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These changes are effective October 1, 2013: 

In addition to what passed in 2011, the following is added to the definition of “pain management clinic

a. Suboxone will now be included in the type of prescriptions that are considered to determine whether the location is considered a pain management clinic; 

b. Patients of health care providers who do not prescribe controlled substances shall be excluded from the count to determine if a clinic should be registered with the Department of Health; and

c. "Pain management clinic" also means any privately owned clinic, facility, or office that both advertises in any medium for any type pain management services and at which one or more employees or contractors prescribe controlled substances.  Pain clinics which advertise but do not meet the prescribing threshold of a majority of patients receiving controlled substances for 90 or more days in a 12-month period must still register. 

Patients of a pain management clinic must present a current and valid government issued identification or current health insurance card issued by either a government or private carrier. 

Providers must conduct urine drug screening in accordance with a written drug screening and compliance plan, which may include testing on initial assessment or upon new admission.

A physician may not serve as the medical director for more than four pain management clinics.

Administrative penalties for violating pain clinic requirements have changed from $1,000 per day to a minimum of $1,000 per day, not exceeding $5,000 per day.  The owner, co-owner, or operator of an uncertified pain management clinic will also now be subject to these penalties.

The clinic will no longer be able to accept a money order as a form  of payment. 

Questions?

While the Supreme Court decision last year ruled that mandatory Medicaid expansion was unconstitutional, it did not do the same for the individual mandate.  This means that by January 1, 2014, the 60,000 to 70,000 individuals in Tennessee eligible for, but not currently enrolled in, TennCare will likely sign up for the program.  So despite Haslam’s decision not to expand TennCare, the program will expand anyway with this influx of new patients, and without any federal funds to support it.  This new patient population will mean more TennCare traffic for physicians in the state, especially primary care physicians.

Additionally, there is uncertainty as to whether TennCare can financially support a substantial increase in members and continue to reimburse physicians at the current (albeit already low) rates.  Currently Tennessee levies a 5.5 percent tax on all premium dollars collected from TennCare MCOs.  If Haslam had opted for Medicaid expansion, the federal government would have fully paid for it for the first three years through premiums on the TennCare MCOs, making those funds subject to the 5.5 percent tax.  This could have generated upwards of $90 million in tax revenues for the state. 

Tennessee potentially could have supported the expansion with no cost to the state for the first three to seven years. After the first seven years, the federal government’s support would have decreased to only 90 percent, which would have resulted in a hit to the state budget.  However, without the federal funding, it is unclear whether the state can support the influx of new patients into TennCare next year or in seven years.  The uncertainty of future expenses to the state was a major factor in Haslam’s decision yesterday.

Haslam’s “Tennessee Plan” for healthcare also includes reforming physician reimbursement to account for health outcomes instead of the current fee-for-service model.  Although the governor did not discuss specifics, reimbursement based on health outcomes typically refers to global or bundled payments and shared financial risk among providers and insurers.  This type of payment system is already being implemented in accountable care organizations (ACOs) and medical homes within the state.  Because most of these health care delivery systems are fairly new, it is hard to determine the long term benefits or detriments of their payment processes on physicians.  However, we do know that they are typically heavily centered on primary care physicians and preventive care. 

PROS

·         Time Saved – Coupling electronic remittance advice (ERA) with auto posting of payments, which can be set up via your practice management system or your practice’s Automated Clearinghouse (ACH), EFTs can literally save a practice several man hours of data entry per day.  The main goal of HHS’s recent regulations on EFT standards is to automatically reconcile electronic reimbursements with ERA statements.  Right now, most health plans send these two separately so that your office staff then must reconcile the payment with the ERA, or RA if you still receive paper statements.  These new EFT standards will require health plans to send them at a maximum only 3 days apart with the goal of eventually requiring them to be sent simultaneously, which would cut down significantly on time spent putting them together manually.

·         Quicker Reimbursement – The most obvious benefit to EFTs is cutting out the middle man, in this case the postal service. Instead of waiting weeks to receive reimbursement via snail mail, reimbursements are sent directly to your bank account. Couple EFTs with electronic claims submission and practices could see a turnaround time of less than a week. 

