HIPAA âminimum necessaryâ - Health Care Compliance Association

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A Master Class in Hospital Reimbursement ComplianceA Six-Part Audio/Web Conference Series by HCCACMS Data Mining Implications Audio CD AvailableRACs Auditors and Other New Predators Audio CD AvailableCompliance Issues Arising Out of Graduate Medical Education (GME) Audio CD AvailableAuditing Compliance with the Provider-Based Status Rules Audio CD AvailablePresent on Admission and Hospital-Acquired Conditions Audio CD AvailableOrganizational Culture and Compliance April 8Special member rate of only $750 for all six sessions!moderated by: Lawrence W. Vernaglia, Partner, Health Care Industry Team, Foley & Lardner, LLP, Boston, MAQuality of Care Initiatives Gaining Momentum - April 24Speakers:Jacqueline c. Baratian, General Counsel, Alston & Bird LLPKatie A. Arnholt, General Counsel OIG/OCIGWilliam Mathias, Principal, Ober/KalerCompliance Week (FREE) - April 25Tips for innovative and fun ways to Celebrate Compliance Weekthroughout you organization May 26-30, 2008Speakers:Jenny O’Brien, Halleland, Lewis, Nilan & Johnson,Steve Lokensgard, Compliance Officer – Allina Hospitals & ClinicsRecovery Audit Contractors (RACs) - April 30Speakers:William Moran, Senior Vice President, Strategic ManagementKaren Feeley, Director of Network Patient Services at New York Presbyterian HospitalCMS RepresentativesPricing for all Conferences:Members $175 per sessionNon-members $215 per sessionAll CD sessions are 90 minutesJoin HCCA today for only $200 ($295 regularly)and receive the member rate!To purchase visit www.hcca-info.orgAudio/Web Conferences Available on CDMore Audio/Web Conference Titles are Available at www.hcca-info.org/audiocdsAll Sessions begin at 12PMCentral | (90 minutes) 1.2 CEUsApril 200854Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Outpatient therapyclinics and theirreferring physicians:Fraud and abuse risksEditor’s note: Kathie McDonald-McClure isan attorney with the law firm of Wyatt Tarrant& Combs, LLP in Louisville, KY. She may bereached by telephone at 502/562-7526.In the November 2007 issue ofCompliance Today, in an articletitled, “Therapy provided “incidentto”: Developing a framework for complianceby identifying risk,” Nancy J. Beckley aptlyidentified compliance risks for physicians whooffer physical or occupational therapy in theiroffices, including risks under the Stark Law 1and the Anti-kickback Statute. 2 The risks forthe physician practice under these two lawsare amplified when the physician practice hasa compensation arrangement with a therapyclinic or its owner. 3 To complicate matters,these parties may have more than one compensationarrangement with one another, furtherincreasing the risks. This article exploresthe types of relationships that arise betweenphysician practices and therapy clinics and theStark and Anti-kickback risks implicated.The development of compensation arrangementsbetween the physician and therapist canbe a very natural outgrowth of establishing aprior relationship with one another. The relationshipmay begin when the physician referspatients to the therapy clinic. If patient feedbackto the physician is positive, the physicianlikely will refer more patients to the clinic withconfidence that the therapy clinic will provideprompt, quality care for the patients. Thetherapy clinic, in turn, may further gain thephysician’s trust and confidence by keeping theBy Kathie McDonald-McClure, Esq.physician informed about the patient’s care,or providing information about the clinic’sexpertise with certain therapy techniques.The Medicare coverage rules ensure dependenceof outpatient therapy clinics onphysician involvement for their continuedexistence and profitability. Medicare and mostthird-party payers will not cover physicaltherapy unless a physician orders the therapyand certifies continued therapy every 30 days.Because of this dependent relationship, itbehooves the clinic to ensure that it maintainsa good relationship with referring physicians.Good relationships can lead to compensationarrangements. Types of compensationarrangements that may arise after establishingan initial physician referral relationship mightinclude a consulting or medical directoragreement, a lease agreement, or even a managementagreement for a therapy programin the physician’s office. Each one of theserelationships must comply with the Stark Lawand the Anti-kickback Statute.Health Care Compliance Association • 888-580-8373 • www.hcca-info.orgStark LawThe Stark Law generally prohibits referrals forcertain designated health services (DHS) by aphysician to an entity with whom the physicianhas a “financial relationship.” Stark specificallyincludes physical therapy (PT) andoccupational therapy (OT) services on the listof DHS. Physician groups and therapy clinicsshould not bill for any services provided to apatient referred by either party to the other,where the parties have a compensation arrangementin addition to a referral relationship,unless the compensation arrangementcomplies with the Stark Law.Stark carves out some compensation arrangementsthat do not pose a substantial risk offraud and abuse. These carve-outs are called“exceptions.” The exceptions protect certaincompensation arrangements from violatingthe law, but only if the arrangement meetsevery requirement of an exception. To violateStark does not require any “intent”– rather,Stark is a strict liability law.Anti-kickback StatuteThe Anti-kickback Statute makes it a criminaloffense to intentionally offer, pay, solicit, orreceive any remuneration, with a purpose ofinducing or rewarding referrals of items orservices reimbursable by a federal health careprogram. The Act is violated when an entitypays remuneration to a referring physician,knowingly and willfully, to induce orreward referrals of items or services payableby Medicare or Medicaid. For purposes ofthe Anti-kickback Statute, “remuneration”includes the transfer of anything of value, directlyor indirectly, overtly or covertly, in cashor in kind. By its terms, the statute attributescriminal liability to parties on both sides of animpermissible “kickback” transaction.Similar to Stark, the Anti-kickback Statutesets forth “safe harbors” for relationships thatare deemed not to pose a substantial riskof fraud and abuse. Failure to meet everyelement of a safe harbor alone will not meanthe relationship violates the statute, but therelationship remains “suspect.” Unlike Stark,the Anti-kickback Statute is not one of strictliability because it requires intent.Stark vs. Anti-kickback. The fact that arelationship meets a Stark exception does notContinued on page 5655April 2008
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Volume TenNumber FourApril 2008Publ
Page 7 and 8: documented system of incurred expen
Page 10 and 11: Quality of care incardiac casesEdit
Page 13 and 14: “Red flags” and compliance prog
Page 15 and 16: complete Extraordinary Circumstance
Page 22: EXPERIENCE. I
Page 26 and 27: focusfeatureCode RACIs your hospita
Page 28 and 29: April 200828Health Care Compliance
Page 30 and 31: Complianceand the rise inuncompensa
Page 32 and 33: HCCA Regional ConferencesJoin us at
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Page 36 and 37: HCCA Training ResourcesGuidebooks &
Page 40 and 41: Winds of change inReimbursement, Pa
Page 42 and 43: Implications of PPSreform for home
Page 44 and 45: Refocusing thecompliance paradigmEd
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Page 48 and 49: April 200848Medicare Advantageand P
Page 50 and 51: Online Compliance Trainingauthored
Page 52 and 53: Every day, clinical and researchpro
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