Medicare Part A - Pays for inpatient hospital, SNF, HH related to hospital stay, and
hospice care. Financing comes from a 2.9% payroll tax split between employers and
employees.
Medicare Part B - Pays for physician, outpatient hospital, ESRD, lab, DME, and some
HH. Coverage is voluntary - about 92% of beneficiaries are enrolled. 25% is covered by
beneficiary premiums/75% other government revenues
Medicare Part C - Medicare Advantage Program - typically private managed care
companies are paid capitation by the government to provide all Part A, B, & D services.
Medicare Part D - standard rx benefit. Beneficiaries are responsible for a portion of the
cost which varies on brand vs. generic and how much money they have already spent
on rx that year.
Elliot Fisher - Introduced the Accountable Care Organization and incorporated it into
Medicare Shared Savings Program provisions of the PPACA.
Accountable Care Organization - Advocates for coordination of health services by
organizations with an intention to promote an integrated approach to health care with
efficiency and cost savings.
State Scope of Practice Restriction - intended to ensure that professionals offer services
according to their skill and training.
Stark Law - Prohibits physicians from referring patients for designated health services
where there is a financial relationship between the providers. CMS publishes a list of
CPT codes on an annual basis that identify DHS services.
Federal Anti-Kickback Statute - Prohibits providing remuneration or giving of value with
the intent of inducing referrals. Includes both criminal and civil penalties.
The Federal Health Care False Claims - May not knowingly submit a false claim for
payment - includes actual knowledge or deliberate disregard such as when bills were
submitted that would be paid for services not rendered
Qui Tam Actions - Part of the False Claims Act - allows a "relator" to bring a suit on
behalf of the government after filing an action under seal. The government will review
the act and choose whether to intervene (join the suit). Individuals may continue without
the government joining if they desire. Relators will get between 15-30% of the recovery
depending on whether the government joined the case.
, Corporate Practice of Medicine - Avoids commercialization, lay control, and limited
liability of the corporate form. These professionals should not have their actions
controlled by someone else as the "patient" is their client and their needs should dictate
the relationship. Stems from the Learned Professions Doctrine.
Financial Relationship - ownership/investment interest (may be through debt/equity) or a
compensation arrangement (may be direct/indirect such as an immediate family
member)
Remuneration - Any payment or benefit in cash or in kind with the exception of
forgiveness of amounts for inaccurate/mistakenly performed services/correction of
minor billing errors, provision of items used to collect, transport, process, or store
specimens for the entity providing the service or as needed to communicate results, and
certain payments made by an insurer to the physician for services rendered to a
beneficiary
Referral - Request by a physician for, or ordering of, or the certifying or recertifying of
the need for a covered item or service (including consults) or the request or
establishment of a plan of care by a physician which includes the provision of DHS. It
includes referrals within the physician's own practice and can be in any form including
written, oral, or electronic. DHS is not considered performed by the physician if anyone
provides it.
Referral exceptions - A request by a radiologist for diagnostic radiology services or by a
pathologist for clinical diagnostic lab tests and pathological exam services, or by a
radiation oncologist for radiation therapy.
Entity furnishing DHS - 1. the person or entity to whom CMS makes payment either
directly or upon assignment on the patient's behalf 2. Is the person to which the right to
payment has been reassigned 3. is a health plan that employs a supplier or operates a
facility that could accept reassignment from a supplier
Employment exception - Allows employees to make referrals when they are employed
for identifiable services, amount of remuneration is fair market value and is not linked to
volume of referrals and that remuneration is reasonable even if there were no referrals
made.
In office ancillary services exception - 1. Applies to all DHS except DME (other than
infusion pumps) and parenteral and enteral nutrients, equipment and supplies. 2. must
be furnished by personally by a physician who is a member of the same group practice
or an individual who is supervised by the referring physician or another physician in the
group practice and 3. occurs in the same building or in the group practices centralized
building used for rendering the practices DHS and 4. must be billed by the physician
performing or supervising the services/the group practice 5. this can apply to an
individual's practice as well as group practices if all requirements are met
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