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What is the anti-kickback rule?
Providers may not knowingly and willfully accept remuneration in return for generating Medicare/Medicaid business
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What are the elements to the personal service arrangment?
- (1) in writing
- (2) signed
- (3) specifies the services covered
- (4) covers all the services provided by physician to entity
- (5) services do not exceed reasoonable and necessary
- (6) at least 1 year
- (7) compensation (i) set in advance, (ii) does not exceed FMV, and (iii) does not take into account volume or value of referrals (except for physician incentive plan)
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What are the elements of the bona fide employment exception?
- (1) Employment for indentifiable services
- (2) FMV compensation
- (3) Not based on volume or value of referrals,
- (4) except for productivity bonuses based on services personally performed by physician
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What are the elements of an equipment lease?
- (1) in writing
- (2) signed
- (3) identifies the equipment covered
- (4) at least 1 year
- (5) only reasonsable and necessary equipment
- (6) equipment used exclusively by leasee during leased time
- (7) rent set in advance
- (8) rent is FMV
- (9) rent not based on volume or value of referrals
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What are the elements to the office space rental?
- (1) in writing
- (2) signed
- (3) identifies the premises
- (4) at least 1 year
- (5) only reasonsable and necessary space
- (6) space used exclusively by leasee during leased time
- (7) rent set in advance
- (8) rent is FMV
- (9) rent not based on volume or value of referrals
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What is the in office ancillary care exception?
- (1) Services furnished personally by (i) the referring physician, (ii) a physician in the referring physician's group, or (iii) an individual supervised by (i) or (ii)
- (2) at a specific location
- (3) billed by the physician, or other appropriate party
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What are physician services under the physician services exception?
42 CFR 410.20(a) Medicare Part B pays for physicians’ services, including diagnosis, therapy, surgery, consultations, and home, office, and institutional calls.
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Physician Services Exception
Physician services performed personally or under the supervision of another physician in the referring physician's group practice
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What is the definition of a group practice?
- (1) A single legal entity
- (2) Two or more physicians as owners or employees who (a) provide and (b) bill substantially all their care through the practice
- (3) Sharing of income and overhead (a) prospectively (b) using a method blessed by the statute
- (4) Unified business
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What are the exceptions to the definition of a referral?
- DHS personally performed by the physician
- Or
- Certain requests by pathologists, radiation oncologists,
- radiologists
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What is a referral (not including exceptions)?
- Request, order, or certifying of need for DHS (whether
- written, oral, or electronic) payable by medicare
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Feared Approa(c)h Ahead
Clinical Laboratory Services
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Feared Approac(h) A(h)ead
- Home health services
- AND
- Inpatient and outpatient hospital services
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Feared Appr(o)ach Ahead
Outpatient speech-language pathology services
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Feared A(pp)roach Ahead
- Physical therapy services.
- AND
- Prosthetics, orthotics, and prosthetic devices and supplies.
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Feare(d) Approach Ahea(d)
- Outpatient prescription drugs
- AND
- Durable medical equipment and supplies
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Types of ownership interests
Investment, Ownership, Compensation
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Fea(r)ed App(r)oach Ahead
- Radiation therapy services and supplies
- AND
- Radiology and certain other imaging services
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(F)eared Approach Ahead
- [F]eeding
- Parenteral and enteral nutrients, equipment, and supplies.
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What does each letter in the DHS acrynom (Feared Approach Ahead) stand for?
- [F]eeding
- E
- A
- [R]adiation therapy
- E
- [D]rugs
- A
- [P]hysical
- [P]rosthetics
- [R]adiology and imaging
- [O]ccupational
- A
- [C]linical
- [H]ome
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What is the DHS acrynom?
Feared Approach Ahead, without AE
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How many DHS categories?
- Thirteen
- ... an unlucky number
- or
- 10 + DHS (3)
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How many elements in a Stark violation?
- Six or
- Stark (5) + exception (1) = 6
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What are the elements of a Stark violations?
- Prohibits a:
- (1) physician from making
- (2) referrals for certain
- (3) designated health services (DHS)
- (4) payable by Medicare
- (5) to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation),
- (6) unless an exception applies.
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