Physician Referral Starks Policy

(Effective Date: April 22nd, 2020) 

SCOPE: This policy applies to all Meridian Advanced Psychiatry, LLC (“MAP”) employees, including full-time, part-time, temporary contract employees, and Vendors. 

PURPOSE: The purpose of this Policy is to ensure that Meridian Advanced Psychiatry (“MAP”) has business practices that are conducted in conformity with the Physician Self-Referral or Stark Law.

Summary of the Law 

The Stark Law is a healthcare fraud and abuse law that prohibits physicians from referring patients for certain designated health services paid for by Medicare to any entity in which they have a “financial relationship.”  The federal government interprets the term “financial relationship” broadly to include any direct or indirect ownership or investment interests by the referring physician, as well as any financial interest held by any of the physician’s immediate family members.  Unlike the federal Anti-Kickback Statues, the Stark las is not a criminal statute.  However, the Office of the Inspector General (OIG) for the Department of Health and Human Services (HHS) can pursue a civil action against Stark Law violators under the civil monetary penalties las.  Stark Law violations can result in penalties of up to $15,000 for each bill service that is based on a prohibited referral, plus three times the amount of the government overpayment.

Relevant Purpose.   

The Stark Law prohibits referrals for certain Medicare items and services (“Designated Health Services”) furnished by an entity with which the referring physician (or an immediate family member, as defined by Stark) has a “financial relationship”, unless a specific statutory or regulatory exception applies. 

  • Designated Health Services (DHS) means and includes: 
    1. Clinical laboratory services; 
    2. Physical therapy services; 
    3. Occupational therapy services; 
    4. Radiology services, including CT, MRI, Ultrasound and Nuclear Medicine; 
    5. Radiation therapy services and supplies; 
    6. Durable medical equipment and supplies; 
    7. Parenteral and enteral nutrients, equipment and supplies; 
    8. Prosthetics, orthotics and prosthetic devices; 
    9. Home health services and supplies; 
    10.  Outpatient prescription drugs; and 
    11. Inpatient and outpatient hospital services.
  • Immediate Family Member means and includes: 
    1. husband or wife;  
    2. natural or adoptive parent, child, or sibling;  
    3. stepparent, stepchild, stepbrother or stepsister; 
    4. father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; 
    5. grandparent or grandchild; or 
    6. spouse of grandparent or grandchild.
  • Referral and Referring Physician means and includes: 
    1. Any request, order or certification by a physician for DHS; 
    2. Any consultation request by a physician for DHS; and  
    3. A request, order or certification by a physician of a plan of care that includes the provision of a DHS.

Under certain conditions, a referral under Stark does not include the following: a request by a pathologist for clinical diagnostic tests and pathological examinations; a request by a radiologist for diagnostic radiology services; or a request by a radiation oncologist for radiation therapy.

  • Financial Relationship means and includes both: 
  1. A physician, or immediate family member, ownership in an entity, which, in turn, holds an ownership interest in an entity receiving the DHS referral; and 
  2. A compensation arrangement with the entity providing the DHS involves any remuneration between a physician, or immediate family member of the referring physician, and an entity, other than remuneration specifically excluded by Stark. This includes both a direct compensation arrangement and certain indirect compensation arrangements as defined by Stark.

GUIDELINES/PROCEDURES 

  1. UHA will not enter into any arrangements that violate Stark unless an exception applies.  
  2. To ensure compliance with the Stark statute and this policy, any arrangement with a physician must be directed to and reviewed by the Office of General Counsel. This review will consider and employ, as applicable, measures to ensure the arrangement meets an exception or safe harbor under Stark.
  3. Employees and affiliated physicians and health care providers are required to promptly report all known and suspected violations of this policy to the UHA Director of Compliance. UHA prohibits retaliation against any individual for reporting conduct that the individual, in good faith, believes is a potential violation of applicable law or UHA policy. 
  4. The Office of General Counsel and UHA Director of Compliance will coordinate on any necessary corrective actions for any arrangements that appear to violate Stark.

REFERENCES 

  • Social Security Act, Section 1877 
  • 42 U.S.C. Section 1395nn 
  • 42 C.F.R. Section 411 et. al

POLICY – SUSPECTED VIOLATION 

All suspected violations of the Stark Laws must be reported to the Compliance Officer who will investigate the incident and take appropriate remedial steps to address the issue.