·         Increased Security – Since the reimbursement money would be automatically deposited in your bank account, there is no threat of it being lost or stolen through the postal service.  A 2010 survey on electronic payments performed by the Association for Financial Professionals (AFP) found that 90 percent of organizations that experienced payment fraud in 2008 were victims of paper check fraud, while only 7 percent of organizations that experienced payment fraud were victims of EFT fraud.

·         Decreased Administrative Costs – Similar to the way in which EFT can save time, it can also save money by reducing administrative overhead costs.  As mentioned above, the new EFT standards will require EFTs and ERAs to be automatically reconciled, reducing the amount of paperwork and administrative man power needed, which would ultimately reduce costs.

CONS

·         Refunding Overpayments - One minor irritant associated with EFTs is that instead of simply sending the original check back to the insurer when your practice is accidently paid for services you did not perform, your staff will need to generate a refund and associated paperwork and send that into to the insurer.  This could create some administrative headaches.

·         Elapsed time between the origination of the ERA and the EFT – Although this problem should eventually be fixed with the HHS regulation standards (mentioned above), currently providers report a lengthy duration of time between the receipt of the ERA and the availability of funds for use in their bank accounts via EFT. The delay in receipt between the ERA and the EFT by more than two or three days creates major problems for physicians with significant reassociation and reconciliation management issues.  Again, eventually health plans will be required to fix this issue, but in the interim while they work out all the kinks, it could disrupt your practice’s management routine.

In fact, the Urban Institute and Robert Wood Johnson Foundation conducted a survey to predict approximately how many Americans would churn between eligibility and non-eligibility for these programs.[1] Their results showed that 6.9 million people may move from Medicaid to subsidized coverage in the exchange and vice versa. Further, 19.5 million people may move between Medicaid and ineligibility for all insurance subsidy programs due to increases in income and affordable employer-sponsored insurance.

All of this patient churning between health care plans means patients can lose access to providers who are in one network but not another. As a result, it can impact continuity of care for patients as well as payments for physicians. With patients cycling in and out of eligibility levels and different physicians’ offices, payments could be misdirected or charged at varying rates depending on the patient’s coverage at the time of billing.

In order to keep up with patients and payments, physicians need to have real-time information about coverage of each of their patients. The exchange should provide a reliable working system to perform patient eligibility verification. Without accurate verification, physicians run the risk of not being paid for services performed in good faith reliance on the exchange or insurance plan’s representation of eligibility. It is TMA’s position that non-payment or retroactive recovery for such reliance should be prohibited by the rules of participation in the exchange; physicians should be held harmless if it is later determined that the patient had unpaid premiums on the date of service but eligibility was verified.

In terms of a system for eligibility verification, the federal government has issued rules to supposedly streamline the process for enrollees. On January 14th, HHS issued proposed regulations for coordinating Medicaid and exchange eligibility notices and appeals, among other things, which will be reported in the Federal Register and open for comments on January 22nd.[2] The most relevant section of the proposed regulations amends parts of 45 CFR § 155, which deals with eligibility determinations within the exchange. The proposed regulations mostly make technical corrections and clarifications to the already finalized rules in 45 CFR § 155. Those rules lay out procedures for verifying individuals’ eligibility for Medicaid and subsidies, or “tax credit and cost sharing reductions” as they are called in the regs.

The rules in 45 CFR § 155 require that the exchange determine eligibility “promptly and without undue delay.”[3] They also have plenty of other requirements for what applicant information the exchanges will need to verify and how. HHS has promised that it is developing a web site and the ability to electronically deliver eligibility verification information to QHP issuers.[4]

Unfortunately though, neither the finalized rules nor the proposed regulations address providers’ options for recovery if payments are not made due to an incorrect representation of eligibility in any of the exchange’s plans. For states with their own exchanges, those types of rules would be left up to the exchanges to decide for themselves. In Tennessee’s case, presumably the federal government will be in charge of implementing those guidelines, although they have yet to do so.

In the mean time, Tennessee state government has taken matters into its own hands to combat patient churning. At the urging of stakeholders, the Tennessee Insurance Exchange Planning Initiative, established in 2010, developed a “bridge” option for families whose individual members would qualify for varying coverage plans within the exchange.[5] This option would allow families to hold coverage through a common insurer or provider network over a period of time, even if their eligibility statuses change. TennCare MCOs would provide a single card to an entire family while a dependent is enrolled in Medicaid or CHIP, thus promoting continuity of care.

