Physician Financial Relationships With Others

Copyright 1996-97 William L. Manning except as otherwise noted. All rights reserved.

Last updated by Bill Manning on 8/03/97

About This Page Antikickback, fraud and abuse, false claims, Stark I & II -- these terms invoke (and should invoke) fear in physicians and those who have commercial relationships with physicians. Many business relationships between and among physicians and others, while they may be appropriate and de rigeur in other industries, are illegal under various federal and state laws and could lead to Medicare/Medicaid program exclusion, civil and criminal penalties and a loss of federal tax-exempt status for hospitals. The relevant statutes, regulations, case law and agencies' enforcement activities are collected here for the convenience of lawyers and their clients. Most of the links from this page are to sites maintained independently of The Health Law Resource. As with all information on-line, please check the official sources for the most accurate and up-to-date information.

What's ?

 Selected Resources

• Antikickback: Fraud & Abuse

• 42 U.S.C. 1320a-7b The Medicare and Medicaid Patient Protection Act: Full Text (Criminal penalties)
• Summary of 42 U.S.C. 1320a-7b
• 42 U.S.C. 1320a-7a.  Civil monetary penalties.
• 42 U.S.C. 1320a.  Program Exclusion.
• Antikickback Safe Harbor Regulations (54 Federal Register 35,952 (1991); 42 C.F.R. 1001.952).
• Antikickback Safe Harbor Regulations for Managed Care Plans.
• HHS OIG Special Fraud Alerts Medicare and State Health Care Programs: Fraud and Abuse; Issuance of Advisory Opinions by the OIG
• Financial Arrangements Between Hospitals and Hospital-Based Physicians Report of the HHS OIG, OE1-09-89-0030, available on ACR's WEB site.
• Health Care Fraud: Information-Sharing Proposals to Improve Enforcement Efforts, GGD-96-101.
• OIG Model Compliance Plan for Clinical Laboratories, Federal Register: March 3, 1997 (Volume 62, Number 41, Page 9435-9441). For the file in .pdf format, click here.
• Committee Minutes: Negotiated Rulemaking on the Shared Risk Exception. June 1997 Committee Minutes (sessions of 6/17 & 6/18). Text Version or Adobe Acrobat Version.
• Negotiated Rulemaking on the Shared Risk Exception, Notice of Intent to Establish Negotiated Rulemaking Committee, Federal Register (5/23/97). Text Version. The .pdf version.
• OIG Sanctions Report (cumulative, in effect as of October 1996) in PDF format (1.2 mb) (Adobe Acrobat).
• Health Care Programs: Fraud and Abuse; Revised PRO Sanctions, 1997 Federal Register, 4-29-97.
• Fraud and Abuse: Providers Target Medicare Patients in Nursing Facilities, HEHS-96-18.
• Health Care Fraud = False Claims = Qui Tam Actions, by Edward McDonough, McDonough & Associates, P.C. (Houston, Texas (713) 223-3600).
• GAO Testimony: Fraud and Abuse: Providers Excluded From Medicaid Continue to Participate in Federal Health Programs, by Leslie G.Aronovitz, Associate Director for Health Services Quality and Public Health Issues, before the Subcommittee on Human Resources and Intergovernmental Relations, House Committee on Government Reform and Oversight. GAO/T-HEHS-96-205.
• Complying With The Physician Incentive Plan Regulation
  Resources from the American Association of Health Plans (AAHP) & elsewhere.
  • Federal Rules: Physician Incentive Plans in Medicare/Medicaid Health Plans.
  • Notice on Physician Incentive Regulation Compliance Dates.
  • Physician Incentive Plan Regulation -- Clarification AAHP Disclosure Forms and Instructions
  • Self Extracting zip file, for the Physician Incentive Plan Regulation Material. All three files are in WordPerfect 6.1 format and are contained in this zipped program and are from American Association of Health Plans (AAHP).
  • Implementation of Physician Incentive Plan Regulation Memo, from AAHP
  • AAHP Summary Chart Instructions, from AAHP.
  • AAHP Physician Incentive Plan Worksheet, from AAHP.
• Acceptance of External Funds by Physician Organizations, Peter Ubel, Univ. of Penn., Center for Bioethics.
• Health Care Fraud Prevention and Detection White Paper, 10/93, WEDI.

