First, decide whether you need to be worried about the Stark law at all. The Stark law is named after Rep. But, because almost every state has a law against self-referrals, you do need to worry about those regulations — you could think of them as mini-Stark laws — as they frequently track, in whole or in part, the federal Stark laws.
Sometimes these laws are even stricter than the federal ones, so have your attorney advise you on the specifics of your state. These include. For further details, see the online CMS code list. But a violation of the Stark laws will cost you money; a violation of the anti-kickback statute can land you in jail and cost you money, too.
Not only are they not the same law, they have a very different scope and are in two different titles of the Social Security Act:. The Stark statute does not require bad intent i. The Stark statute exceptions define the boundaries of permissible behavior. The statute is a prohibition that can only be overcome by complying explicitly with an exception. In every situation where the Stark statute applies, the anti-kickback statute applies too.
These are the keys to being considered a group practice under Stark: A group practice must involve at least two or more physicians who are legally organized in a partnership, professional corporation, foundation, nonprofit corporation or other similar association.
Each physician who is a member of the group including shareholders, partners and employees but not independent contractors must provide substantially his or her normal full range of DHS and other services in the group practice through the joint use of shared office space, facilities, equipment and personnel.
In essence, a practice must operate out of one financial identity to meet the standards for a unified business. However, this does not mean that the group cannot have cost centers, for example, by office location. Cost centers are allowed, provided the accounting methods used to create them do not produce profit sharing or compensation that reflects the volume or value of DHS referred by the physicians.
Substantially all of the services of the physicians who are members of the group must be provided through the group and billed under a billing number assigned to the group; and amounts received must be treated as receipts of the group. This requires using a single taxpayer identification number. Yet simply having one tax ID number is not enough. A group must function as a real group to meet the Stark definition of a group practice.
When taken as a whole, the amount of time physician members of the group excluding independent contractors spend in work dedicated to the group must average 75 percent. This standard is intended to weed out virtual groups, partially integrated groups and groups in which physicians do not have their core activities dedicated to the group.
For example, if five physicians work full time with the group and one works half time with the group and half time with the university, the average for the group would be an accept able But if the part-time physicians were independent contractors, the group would qualify.
Note that just because a physician works part time does not necessarily mean he or she counts as part time. For example, if a family practice group hires two physicians who only work 50 percent of the time but all of their professional time is devoted to the practice, they each count as percent rather than 50 percent.
The Stark regulations set forth three profit-sharing models: 1 a per capita or per-physician division of profits e. Groups are not required to use these particular methods; any method is acceptable as long as it is reasonable, objectively verifiable and indirectly related to referrals. When incident-to services are performed, one physician member of the group must be in the office suite unless the services are diagnostic, in which case the rules on diagnostic ser vices supervision pertain.
For example, a family physician who orders and interprets a chest X-ray may be given direct productivity credit for the associated technical component revenues.
Services of nurse practitioners, physician assistants, psychologists or others that are billed on their own numbers, even if those revenues are assigned to the physician group, are not incident-to services and may not be attributed directly to the treating physician.
However, those revenues may be shared in the overall profit distribution. To refer patients to your own nurses or technicians for in-office ancillary services, such as X-rays, your group must qualify as a group practice under the Stark definition. These three standards must be met as well:.
Exceptions include such things as physician services; office space or equipment rental; ownership of publicly traded mutual funds and securities; recruitment; prepaid plans; academic medical centers; and bona fide employment agreements.
A Stark Law update of October 1, , places limits on so-called under-arrangements relationships between hospitals and third-party health services in which a hospital will both bill and collect for the service while paying a fee to the third-party provider.
The Stark Law now forbids any hospital to seek and bill for outside-provider services stemming from referrals that violate its rules. The law applies equally to individuals or organizations that have either performed or billed for the designated services in question. In rural locations, these restrictions on under-arrangements referrals will not always apply.
Furthermore, Stark Law is somewhat ambiguous concerning the accountability of under-arrangements venues that provide only a minor portion of designated health services.
Stark is a strict liability law. This means that a physician can violate it without intentionally meaning to do so. Nevertheless, compliance is mandatory , and penalties can apply to the physician or designated health services provider who makes or benefits from a prohibited referral. These may include sanctions that:.
Any violation of Stark Law regulations constitutes Medicare fraud, and those who choose to blow the whistle could receive rewards amounting in some cases to millions of dollars. Those who wish to be eligible need to be mindful of some technical requirements. It is also a Stark law violation to refer a Medicare patients to health care facilities in which you or a relative has an ownership interest. The law is named for Congressman Pete Stark who sponsored the initial bill.
Examples of Stark Law violations Medicare or Medicaid rules do not allow a health care provider to bill the government for any services to patients that were obtained through an unlawful Stark law referral.
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