The bridge option could have positive consequences for provider reimbursement too. Under the bridge, families would qualify for cost-sharing subsidies toward their deductibles, which means insurance companies will pay 94 percent of payments and patients only 6. Therefore, providers are more likely to be reimbursed the full amount of services since a low income family is more likely able to pay only 6 percent of their deductible as opposed to 40 percent under a different plan. Although the payment rates may be lower in the bridge option, providers would have a guaranteed payment of 94 percent as opposed to just 60 percent. An in-depth explanation of the bridge product can be found here.

It is unclear at this point whether the bridge option will be available if Tennessee opts to do a fully federally-facilitated exchange rather than a partnership. If not, perhaps the federal government will consider adopting it into their own regulations. Either way, the TMA Advocacy and Governmental Affairs divisions will continue to monitor how the new federal regulations will affect insurance payments and continuity of care for Tennessee physicians.

[1] Matthew Buettgens, Austin Nichols, and Stan Dorn, Churning Under the ACA and the State Policy Options for Mitigation, URBAN INSTITUTE AND RWJ FOUNDATION, June 2012.

[2] Medicaid, Children’s Health Insurance Programs, and Exchanges, (CMS-2334-P) (amending 42 CFR 430, 431, 433, 435, 440, 447, and 457; 45 CFR 155).

[3] 45 CFR § 155.310(e).

[4] General Guidance on Federally-Facilitated Exchanges, Center for Consumer Information and Insurance Oversight, CMS, May 16, 2012, p. 16.

So far what we know about private insurance reimbursement within the federal insurance exchange is, well, nothing. This uncertainty is mostly due to the federal government’s lack of guidance on how the federal exchanges will operate. What we do know is how they propose to regulate insurance companies regarding risk adjustments, reinsurance, and payment parameters.[1] While these proposed regulations do not specifically address provider reimbursement issues, we can try to predict how the regulations restricting the insurance companies will impact physician reimbursement down the line. Remember, I said “try.”

One major cost addressed in the proposed regulations that could be passed on to physicians is the user fee. The US Department of Health and Human Services (HHS) proposes to charge issuers of qualified health plans (QHPs) (i.e., insurance plans approved to participate in the exchange) user fees to fund the administrative costs of operating the federally-facilitated exchange.[2] According to the proposed regulations, the monthly fee will be calculated at a rate equal to 3.5 percent of the monthly premium charged by the issuer for each plan they sell. The rate is supposed to align with those imposed by States operating their own exchanges, so it could be adjusted in the final rules. Also, keep in mind that these are proposed regulations, which means everything in them could change before they are finalized.

Because of these user fees, coupled with the regulation’s new risk adjustment mechanisms and the ACA’s restriction on insuring seniors and people with preexisting conditions, some large insurance companies are warning of “rate shock” starting in 2014. They are applying that term both to consumers in the form of premiums and to physicians as reimbursements. At its annual conference last month, Aetna’s CEO described the company’s plans for offering insurance through the exchanges.[3] He predicted that some premiums could rise by as much as 100 percent. Even more troubling is that they expect to reimburse hospitals and physicians at rates similar to government programs instead of the traditionally higher rates of private insurance.[4]

On the flip side, other insurance company representatives have argued that large hospital and healthcare systems, like HCA in Nashville, will not negotiate with companies who propose such low reimbursement rates.[5] Therefore, warnings of rate shock may be premature and unwarranted.

All of these threats and speculations from insurance companies really boil down to one conclusion: nobody knows exactly what reimbursement will look like in the exchanges. Blue Cross Blue Shield of Tennessee has stated on their website that while “it is unlikely traditional commercial insurance rates will be supported by the exchange,” traditional Medicaid and TennCare rates will likely not apply either.[6] So far it seems that rates will fall somewhere in the middle of the insurance rate spectrum.

Tennessee physicians will have to wait and see how insurance companies react to the exchange’s open enrollment starting in October of this year. In the meantime, preparation for possible lower reimbursement rates must include managing your patient population. Getting the right patient mix will be key to maintaining profits. If lower reimbursed patients are a large percentage of the mix, it could hurt a practice’s bottom line, resulting in staff lay-offs and cutbacks. Physicians should strive to maintain the right blend of government-funded, self-insured, and commercially insured patients.

