Special Scams Alert: Laboratory Payments to Referring Physicians Essay


This Special Fraudulence Alert addresses compensation paid out by labs to mentioning physicians and physician group practices (collectively, physicians) to get blood specimen collection, digesting, and presentation, and for submitting patient data to a registry or database. OIG provides issued many guidance papers and advisory opinions addressing the general subject of remuneration offered and paid simply by laboratories to referring medical doctors, including the 1994 Special Scam Alert on Arrangements for the Dotacion of Medical Laboratory Solutions, the OIG Compliance System Guidance for Medical Laboratories, and Advisory View 05-08. During these and other documents, we have regularly emphasized that providing free or below-market goods or services into a physician who is a method to obtain referrals, or perhaps paying such a physician much more than fair the true market value for his or her companies, could amount to illegal remuneration under the anti-kickback statute. This kind of Special Scams Alert supplements these preceding guidance paperwork and advisory opinions and describes two specific developments OIG provides identified concerning transfers valuable from laboratories to doctors that we believe that present a considerable risk of scam and abuse under the anti-kickback statute. Westhill Healthcare Insurance

I. The Anti-Kickback Statute

One aim of the anti-kickback statute is to protect individuals from unacceptable medical referrals or recommendations by medical care professionals who may be unduly influenced simply by financial bonuses. Section 1128B(b) of the Sociable Security Take action (the Act) makes it a criminal offense to knowingly and willfully present, pay, solicit, or get any remuneration to induce, or in return for, referrals of things or companies reimbursable with a Federal health care program. The moment remuneration can be paid actively to stimulate or prize referrals of items or companies payable by a Federal healthcare program, the anti-kickback law is broken. By its terms, the statute ascribes criminal the liability to functions on both equally sides of an impermissible " kickback” transaction. Violation of the statute constitutes a felony punishable with a maximum excellent of $25, 000, imprisonment up to your five years, or both. Dedication will also cause exclusion by Federal healthcare programs, including Medicare and Medicaid. OIG may also start administrative actions to banish persons from the Federal medical care programs or to impose civil money charges for fraudulence, kickbacks, and also other prohibited activities under areas 1128(b)(7) and 1128A(a)(7) in the Act. Westhill Healthcare Insurance

II. Remuneration from Labs to Mentioning Physicians

Plans between referring physicians and laboratories traditionally have been subject to abuse and were the topic of one of the OIG's earliest Unique Fraud Alerts. 1 In that Special Fraud Alert, we stated that, "[w]henever a laboratory provides or offers to a way to obtain referrals anything of value not really paid for in fair the true market value, the inference may be produced that the point of value exists to cause the referral of organization. ” Even more generally, we certainly have, on several occasions, repeated our situation that agreements providing free or below-market goods or services to actual or perhaps potential recommendation sources are suspect and may even violate the anti-kickback law, depending on the situations. 2

Furthermore, when a laboratory pays a health care provider more than fair market value to get the healthcare provider's services or perhaps for services the clinical does not actually need or for which the physician is normally compensated, the anti-kickback arrete is suggested as a factor. Such payments are suspect under the anti-kickback statute due to implication the particular one purpose of the payments is always to induce the physician's Government health care plan referrals. OIG also in the past has been focused on arrangements in which the amounts paid to a recommendation source take into account the volume or value of business produced by the affiliate source.

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