Which Is an Exception to the Anti-Referral Law

(i) The same building (as defined in section 411.351), but not necessarily in the same room or part of the building where all the conditions set out in paragraphs (b)(2)(i)(A), (b)(2)(i)(B) or (b)(2)(i)(C) of this section are met: These final provisions introduce an entirely new framework for structuring authorized agreements and relationships between health care providers and payers. This white paper will examine this new framework and the new definitions, exemptions and exemptions that together are expected to play a central role in innovating care coordination and healthcare payment models for years to come. The OIG provided some examples of agreements that could be structured to comply with Safe Harbour for care coordination. The OIG suggests that Safe Harbour could be used for care coordination to coordinate care between hospitals and post-acute care providers, specialists and primary care providers, or hospitals and doctors` offices and patients. Such coordination could include hiring care managers, providing care or managing medications, creating a patient-centred medical home, assisting in effective transitions of care, sharing and using health data to improve outcomes, or sharing responsibility for care to a patient across the continuum of care. These agreements, of course, involve referrals between care providers, but they include useful activities beyond simply recommending a patient or ordering an item or service. The OIG notes that it “sees a clear distinction between coordinating and managing patient care transitions with the goal of improving the quality of care or improving efficiency that would fit the definition, and passing patients through health care facilities to benefit from a reimbursement system or generate revenue that would not fit the definition.” 11 Similarly, the OIG found that agreements involving the provision of data analytics software, care managers, or remote patient monitoring could likely fall within the scope of safe haven. The OIG explicitly responded to commentators that income guarantees are not in-kind benefits and are therefore not eligible for protection under Safe Harbor care coordination agreements.12 As a result, CMS finalized an amendment to the indirect compensation exception in the Stark Final Rule to address this issue. CMS intends to link the value-based objective of the agreement to VBE as a whole. The exception does not protect a “side agreement” between two NA participants that is not related to the objectives (i.e., value-based purposes) of the VBA in which they participate, even if the agreement itself serves a value-based purpose.13 Preventive Services.

Vaccines, vaccinations and screening tests are usually allowed with striking exceptions, as long as they are not administered too often. Tests must be covered by Medicare. The new rule also addresses the definition of “compensation” and extends the exception for “supply of articles, equipment or supplies” to include the supply of surgical items, appliances or consumables. (ii) If, at the time of referral, there are fewer than 5 other providers within 25 miles of the physician`s office, the physician must list all other imaging service providers within 25 miles of the location of the attending physician`s office. The provision of the written list of other suppliers is not required if no other supplier provides the services for which the person within the 25-mile radius is recommended. The final two provisions are intended to protect only remuneration that takes place under a “value-based agreement” under an EVB. To understand what this means, a useful starting point may be to focus on what needs to be at the heart of an eligible agreement – the “value-based objective” of the agreement. Each protected agreement must essentially have one or more objectives based on values defined as follows: (iii) One or more affiliated hospitals where the majority of physicians on medical staff are faculty physicians and where the majority of all hospital admissions are made by faculty physicians. For the purposes of this paragraph (e)(2)(iii), the hospital may be the same hospital that meets the requirement of paragraph (e)(2)(i) of this section. For the purposes of this paragraph (e)(2)(iii), a faculty member is a physician who is a member of the faculty of the affiliated faculty of medicine or the faculty of one or more of the teaching programs of the accredited teaching hospital. To satisfy this paragraph (e)(2)(iii), the faculties of an affiliated medical school or an accredited university training program may be grouped together and residents and non-medical professionals do not need to be counted.

Each faculty member can be counted, including courtesy professors and volunteers. To determine whether the majority of physicians on medical staff are faculty members, the affiliated hospital must include or exclude all physicians with the same class of privileges in the affiliated hospital (e.g., physicians with courtesy privileges).