In the midst of all this uncertainty, there is some good news. As of right now, the insurance exchange will only be open to small businesses (less than 100 employees) and individuals who do not receive insurance through their employer. This means that larger businesses will continue to provide insurance to their employees by contracting with insurance companies as they have always done, hopefully at traditional insurance rates. Also, uninsured patients that previously received physician services for free will be covered under Medicaid. As a result, physicians will at least be compensated on some level for those patients where they previously were not, which may balance out the lower reimbursements received from previously higher reimbursed patients. Of course, that will depend on how well physicians manage their patient population.

As always the TMA Advocacy and Governmental Affairs divisions will continue to keep Tennessee physicians informed of any changes regarding insurance in the state. Look for the final entry in this series discussing patient churning in the coming weeks!

[1] Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014, 77 Fed. Reg. 73117 (Dec. 7, 2012) (amending 45 CFR 153, 155-158).

[2] Id. at 73181

[3] Alex Nussbaum, Aetna CEO Sees Obama Health Law Doubling Some Premiums, BLOOMBERG, Dec. 13, 2012.

[4] Avik Roy, Aetna CEO Bertolini: Get Ready for ‘Rate Shock’ as Some Health Insurance Premiums to Double in 2014, FORBES, Dec. 18, 2012.

[5] Id.

With the ACA and all of its coordinated care efforts, PCPs will be at the forefront of the health care delivery system. Unfortunately, as everyone in healthcare is well aware, we have a physician shortage in this country that is ever growing, especially within primary care. A recent study by the Mayo Clinic found that fewer than 22 percent of general internist medical students plan to become PCPs.[3] The majority, 64 percent, stated they would be entering a specialty instead. Another study found that we will need over 50,000 more PCPs by 2025 due to the ACA provisions, normal population growth, and the aging baby boomer generation.[4] The baby boomer generation not only affects the increase in the over 65 patient population but also the decrease of working physicians, as many will reach retirement age and leave the primary care practice that fewer new physicians are entering.

People have conducted several studies and surveys to determine the reasons why fewer physicians are choosing to stay with primary care. One such study found that lagging salary growth over the past decade may be the cause.[5] Since the 1980s, physicians’ salaries have grown much slower than other healthcare professionals, including pharmacists, dentists, and nurses. While some specialties undoubtedly earn more than others, the study revealed that PCPs were the lowest earners. The researchers also suggested this may be because more women and minorities are becoming physicians, who tend to get paid less than white, male physicians.[6] Whatever the reason, salary is certainly not enticing more medical students to become PCPs.

Offering Incentives

So how do we get physicians to join and stay in primary care?

Probably the most obvious answer to that question is to offer physicians and medical students the two things most people in any profession want: more money and an enjoyable working environment. The federal government already has a loan repayment program through the National Health Service Corps to incentivize PCPs to practice in underserved areas, but those programs are relatively small.[7] Since raising taxes or increasing fees to fund this program may be difficult to justify in this economy, some experts have suggested increasing PCPs’ revenue stream by taxing their income at a much lower level than it is right now.[8] This could incentivize medical students to pursue primary care with the promise of future earnings.

There are some encouraging signs that the federal government is already starting to treat the PCP shortage as a priority. In November, CMS released final rules requiring some states to reimburse Medicaid general internists, family care physicians, and pediatric physicians at rates at least equal to Medicare reimbursement for certain services, which will result in a 73 percent increase in reimbursement for these services.[9] The increase will be fully federally funded in 2013 and 2014, and the rule requires each state to submit its plan for this new program by the end of this year. While the rule requires states to start the new reimbursement rate on January 1, 2013, CMS has not yet approved any state’s plan, which means the reimbursements will not take place at the first of the year as expected. However, this rule is an unprecedented federal step in the right direction for encouraging growth in the primary care field.

Some states have joined the push for primary care by starting primary care initiatives to better train PCPs and address the issues surrounding the practice. California and Connecticut have started primary care institutes with collaboration from the various healthcare sectors to create incentives for pursuing a primary care career and retaining physicians that are already practicing.[10],[11] Connecticut’s even includes a simulation studio for physicians to learn about their office’s work flow and efficiency that includes state of the art technology. Both of these initiatives are geared toward addressing the PCP shortage at a state level and creating better primary care environments.

