditions
• Arrangement covers all services furnished by the physician to the entity
Conditions
• The aggregate services contracted do not exceed those that are reasonable...
Conditions
...and necessary for the legitimate business purposes of the arrangement
Conditions
• The term of each arrangement is for at least 1 year
Conditions
• The compensation to be paid over the term of each arrangement is set in advance,...
Conditions
...does not exceed fair market value, and (except in the case of a physician incentive plan)...
Conditions
...is not determined in a manner that takes into account the volume or value of any referrals...
Conditions
...or other business generated between the parties
Conditions
• The services to be furnished under each arrangement do not involve the counseling...
Conditions
...or promotion of a business arrangement or other activity that violates any federal or state law
Conditions
• A holdover personal service arrangement for up to 6 months...
Conditions
...following the expiration of an agreement of at least 1 year...
Conditions
...that met the conditions mentioned is allowed,...
Conditions
...provided that the holdover personal service arrangement is on the same terms...
Conditions
...and conditions as the immediately preceding agreement
Physician Recruitment
Phase III made several changes to this
exception
Physician Recruitment
• Allows a hospital to recruit a physician from outside its geographical service area (GSA)
Physician Recruitment
• Does not apply to physicians already on staff in any category of privileges; active or not
75% Zip Code Test
• The GSA served by the hospital with the smallest number of contiguous zip codes...
75% Zip Code Test
...from which the hospital drew at least 75% of its inpatients
75% Zip Code Test
• Hospitals with service areas may not be able to configure a list of wholly contiguous zip codes...
75% Zip Code Test
...meeting the 75% test; those hospitals may use the area of contiguous zip codes that gets them closest to the 75%
75% Zip Code Test
• Rural hospitals also have the option to increase the percentage to 90%
75% Zip Code Test
• Rural area or health professional shortage area (HPSA) are allowed to...
75% Zip Code Test
...reallocate some existing overhead as part of recruitment arrangement
Practice Restrictions
• No moonlighting• No solicitation of patients
or employees
Practice Restrictions
• Mandatory acceptance of Medicaid and indigent patients
Practice Restrictions
• Prohibiting use of confidential or proprietary information of the practice
Practice Restrictions
• Requiring the recruit to repay practice losses in excess...
Practice Restrictions
...of the amount covered by hospital recruitment payments
Practice Restrictions
• Requiring repayment of reasonable liquidated damages...
Practice Restrictions
...if the recruit leaves the practice but remains in the community
Practice Restrictions
• Imposing a limited reasonable non-compete clause
Retention Payments
• Phase II, physician must have a bona fide written offer
Retention Payments
• Phase III, physician certifies in writing that he/she has a bona fide opportunity...
Retention Payments
...for future employment at least 25 miles outside the GSA
Retention Payments
• The physician must certify the offer was made
Retention Payments
• CMS will ask the hospital/practice for the certification letter provided by the physician
Retention Payments
• CMS will ask the physician for the proof that the offer was made...
Retention Payments
...when investigating retention payments
Retention Payments
• Payment may not exceed the lower of an amount equal to 25%...
Retention Payments
...of the physician’s annual income or the reasonable costs...
Retention Payments
...the hospital would expend to recruit a new physician
Retention Payments
• The hospital/practice would need documentation showing...
Retention Payments
...how much it cost to recruit a physician in the same...
Retention Payments
...or similar field in order to prove reasonable cost
Retention Payments
• Without documentation CMS might take the attitude the hospital/practice...
Retention Payments
...is paying the physician prohibited remuneration
Non-monetary Compensation
• Phase III permits non-monetary compensation not to exceed applicable limit ($355 in 2011),...
Non-monetary Compensation
...if it does exceed, the physician repays any excess in the same calendar year...
Non-monetary Compensation
...or within 180 days after received, whichever is earlier
Non-monetary Compensation
• The DHS entity must have a tracking mechanism
Non-monetary Compensation
• The annual appreciation event must include all medical staff
Non-monetary Compensation
• CMS allows either a celebration for Doctor’s day or a Christmas event
Professional Courtesy
• Allows hospital or provider to offer healthcare...
Professional Courtesy
...to physicians and families at reduced or no cost
Professional Courtesy
• No longer required to notify insurers of reduction or elimination of co-pay
Compliance Training
• Permits non-monetary compensation for compliance training...
Compliance Training
...in which a physician receives continuing medical education (CME),...
Compliance Training
...the primary purpose must be compliance
Compliance Training
• "Other" education may be included but should mostly be compliance education
Physician Ownership
• Physician ownership interest does not include security interest by physician...
Physician Ownership
...in equipment sold to hospital and financed with loan by physician to hospital
Signature Requirements
• Applies to all signature requirements with exceptions:
Signature Requirements
– rental of space– rental of equipment– physician recruitment
Signature Requirements
– FMV–indirect compensation– referral services– obstetrical malpractice
subsidies
Signature Requirements
– retention payments in underserved areas
– electronic medical records (EMR)
Signature Requirements
• If non-compliance is inadvertent; 90 days to obtain signature (if not inadvertent, then 30 days)
Period of Disallowance
• Sets the outer limits during which DHS providers can be guaranteed that billing is permitted
Period of Disallowance
• Phase II: the period of disallowance began the date of noncompliance to the date...
Period of Disallowance
...the relationship or arrangement became compliant or was terminated
Period of Disallowance
• Phase III: period of disallowance begins from the date of noncompliance, but ends no later...
