Does the Social Security Act prohibit physician referrals to Medicaid?
In addition, section 1903 (s) (42 U.S.C. 1396b) of the Social Security Act extends this referral prohibition to the Medicaid program. The physician self-referral law can be found in section 1877 of the Social Security Act (42 U.S.C. 1395nn). The regulations are located in Title 42 of the Code of Federal Regulations §411.350 – §411.389.
Who is responsible for enforcing the Affordable Care Act?
Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws.
What federal laws apply to physicians?
The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL).
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.
Why is it called the Stark Law?
The term Stark Law refers to former U.S. Representative Pete Stark of California, who originally introduced the physician ethics bill in the late 1980s that would later evolve into this law.At that time, healthcare services were provided mostly on a fee-for-service basis, meaning that healthcare providers (HCPs) were ...
What is stark and anti-kickback law?
The Anti-Kickback Statute and Stark Law prohibit medical providers from paying or receiving kickbacks, remuneration, or anything of value in exchange for referrals of patients who will receive treatment paid for by government healthcare programs such as Medicare and Medicaid, and from entering into certain kinds of ...
What law prohibits the giving of payment for referrals of federally funded business?
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.
Who does the Stark Law impact?
KEY POINTS. The Stark statute applies only to physicians who refer Medicare and Medicaid patients for designated health services to entities with which they (or an immediate family member) have a financial relationship. There are almost 20 exceptions to the Stark statute.
What does Stark Law prohibit?
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 Stark Law quizlet?
THE STARK LAW. Prohibits a physician from referring Medicare patients. for designated health services to an entity with which. the physician (or immediate family member) has a. financial relationship, unless an exception applies.
Why is the Stark Law important?
The Stark Law matters because it tried to fight a very insidious erosion of the foundation of the trust between a doctor and patient. But the Stark Law also matters because patients and the American taxpayers wind up footing the bill for the bribery.
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 is the False Claims Act in healthcare?
What is the Federal False Claims Act? The Federal False Claims Act is a federal statute that establishes liability for knowingly presenting a false or fraudulent claim for payment to the United States government or to a government contractor. This includes claims submitted to Medicare or Medicaid.
Who enforces Stark Law?
Government agencies, including the U.S. Department of Justice (DOJ), the U.S. Department of Health & Human Services (HHS), the HHS Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), enforce these laws. The civil FCA, 31 United States Code (U.S.C.)
Which of the following is an example of a Stark Law violation?
An example of a Stark law violation is a hospital paying doctors money to refer cardiac patients to their hospital. Similarly, it is a violation of Stark for a laboratory or outpatient clinic to pay hospitals to refer patients to them.
What are Medicare regulations?
Medicare Regulations means, collectively, all Federal statutes (whether set forth in Title XVIII of the Social Security Act or elsewhere) affecting the health insurance program for the aged and disabled established by Title XVIII of the Social Security Act (42 U.S.C.
What is a kickback in healthcare?
Kickbacks are anything of value presented to a practitioner or supplier that may induce that entity to refer health services back to the source of remuneration.
When did self referrals become effective?
Self-referral regulations for rehabilitation and other services become effective January 4, 2002 even though this expansion was included in1993 legislation (OBRA 1993).
How many descriptions of fair market value are there in the Stark Law?
There are three descriptions of fair market value in the Stark law, and can be applied to kickback laws as well:
What was the purpose of the Stark I amendments?
The Stark II amendments in OBRA 1993 [2] were driven by studies revealing soaring incidence of radiology procedures and physical therapy when the physician had ownership interest in the radiology or rehabilitation facility.
Can a physician make a referral for a medical bill?
Yes and No. 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. The anti-kickback regulations apply only to services reimbursed by Medicare or Medicaid. See regulatory references.
Does Medicare cover hearing aids?
While Medicare does not cover hearing aids, a Medicaid program that defines hearing aids as durable medical equipment or a prosthetic device (Stark designated health services) could link the audiology services to the self-referral law. This issue is subject to further legal interpretation.
Can you get kicked off for office rent?
Yes. And if your rental is at fair market value, you are protected from kickback accusations. If you pay monthly office rent that is, let's say, one-third less than the normal/usual rate, you are, in essence, receiving a "gift" from the physician. Remuneration of any kind, except in reasonable exchange for goods and services, places you in danger of violating the kickback law because the remuneration could become an incentive for you to refer patients to that physician.
What can I do to avoid violating the Stark Law?
For entities looking to stay on the right side of the rules, there are a variety of compliance recommendations. Business entities should:
Does the Stark Law apply to all healthcare referrals?
No. As mentioned above, the Stark Law only applies to Medicare participants who receive a referral for a designated health service. This means that a referral for a private-pay (or even self-pay) patient would not fall under the law’s requirements.
What are the laws that apply to physicians?
The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws. As you begin your career, it is crucial to understand these laws not only because following them is the right thing to do, but also because violating them could result in criminal penalties, civil fines, exclusion from the Federal health care programs, or loss of your medical license from your State medical board.
What happens if you are excluded from Medicare?
