To combat a specific type of Medicare fraud
Medicare fraud
In the United States, Medicare fraud is the collection of Medicare health care reimbursement under false pretenses. There are many different types of Medicare fraud, all of which have the same goal: to collect money from the Medicare program illegitimately.
Full Answer
Is it legal to pay someone to refer you for referrals?
However, in the Federal health care programs, paying for referrals is a crime. The statute covers the payers of kickbacks-those who offer or pay remuneration- as well as the recipients of kickbacks-those who solicit or receive remuneration. Each party's intent is a key element of their liability under the AKS.
Is it illegal to pay someone to refer you to Medicare?
Just as it is illegal for you to take money from providers and suppliers in return for the referral of your Medicare and Medicaid patients, it is illegal for you to pay others to refer their Medicare and Medicaid patients to you. The kickback prohibition applies to all sources of referrals, even patients.
Are referrals from a doctor to a designated health service allowable?
Referrals from a doctor to a designated health service are allowable if the compensation isn’t monetary – cash, check, money, etc. The compensation should be services or items that have small value – $300 or less.
Does Stark Law allow referrals for financial interests?
Fortunately, Stark Law does allow referrals – if it can be shown the financial interest meets an approved exception. Some Stark Law approved exceptions are related to just compensation. Other exceptions are related to just ownership and investment.
What type of clients does the federal Stark Law prohibit a physician from referring to a health care provider if a financial relationship exists?
The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.
What is considered an illegal provider relationship?
Which of the following is considered to be an illegal provider relationship? Any person or entity who knows, or should have known, of the presentation of a false or fraudulent claim to the government for payment or approval is subject to .
Which law prohibits physicians from making referrals to an entity for designated services when the physician or her family member has a financial stake in the entity?
The Stark lawThe Stark law prohibits a physician's referral for certain designated healthcare services (DHS) to an entity if the physician (or a member of the physician's immediate family) has a financial relationship with the entity, unless the referral is protected by one or more exceptions provided in the law.
What are 10 specific designated health services DHS for which referrals by physicians who have financial relationships with the entity providing the DHS are prohibited?
There are 10 specific DHS for which referrals by physicians who have financial relationships with the entity providing the DHS are prohibited: clinical laboratory services; physical and occupational therapy and speech-language pathology services; radiology and certain other imaging services; radiation therapy services ...
What is the Red Flags Rule healthcare?
The Red Flags Rule requires that organizations have “reasonable policies and procedures in place” to identify, detect and respond to identity theft “red flags.” The definition of “reasonable” will depend on your practice's specific circumstances or specific experience with medical identity theft as well as the degree ...
What is an illegal provider relationship in healthcare?
The Stark law prohibits a physician with a financial relationship in an entity from making a referral for designated health services covered by Medicare and Medicaid to that entity even if the services are billed to an individual or other third party payer.
What are CMS guidelines for referrals?
In a CMS compliant situation, you would 1) ask for referrals without mentioning any benefit to the enrollee and then 2) present a thank-you gift for the referrals he or she has provided. Second, the gifts you provide must be of a nominal value.
Which is an exception to the anti referral law?
Physician services that are furnished (i) personally by another physician who is a member of the referring physician's group practice or (ii) under the supervision of another physician who is a member of the referring physician's group practice are exempt for the self-referral prohibition.
What 5 elements must exist for a Stark Law violation to occur?
In order for a relationship to implicate Stark, five basic elements must be present: (1) a physician must make (2) a referral for the furnishing of (3) designated health services payable by Medicare (4) to an entity (5) with which he/she (or an immediate family member) has a financial relationship.
What is the difference between Stark 1 and Stark 2?
There are two components to the Stark statute. Stark I deals with clinical laboratory services, and Stark II, which came out in 1995, extended the reach of the prohibition to 11 categories of designated health care services.
What is a referral under the Anti-Kickback Statute?
The federal Anti-Kickback Statute (AKS) (See 42 U.S.C. § 1320a-7b.) is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of business reimbursable by federal health care programs.
What are the three groups of stark exceptions?
Many exceptions are related to all three – compensation, ownerships, and investment.QUICK SUMMARY OF FEDERAL “STARK” SELF-REFERRAL & ANTI-KICKBACK LAW AND CALIFORNIA SELF-REFERRAL AND FEE-SPLITTING PROHIBITIONS. ... ANTI-KICKBACK, FEE-SPLITTING & STARK.More items...•
What Are the Stark Laws?
