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Idaho Fraud and Abuse Statutes: Requirements, Penalties and Repayments
/in Fraud and Abuse, Healthcare Law, Idaho Healthcare LawBy Kim Stanger
Most Idaho healthcare providers are—or should be—aware of federal fraud and abuse laws, including the False Claims Act, Anti-Kickback Statute, Ethics in Patient Referrals Act (“Stark”), and the Civil Monetary Penalties Law, but they may not realize that Idaho has its own fraud and abuse laws that also apply. Violations may result in criminal, civil, and administrative penalties in addition to the obligation to repay amounts received in violation of the rules and provider agreement.
1. Idaho Anti-Kickback Statute. It is illegal for a health care provider to engage in the following misconduct:
(1)(a) Knowing that the payment is for the referral of a claimant to a service provider, either to accept payment from a [healthcare] provider or, being a [healthcare] provider, to pay another; or
(b) To provide or claim or represent to have provided services to a claimant, knowing the claimant was referred in violation of paragraph (a); [or]
(2) [E]ngage in a regular practice of waiving, rebating, giving, paying, or offering to waive, rebate, give or pay all or part of a claimant’s deductible or claim for casualty, disability insurance, worker’s compensation insurance, health insurance or property insurance.
(Idaho Code § 41-348). The statute applies to referrals for “health care services”, which are defined as “a service provided to a claimant for treatment of physical or mental illness or injury arising in whole or substantial part from trauma.” (Id. at § 41-348(2)). Violations may result in civil monetary penalties of up to $5,000. (Id. at §§ 41-348(4) and 41-347(1)). Significantly, the Idaho statute is broader than its federal counterpart: it applies to services payable by private payers as well as government programs. Read more
Sports and Student Physicals: Legal Issues
/in Hospitals & Health Systems, Physician PracticesBy Kim Stanger
It’s that time of year when many healthcare providers offer free or discounted sports or student physicals as a community service or marketing ploy. If you participate in such programs, make sure you consider the legal issues, including the following:
Read more
Paying Hospital-Employed Physicians for Services Performed by Others
/in Reimbursement & CollectionsBy Kim Stanger
The Ethics in Patient Referrals Act (“Stark”) prevents hospitals from paying employed or contracted physicians in the same way that physicians are or were paid by independent physician groups. Specifically, physician groups may generally pay physicians a share of the profits from services performed by others, but hospitals may not pay physicians in a way that varies with the volume or value of referrals for certain services payable by Medicare or Medicaid, which usually precludes paying physicians a share of profits or a percentage of fees for services referred or ordered by the physician but performed by others.
Stark Requirements. Per Stark, if a physician (or a member of the physician’s family) has a financial relationship with an entity, the physician may not refer patients to that entity for certain designated health services1 payable by Medicare or Medicaid unless the financial arrangement is structured to fit within a regulatory safe harbor. (42 USC § 1395dd; 42 CFR § 411.353). Under Stark’s “group practice” safe harbors, physician groups that qualify as a “group practice” may pay physician group members based on services the physician personally performs, services billed “incident to” the physician’s personally performed services, or, subject to certain limits, a portion of the overall profits of the group, including profits from services derived from services performed by others. (See 42 CFR §§ 411.353 and 411.355(a)-(b)). These “group practice” safe harbors are not available to physicians who are employed by the hospital. Read more
Utah Care-Review Privilege
/in Liability & Risk Managementby Cory Talbot
Utah adopted a care-review privilege “to improve medical care by allowing health-care personnel to reduce morbidity or mortality and to provide information to evaluate and improve hospital and health care.”1 In January, the Utah Court of Appeals gave some helpful guidance about the application of this privilege in Vered v. Tooele Hospital Corporation.2
The Care-Review Privilege Generally
Before discussing the Vered case, we will go over a number of general background issues regarding the scope and application of the care-review privilege. Read more
Want to Hire an Employee Subject to a Noncompete Agreement?
/in Contracts & Transactions, Employmentby Nicole Snyder
Republished with permission from Idaho Medical Group Management Association (MGMA). Original article appeared in Idaho MGMA’s May 2018 e-newsletter.
As the healthcare industry grows, and at a time when unemployment is low, it can be very frustrating to find potential employee candidates who are bound by noncompete agreements with current or former employers.
Medical practices shouldn’t be too quick to throw in the towel before rejecting candidates on the basis of having a noncompete agreement. Here are some pointers to help with the hiring process in these situations: Read more