• Select New & Pending Federal Legislation

  • Health Insurance Portability and Accountability Act Of 1996
    • Text of Enrolled Bill
    • References in the Congressional Record, including references to Committee Reports
    • Summary of legislation from HHS

Prohibitions on Certain Physician Referrals

• 42 U.S.C. 1395nn: "Stark"
• Digest/Explanation of Stark II from Lynn Westenberg, Senior Attorney, American College of Radiology, October, 1994.
• 42 U.S.C. § 1320a-3. Disclosure of ownership and related information; procedure; definitions; scope of requirements.
• 42 U.S.C. § 1320a-3a. Disclosure requirements for other providers under part B of Medicare.
• 42 U.S.C. § 1320a-5. Disclosure by institutions, organizations, and agencies of owners, officers, etc., convicted of offenses related to programs; notification requirements; ''managing employee'' defined.
• New Stark II Rules on Referrals Will Further Restrict Medical Practices, Neil Caesar, J.D., in Managed Care Magazine.
• Program Integrity: Reinventing Government Efforts and Implementation of Physician Self-Referral Prohibitions, Testimony of Kathleen Buto, Associate Administrator, on before the Subcommittee on Health, House Committee on Ways and Means, May 3, 1995.
• Select New and Pending Federal Legislation

Selected Additional Resources

• DHHS OIG Audit Process Handbook with auditors' tools to conduct audits and prepare reports. (1.2 mb). Requires Adobe Acrobat(tm) Reader.
• Federal Law Enforcement: Investigative Authority and Personnel at 32 Organizations., GAO Report GGD-97-93, 7-22-97, Requires Adobe Acrobat(tm) Reader.
• BUSINESS CRIME: Negotiating Collateral Provisions of Federal Plea Accords, (NYLJ) 10/10/96.
• FEDERAL DISCOVERY: Work Product Privilege of Internal Investigations, (NYLJ) 08/16/96.

Recently In the News

• Tenet Resolves OrNda Whistle-Blower Suit, Reuters, 7-25-97.
• Hospitals Ask Government For A Moratorium On Fraud Claims, Reuters, 7-10-97
• American Home Products Ordered To Pay $45 Million In Fraud Case, Reuters, 7-07-97
• Operation Restore Trust Objectives and First-year Accomplishments, HHS OIG Fact Sheet; 05/13/96.
• Sounding Board: Auditing the Medicare-Billing Practices of Teaching Physicians -- Welcome Accountability, Unfair Approach, New England J. of Medicine, Volume 336, Issue 18, 5-01-97.
• Stiffer penalties proposed for Medicare and Medicaid fraud, Clinton sent a bill to Congress The Medicare and Medicaid Fraud and Abuse Prevention Act); Ron Fournier, A.P., 3-26-97.
• Clinton To Propose Medicaid/Medicare Anti-Fraud Bill, Reuters, 3-26-97.
• New HCFA Rules Could Put MDs At Risk, Andrew Bowser, Medical Tribune: Family Physician Edition 38(5): 1997.
• Physician Deals Top List Of Healthcare Mergers, Reuters, 3-13-97.
• Automation Fosters Health Care Fraud, By Malcolm K. Sparrow, Feb 97
• Physician Financial Incentives Affect ED Admission Rates For "Lower-Acuity Conditions", Reuters, 2-18-97.
• Michigan Attorney General Kelley Charges Doctors in Medicaid Fraud Scheme, PRNewswire, 2-13-97.

 Explore These Relevant Links

• IGNet
• A-96 Edition of AMA PolicyFinder, Provides a Microsoft Windows interface to browse or search: (1) the policies of the AMA House of Delegates; (2) the AMA Constitution and Bylaws, and (3) the Current Opinions of the Council on Ethical and Judicial Affairs.
• State Legislative Profiles, MGMA representatives and state legislative information.

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Last updated by Bill Manning on 8/03/97

Visitors Since 1/06/97