The Stark Amendment to Omnibus Budget Reconciliation Act of 1989 — and its various amendments and administrative rules/regulations — is the federal government’s system to prevent physicians from referring patients to entities with which they have a financial relationship.
Are There Exceptions to Stark Laws?
Yes, certain exceptions can apply to Stark Laws. For example, if the physician personally provides the services, or if he/she is an employee of a medical group that provides the service, there may be no liability. This allows for multidisciplinary practices, so long as the physician meets the definition of “physician in the group practice.”
Is There a Way to Determine Whether Stark Laws Apply to a Particular Arrangement?
There are certain questions a physician or medical services company must answer in order to know if there may be an issue under Stark Law:
What are the fraudulent schemes found to violate the False Claims Act?
Common fraudulent schemes found to violate the False Claims Act (FCA) include: billing for services not provided. billing for a test or service that is not medically necessary or reasonable. paying or accepting kickbacks. making referrals based on the provider’s personal financial interest.
Why do skilled nursing facilities and rehabilitation service providers perform unnecessary, and sometimes harmful, physical therapy on patients?
skilled nursing facilities and rehabilitation service providers performing unnecessary, and sometimes harmful, physical therapy on patients in order to maximize reimbursement.
What is a substance abuse treatment center billing?
substance abuse treatment centers billing for counseling services that they did not provide and/or for which they failed to document information required for payment by state or federal regulations. mental health treatment centers billing for treatment provided by unlicensed individuals.
Does Medicare cover ambulances?
For example, in addition to covering emergency transports, Medicare covers limited, medically necessary, nonemergency ambulance transportation to particular locations, such as a dialysis facility, if a physician has certified that the transport is medically necessary.
What is a referring physician?
The referring physician or. A doctor who is a member of the same practice group as the referring doctor or. Someone who is supervised by the referring doctor or someone in the referring doctor’s practice group. Where the services are performed. The services are done:
What is Medicare billing?
The billing to Medicare/Medicaid used an approved billing number. Services Furnished by an Organization to Enrollees. Doctors can make referrals to organizations that provide prepaid health services to enrollees.
How many doctors are required to be in a group practice?
A group practice is a complicated term that has many requirements. In short, it requires that at least five doctors work together for the common good of the practice.
Can a doctor make referrals to an academic medical center?
Academic Medical Centers. A doctor who has a financial relationship with an academic medical center can make referrals to that center if: The doctor is “ bona fide” employee of the medical center. Has a valid state license in the state where the medical center is located. Is a member of the facility’s faculty.
Is a referral permissible?
Physician services. Referrals are permissible if the medical services are: Performed by a doctor who is a member of the group practice. Performed by a doctor under the supervision of a doctor who is a member of the group practice. In-Office Ancillary Services.
Does Stark Law allow referrals?
Fortunately, Stark Law does allow referrals – if it can be shown the financial interest meets an approved exception. Some Stark Law approved exceptions are related to just compensation. Other exceptions are related to just ownership and investment.
What is The Physician Self Referring Law (Stark law)
Before we jump into the article, we need to discuss what the Stark law is and why the Centers for Medicare and Medicaid Services (CMS) find it important. This time, The official Office of Inspector General website of Health and Human Services states that the Stark law is one of the 5 most important Federal fraud and abuse laws.
Office of Inspector General
The Office of Inspector General website gives an example, “if you invest in an imaging center, the Stark law requires the resulting financial relationship to fit within an exception. Or you may not refer patients to the facility and the entity may not bill for the referred imaging services.”
Penalties for Violating the Physician Self Referral Law
The penalties for violating the Physician Self-Referral Law (Stark law) are up to $15,000 per service submitting claims in violation of the law. In addition, penalties of up to $100,000 for “circumvention schemes” between physicians or entities entering into arrangements can be levied.
Why Change The Physician Self Referral Law
King writes “ [healthcare] industry wants CMS to adopt new regulations on Stark because the law has had a chilling effect on participation in value-based payment agreements.” King’s article does not mention what “value-based payment agreements are.
Physician Self-Referral
Allowing a physician to self-refer to an organization that they have a financial interest in can obviously lead to fraud, waste, and abuse of Medicare . For example, if a physician has a financial interest in a company that provides MRI’s the physician might be more inclined to refer a patient for an MRI that may not be medically necessary.
Likelihood of Stark Law Changing
King reports Stark reform does not have much momentum with Congres. King states, “Lawmakers in prior congressional sessions have introduced bills to adopt reforms.
More Research
This link is provided for The Physician Self-Referral Law, via the official website for the Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/index.html?redirect=/physicianselfreferral/