Period of Disallowance
...than the date on which all excess compensation is returned to the party that paid it
Percentage-based Compensation
Percentage-based Compensation
• Phase III: no percentage-based compensation
Percentage-based Compensation
• Arrangements were paid on a percentage of revenues realized,...
Percentage-based Compensation
...thus violating the ban on the volume and value of referrals
Per-click Leases
• No longer permitted in phase III
Per-click Leases
• CMS believed that per-click leases may “reward” physician-lessors for referral
Per-click Leases
• No longer permitted in phase III
Academic Medical Centers (AMC)
AMC
• Phase III kept the phase II changes with minor clarifications:
AMC
– requires the medical staff category used in the numerator be used in the denominator
AMC
– compensation for each AMC component to a faculty physician must be set...
AMC
...in advance and not based on volume or value of referrals
Implants Furnished in an Ambulatory Surgery Center
(ASC)
Implants: ASC
• Exception permits physician owners of ASC to order and perform surgeries that include...
Implants: ASC
...implantation of durable medical equipment (DME) or other devices
Implants: ASC
• The exception makes clear that the ASC, not the physician, must submit the claim
Office Space Rental
• Rental rate must be set in advance
• Prorated rental for common areas
Office Space Rental
• May terminate office space lease within 1st year and may enter into new lease for different space
Office Space Rental
• Allocate cost of improvement over life of lease
Office Space Rental
• May impose a holdover premium, may not exceed 6 months
Ownership/ Investment Interest in Retirement Plans
Ownership/Investment
• Only retirement plans sponsored by a physician’s employer qualify for Stark exemption
Community-wide Health Information Systems
Community-wide...
• Items/services are available to physicians to enable...
Community-wide...
...participation in community-wide health information system
Community-wide...
• Available to all who wish to participate
Community-wide...
• Arrangement does not violate anti-kickback statute (AKS)
Electronic PrescribingE-prescribing (eRx)
E-Prescribing
• Nonmonetary remuneration necessary and used solely...
E-Prescribing
...to receive and transmit electronic prescription information
eRx Conditions
• Hospital to a physician who is a member of its medical staff
eRx Conditions
• Group practice to a physician who is a member of the group
eRx Conditions
• Part D prescription (PDP) sponsor or Medicare Advantage (MA) organization...
eRx Conditions
...to a prescribing physician
eRx Conditions
• The donor does not take any action to limit or restrict the use or compatibility...
eRx Conditions
...of the items or services with other electronic prescribing or...
eRx Conditions
...electronic health records systems
eRx Conditions
• Receipt of items/services is not a condition of doing business
eRx Conditions
• Arrangement set forth in writing
Electronic Health Record (EHR)
EHR Conditions
• Items and services are provided to a physician
EHR Conditions
• Software is interoperable
EHR Conditions
• No limits or restrictions on the use, compatibility, or interoperability of items/services...
EHR Conditions
...with other e-prescribing or EHR systems
EHR Conditions
• Before receipt of items/services, physician pays 15% of donor’s cost
EHR Conditions
• Is not a condition of doing business
EHR Conditions
• Does not take into account the volume or value of referrals
EHR Conditions
• Arrangement set forth in writing
EHR Conditions
• For items or services that are of the type that can be used for any patient without regard...
EHR Conditions
...to payer status, the donor does not restrict, or take any action to limit, the physician's right...
EHR Conditions
...or ability to use the items or services for any patient
EHR Conditions
• Items/services do not include staffing of physician offices and are not used primarily...
EHR Conditions
...to conduct personal business or business unrelated to physician's practice
EHR Conditions
• EHR software contains e-prescribing capability
EHR Conditions
• Does not violate AKS
Other Topics
Other Topics
• Remuneration unrelated to DHS: remuneration must be wholly unrelated to provision of DHS
Other Topics
• Obstetrics malpractice insurance subsidies:...
Other Topics
...CMS declined to expand this exception to permit subsidies...
Other Topics
...by all hospitals and for different specialties
Other Topics
• Reporting obligations: much of reported information will be exempt...
Other Topics
...by all hospitals and for all specialties
Other Topics
• Reporting obligations: discretion with regard to reporting deadlines...
Other Topics
...and may extend the deadline past the 30 days when appropriate
Miscellaneous
• Specialty hospital moratorium:...
Miscellaneous
...CMS is exploring changes to the Medicare enrollment form for hospitals
Miscellaneous
• Specialty hospitals are likely to continue to receive heightened attention from CMS
Miscellaneous
• No markup for purchased or reassigned technical and...
Miscellaneous
...professional services (proposed; not final as of yet)
Miscellaneous
• The only exception to the anti-markup rule is for full-time employees
Penalties
• Stark law is a strict liability statute; do not have to prove intent
Penalties
• CMS may deny payment for a claim that violates the Stark law
Civil Monetary Penalties
• $15,000 for each service, plus up to 3 times the amounts claimed
Civil Monetary Penalties
• Circumvention schemes: up to $100,000 for each such arrangement...
Civil Monetary Penalties
...or scheme plus an assessment
Civil Monetary Penalties
• False claims actions: $50,000 to $250,000 plus 3x amounts claimed
Penalties
• Good idea to perform a Stark analysis on all agreements
Penalties
• Agreement must also not violate the AKS
Stark Law
Stark II Phase III
11/30/2013
The accreditation for this program is valid through:
Release Date:
12/01/2011
20711Physician
Stark Law: Part 2If you have any questions about the program
you have just watched, you may call us at: (800) 424-4888 or fax (806) 743-2233.
Direct your inquiries to Customer Service.Be sure to include the program number, title
and speaker.
20711Physician