If you are excluded by OIG from participation in the Federal health care programs, then Medicare, Medicaid, and other Federal health care programs, such as TRICARE and the Veterans Health Administration, will not pay for items or services that you furnish, order, or prescribe. Excluded physicians may not bill directly for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or a group practice. In addition, if you furnish services to a patient on a private-pay basis, no order or prescription that you give to that patient will be reimbursable by any Federal health care program.
What are the criminal offenses that OIG is required to exclude from?
OIG is legally required to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: (1) Medicare or Medicaid fraud , as well as any other offenses related to the delivery of items or services under Medicare or Medicaid; (2) patient abuse or neglect ; (3) felony convictions for other health-care-related fraud, theft, or other financial misconduct ; and (4) felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances. OIG has discretion to exclude individuals and entities on several other grounds, including misdemeanor convictions related to health care fraud other than Medicare or Medicaid fraud or misdemeanor convictions in connection with the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity; provision of unnecessary or substandard services; submission of false or fraudulent claims to a Federal health care program; engaging in unlawful kickback arrangements; and defaulting on health education loan or scholarship obligations.
What is the civil FCA?
The civil FCA protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs' loss plus $11,000 per claim filed. Under the civil FCA, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. The fact that a claim results from a kickback or is made in violation of the Stark law also may render it false or fraudulent, creating liability under the civil FCA as well as the AKS or Stark law.
Why are physicians attractive to kickback schemes?
As a physician, you are an attractive target for kickback schemes because you can be a source of referrals for fellow physicians or other health care providers and suppliers. You decide what drugs your patients use, which specialists they see, and what health care services and supplies they receive.
What is the beneficiary inducement statute?
Besides the AKS, the beneficiary inducement statute (42 U.S.C. § 1320a-7a (a) (5)) also imposes civil monetary penalties on physicians who offer remuneration to Medicare and Medicaid beneficiaries to influence them to use their services.
What does "present a claim that the person knows or should know" mean?
presenting a claim that the person knows or should know is for an item or service that was not provided as claimed or is false or fraudulent;
What are the consequences of offering incentives to patients?
The government is concerned that offering or rewarding such inducements to patients may result in overutilization, biased decisions concerning care, and increased costs to the Medicare, Medicaid or other government programs.
What is a cash incentive?
Cash or instruments convertible to cash; or. An incentive the value of which is disproportionally large in relationship to the value of the preventive care service ( i.e., either the value of the service itself or the future health care costs reasonably expected to be avoided as a result of the preventive care).
What is the anti kickback statute?
The federal AKS prohibits anyone from knowingly and willfully soliciting, offering, receiving, or paying any form of remuneration to induce referrals for any items or services for which payment may be made by any federal healthcare program ( e.g., Medicare, Medicaid, etc.) unless the transaction is structured to fit within a regulatory exception. (42 U.S.C. § 1320a-7b (b)). The statute has been interpreted to cover any arrangement where “one purpose” of the remuneration is to induce referrals for or receipt of federal program business. ( United States v. Kats, 871 F.2d 105 (9th Cir. 1989); United States v. Greber, 760 F.2d 68 (3d Cir. 1985)). An AKS violation is a felony punishable by up to 10 years in prison, a $100,000 criminal penalty, a $100,000+ 1 civil penalty, treble damages, and exclusion from participating in the Medicare or Medicaid programs. (42 U.S.C. §§ 1320a-7 and 1320a-7b (b) (2) (B); 42 C.F.R. §§ 1003.300 and 1003.310; 45 C.F.R. § 102.3). An AKS violation is also a violation of the federal False Claims Act (42 U.S.C. § 1320a-7b (g); 31 U.S.C. § 3729), which exposes defendants to mandatory self-reports and repayments, additional civil penalties of $11,000+ to $22,000+ per claim, treble damages, private qui tam lawsuits, and costs of suit. (31 U.S.C. §§ 3729 and 3730; 42 U.S.C. §§ 1320a-7a and 1320a-7k (d); 28 C.F.R. §§ 85.5 and 1003.200 (a) and (b) (k)).
Can a provider discount a patient who cannot afford to pay their bills?
Demonstrated Financial Need. As a general rule, the AKS and CMPL do not prohibit a provider from discounting or otherwise offering free items or services to patients who cannot afford to pay their bills. (OIG, Hospital Discounts Offered to Patients Who Cannot Afford to Pay Their Hospital Bills ...
Does an item or service induce referrals?
Item or Service Does Not Induce Referrals or Influence the Receipt of Care. The AKS and CMPL are not violated so long as there is no improper intent or knowledge that the free item or service would induce referrals for or receipt of items or services payable by federal healthcare programs.
Can a government regulator extend a free or discounted service?
Depending on the statutes, government regulators and/or private parties may try to extend those prohibitions to free or discounted items or services provided to patients, especially when the program or payments tend to induce the patient to order or receive potentially unnecessary or expensive services.
Is CMPL a violation of the law?
Similarly, the CMPL is only violated if the provider knows or should know that the remuneration is likely to influence a patient to receive such items from a particular provider. ( See 81 Fed. Reg. 88394-95). So long as there is no such improper intent or influence, then the statutes are not violated.