In the private sector, concierge medicine is a tool that hospitals and healthcare organizations are using to entice physicians to stay in primary care. Physicians who practice concierge medicine can use it as an extra source of income on a cash-only basis while still giving their insurance-based patients the option for traditional office visits.[12] It is also a desirable working environment for most PCPs because it gives them fewer patients per hour, which means more time to fully evaluate each patient’s healthcare needs. Burnout in the medical profession is most prevalent among primary care and internal medicine physicians, and one of the chief complaints, after dealing with billing and insurance procedures, is too much patient volume and too little time to fully address patients’ healthcare needs.[13] Utilizing concierge services and other innovative practice solutions may help address these issues.

Preparing for the Inevitable 

Clearly people are starting to formulate long-term plans for solving the physician shortage crisis, but with the insurance exchanges set to begin in a year, physicians need short term solutions as well. What are we to do with the nearly 30 million newly insured patients starting in 2014?

The good news is that the influx of new patients is not likely to overload the system right away or all at once. The majority of these patients, around 88 percent to be exact, will be relatively healthy— ranging in age from 18 to 64 years, which of course leaves out the very young and very old who typically require more care. Further, these newly insured patients will not be accustomed to regular check-ups with a PCP and therefore will likely not seek one out right away. They will wait until they are either sick or injured, which as we previously stated will not be immediate since they are a relatively healthy patient population in general.

Eventually, however, these new patients will seek primary care services, and according to the studies described above, they will only exacerbate the PCP shortage problem. Because the influx will not be immediate, it gives the healthcare community a small amount of time to prepare for and combat the problem.

Many are already taking action, such as hospitals that are increasing residency programs and stepping up physician recruiting. Hospital Corporation of America (HCA), headquartered in Nashville, is adding 400 to 600 residency spots to its hospitals in western Florida, and a large portion will be devoted to internal medicine training.[14] HCA executives hope that by training physicians at their hospitals, they will be more likely to retain those physicians after residency, thereby decreasing the physician shortage in that area. Studies have shown that physicians tend to stay in the state in which they either studied or completed their residency.

Physicians can take matters into their own hands by hiring more mid-level providers, such as nurse practitioners and physician assistants, to prepare for the 30 million newly insured patients. Although these professionals cannot replace a physician in terms of training, with sufficient supervision they can be invaluable tools to address the primary care needs of these new patients. They allow PCPs to increase their patient volume without having to physically see each patient, thereby treating more individuals despite the physician shortage.

  While all of the long-term and short-term plans discussed here may help alleviate the problem, the fact is that we need more physicians to care for the many patients the insurance exchange will bring in 2014. Tennessee physicians need to be prepared for this change and adapt their practices accordingly. As always, the Tennessee Medical Association and its Advocacy Division are here to keep you informed and answer any questions you may have.

Look out for parts 2 and 3 of this series discussing reimbursement issues and patient churning in the coming weeks!

[1] CBO, Estimates for Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision, July 2012.

[2] PWC Health Research Institute, Health Insurance Exchanges: Long on Options, Short on Time, October 2012: 4.

[3] Colin P. West, et al, General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents, 308(21) J. AM. MED. ASSOC. 2241, 2241-2247 (2012).

[4] Stephen M. Petterson, et al., Projecting US Primary Care Physician Workforce Needs: 2010-2025, 10 ANN. FAM. MED. 503, 503-509 (2012).

[5] Seth E. Seabury, et al., Trends in the Earnings of Health Care Professionals in the United States, 1987-2010, 308(20) J. AM. MED. ASSOC. 2083, 2083-2085 (2012).

[6] Genevra Pittman, Salary growth lagging for primary care doctors, REUTERS, Nov. 27, 2012.

[7] National Health Service Corps, Loan Repayment, http://nhsc.hrsa.gov/loanrepayment/

[8] Uwe E. Reinhardt, If Primary-Care Doctors Were Taxed Like Hedge-Fund Managers, Economix blog, N.Y. TIMES, Oct. 26, 2012.

[9] 42 CFR 438, 441, 447

[10] California Advanced Primary Care Institute, http://www.capci.org/index.html

[11] Connecticut Institute for Primary Care Innovation, http://www.stfranciscare.org/cipcihome.aspx

[12] Heather Punke, Using Hybrid Concierge Medicine to Attract, Incentivize Primary Care Physicians, BECKER’S HOSP. REV., Nov. 15, 2012.

