STARK BASIC TRAINING - The American Health Lawyers Association

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SANCTIONS • 1877(g)(1): Denial of claims • Intent is irrelevant • Recoupment • Obligation to make refund to CMS • New compromise authority (§6409 ACA) • 1877(g)(2): Refunds to beneficiary • Coinsurances • Deductible • Often an overlooked obligation 7 SANCTIONS • CMPs for knowing violations only • $15,000/DHS; $100,000 for circumvention schemes • Referring physicians can be liable • Potential False Claims Act liability • Requires intent to defraud 8 4
WHAT’S NOT PROHIBITED • Physicians can make some ancillary services available to patients • Physicians can own DHS entities if they don’t refer to them • Generally, physicians can get fair market value compensation for their services 9 THE MANY REGS… • Phase I: 66 FR 856 (2001) • Phase II: 69 FR 16054 (2004) • Phase III: 72 FR 51012 (2007) • EHR Exception: 71 FR 45140 (2006) • FY 2009 IPPS: 73 FR at 48688 (2008) • CY 2010 PFS: 74 FR at 61932 (2009) • ACA Changes (FR 11/24/10, 11/29/10, 11/30/11) See handout for more… 10 5
Page 1 and 2: STARK BASIC TRAINING Health Care Co
Page 3: THE SOLUTION: MULTIPLE STATUTES •
Page 7 and 8: THREE QUESTIONS 1. Is there a refer
Page 9 and 10: IMPUTED REFERRALS • Consulting ph
Page 11 and 12: WHAT’S NOT A REFERRAL • Request
Page 13 and 14: DESIGNATED HEALTH SERVICES (Not eve
Page 15 and 16: RESOURCES • 1877(h)(6); 411.351
Page 17 and 18: ENTITY • Multiple DHS entities ca
Page 19 and 20: DIRECT DOCTOR DHS ENTITY (No interv
Page 21 and 22: ICA EXCEPTION • Compensation must
Page 23 and 24: “STAND IN THE SHOES” Physician
Page 25 and 26: RESOURCES • 1877(a)(2), (h)(1)
Page 27 and 28: “SERVICE-BASED” EXCEPTIONS •
Page 29 and 30: FMV RESOURCES • Phase I (pp. 944-
Page 31 and 32: GROUP PRACTICE CRITERIA • Group p
Page 33 and 34: GROUP PRACTICE CRITERIA • Share o
Page 35 and 36: 69 IN-OFFICE ANCILLARY SERVICES EXC
Page 37 and 38: IOAS EXCEPTION Where Are Services P
Page 39 and 40: IOAS EXCEPTION How Are Services Bil
Page 41 and 42: RECRUITMENT • Payments made to in
Page 43 and 44: PSA EXCEPTION • Arrangement is se
Page 45 and 46: RENTAL EXCEPTIONS • Lease is in w
Page 47 and 48: EMPLOYMENT EXCEPTION • Employment
Page 49 and 50: Non-Monetary Compensation Exception
Page 51 and 52: NON-MONETARY COMPENSATION EXCEPTION
Page 53 and 54: MEDICAL STAFF INCIDENTAL BENEFITS E
Page 55 and 56:
TIPS • Always draw a diagram •
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STARK BASIC TRAINING - The American Health Lawyers Association

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