[13] Tait D. Shanafelt, et al., Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population, 172(18) ARCH. INTERN. MED., 1377, 1377-1385 (2012).

There are other requirements in the ACA regarding the formation of insurance exchanges, but still little information exists on exactly how a federal exchange will operate. While there are many unanswered questions regarding the operation of an insurance exchange, the most important one for us is: how will it affect physicians?

The easiest answer is that having an insurance exchange will create more insured individuals, which in turn will provide more reimbursement for previously uncompensated procedures. Also, more insured individuals likely means more access to preventive care instead of high-cost emergency and inpatient care, which is one of the goals of the ACA. While these may be the positive result of the insurance exchanges, there are several potential negative consequences that will undoubtedly affect physicians in Tennessee as well. The most pressing concerns include the growing physician shortage, patient churning among health plans, and questions regarding reimbursement. These are issues of which all physicians should be aware in the upcoming year in order to prepare for the changes ahead.

While internal audits may lessen your chance of receiving an audit notice from an insurer, physicians still need to know what to do if they receive one and how to handle an external retrospective audit. There are several steps that can be taken to ensure a less painful (although not entirely painless) process.  One of the first steps in dealing with an external audit is to contact your attorney. You should both review your insurance contract to best understand your rights as a provider. Physicians are given audit notices for a variety of reasons, but the most common are coding errors and perceived overbilling for a certain procedure. Remember, documentation is key to making it through a retrospective audit unharmed. The CMS Evaluation and Management (E/M) services guidelines are still in effect and offer guidance on what the government and insurers are looking for in billing procedures.

The TMA legal department is available to answer any general questions you may have regarding steps for compliance and auditing. Below are some helpful resources to get you started on the right track:

*Tennessee Medical Association – Law Guides: Insurance – Health Carrier Internal and External Review

American Medical Association – How to Perform a Physician Practice Internal Billing Audit

American Medical Association – How to Prepare for a Health Insurer Retrospective Audit

Physicians Advocacy Institute – Medical Audits – What Physicians Need to Know

The healthcare industry is anticipating that insurance companies will analyze ICD-10 data to determine future reimbursement on the Part A and Part B sides of payment models. If documentation is not specific enough for the hospital to bill for its services, you will likely see a lot of requests for additional information and incomplete medical records notifications. This alone could be a huge disruption to your work day.

Practices should not employ or contract with excluded physicians or individuals if it is possible that services furnished by those individuals or entities could be billed to Medicare, Medicaid, or other federally funded programs such as Tricare and Veterans Health Administration. To ensure this, physicians are responsible for accessing the OIG's online database of excluded individuals and entities before they employ an individual or enter into a business contract.   http://oig.hhs.gov/exclusions/

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.

For further information on the exclusion statute, please visit http://oig.hhs.gov/exclusions/background.asp

Physician self-referral was alleged to be a conflict of interest, given that the physician could benefit from the referral suggesting that such arrangements may encourage over-utilization of services, in turn driving up health care costs. In addition, it was believed that the practice of self-referral would create a captive referral system, which limits competition by other providers.

There are exceptions to this law that were enacted to protect legitimate business arrangements that are not likely to result in abuse such as ancillary services offered within a physician’s own practice.  The latest updates in 2010 however, state that a physician within a group practice referring his/her patient for MRI, CT or PET to be provided within the group practice must provide the patient, at the time of the referral, written notice that the patient may obtain these imaging services from a supplier other than the group practice and that notice must include a list of local alternatives. 

Safe harbors protect certain payment and business practices that could otherwise implicate the Statute from criminal and civil prosecution. To be protected by a safe harbor, an arrangement must fit squarely in the safe harbor and satisfy all of its requirements. Some safe harbors address personal services and rental agreements, investments in ambulatory surgical centers, and payments to bona fide employees.

Physicians frequently recommend and prescribe drugs, order tests, refer out to specialists and facilities so they are in a position to be a target for anti kickback arrangements. Many people would like to be the receiver of your referrals. Make sure you are not violating this statue by receiving in-kind services or any other type of payment for your referrals. Remember, the government does not need to prove patient harm or financial loss to the programs to show that a physician violated the Statute. A physician can be guilty of violating the Statute even if the physician actually rendered the service and the service was medically necessary.