Tag Archives: Fraud – Stark


OIG issues another in a string of gainsharing opinions involving hospitals and groups of cardiologists and radiologists. This and the solicitation by HHS of comments on shared savings exceptions and safe harbors confirm HHS’s intent to continue to encourage legitimate cost savings and incentive programs. Link: http://www.oig.hhs.gov/fraud/docs/advisorgopinions/2008/AdvOpn08-21.2.pdf.  … Continue Reading


Advisory Opinion 08-16, the text of which is linked below, involved a nonprofit hospital’s Pay for Performance (P4P) program with a commercial insurer and certain physicians on the hospital’s medical staff. Under the P4P program, the insurer pays the hospital bonus compensation calculated as percentage of the annual base compensation it otherwise pays to the … Continue Reading

Stark IV: Per-Click Leases; Stand-in-Shoes; and Disallowance

The Department of Health and Human Services and Centers for Medicare and Medicaid Services (CMS) published final Stark IV regulations in the Federal Register on August 19, 2008. The web link is ttp://edocket.access.gpo.gov/2008/E8-17914.htm. The final regulations cover issues in addition to physician self-referral. Three issues of particular interest are the per-click compensation arrangements, the Stand-in-shoes regulations, and compliance … Continue Reading

CMS Proposes New “Stands in Shoes” Regulations

STARK: "STAND IN SHOES" REGULATIONS The original proposed physician "Stand in Shoes" regulations provide that any physician would stand in the shoes of any other doctor in the following circumstances: 1.      Another physician who employs the referring physician; 2.      His or her wholly owned professional corporation; 3.      A physician’s medical practice that employs or contracts with … Continue Reading

CMS Posts Stark FAQs

CMS recently modified its website to include a new page called Frequently Asked Questions and just added twelve questions and responses under the Physician Self-Referral page. Access the FAQs. at http://www.cms.hhs.gov/PhysicianSelfReferral/05a_FAQs.asp#TopOfPage.… Continue Reading

2008 Medicare Physician Fee Schedule Delays Stark Rules

2008 MEDICARE PHYSICIAN FEE SCHEDULE DELAYS STARK RULES CMS announced in the 2008 Medicare Physician Fee Schedule final rule that the following proposed revisions will not be finalized until the future publication of a final rule: §                     burden of proof; §                     obstetrical malpractice insurance subsidies; §                     unit of service (per click); §                     payments in lease … Continue Reading

OIG Issues 2008 Work Plan

The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) has issued its fiscal year 2008 Work Plan, identifying investigation projects for the coming fiscal year relating to the Medicare and Medicaid programs. Following is a copy of pages 3 through 13 of the 2008 OIG Work Plan, which identify the … Continue Reading

More Stark III Changes: Physician Recruitment

MORE STARK III CHANGES: PHYSICIAN RECRUITMENT There have been a number of definitional or technical changes to the physician recruitment exception. ·        The definition of the hospital’s geographic service area, which was previously the area composed of these contiguous zip codes from which the hospital drew 75% of its inpatients, has been tweaked to exclude … Continue Reading

CMS Stark Advisory Opinion Rejects Amendment of Recruitment Agreement

CMS ISSUES STARK ADVISORY OPINION PROHIBITING  AMENDMENT OF RECRUITMENT AGREEMENT On October 3, 2007, the Centers for Medicare and Medicaid Services (CMS) issued Advisory Opinion CMS – AO – 2007 – 01 denying permission to the hospital and physician to revise a physician recruitment agreement. The proposed amendment would have deleted and “excess receipts provision, which … Continue Reading

OIG Advisory Opinion: Pay for Call Coverage Approved

OIG ADVISORY OPINION 07-10 APPROVES CALL PAY On September 27, 2007, the Office of the Inspector General of the Department of Health and Human Services posted OIG Advisory Opinion No. 07-10 which approves a tax exempt hospital proposal for compensating physicians for on call coverage. While acknowledging that on call compensation potentially creates considerable risk that … Continue Reading

CMS Issues Final Stark III Regulations

CMS Issues Final Stark Phase III Regulations Stark Phase III Regulations On August 27, 2007, the Centers for Medicare and Medicaid Services (CMS) placed on display at the Office of the Federal Register a final rule on physician "self-referral" of Medicare beneficiaries for certain types of Medicare-covered services. The rule is commonly known as "Stark … Continue Reading

Pete Stark Proposes Elimination of Whole Hospital Ownership Exception

Congressman Pete Stark has proposed a new piece to the Stark legislation which would eliminate the existing “whole hospital” exception for a physician ownership by inserting a provision into H.R. 3162, the Children’s Health and Medicare Protection Act, which would impose new hospital disclosure requirements and new physician ownership limitations. The text of the provision follows … Continue Reading

CMS Proposes to Close Stark Loopholes

CMS has issued regulations within the intent of closing what it perceives to be loopholes in the Stark regulations. The major initiatives are as follows: 1.         The definition of the term “entity” will be expanded to include both sole practitioners as well as other types of entities. The definition will state that an entity will include a … Continue Reading

District Court Rejects Renal Physicians Association Stark Challenge

The United States Court of Appeals has decided that the Renal Physicians Association (RPA), a national professional association, does not have legal standing to challenge the legality of the Stark Regulations. RPA had asserted that certain of the Stark regulations defining fair market value and personal service arrangements for purposes of establishing exceptions to the … Continue Reading

California Prosecutes 3 Doctors for Paying Patients to Submit to Unnecessary Surgery

The California Department of Insurance and the Orange County District Attorney’s Office have arrested three doctors in what they are describing  as the largest medical fraud prosecution in the nation. Some stories are so abhorrent  they taint entire professions. In Orange County, three physicians and a group of ambulatory surgery center developers, some of whom have already … Continue Reading

Employee Whistleblowers Cause $3 Million Dollar OverpaymentSettlement for Tennessee Cardiology Practice

Two former employees of East Tennessee Heart Consultants, a forty physician cardiology practice in Tennessee, tipped off federal prosecutors, who then filed a qui tam claim alleging the cardiology practice had a policy of retaining overpayments for services provided unless refunds were specifically requested, and that the practice maintained its billing records to conceal the … Continue Reading

OIG Reports Enforcement Actions

For those who doubt the possibility of OIG enforcement regarding fraud and abuse violations, the OIG Semi-Annual Report lists the following enforcement results: $2.8 billion on audit and investigative receivables; 3,806 individual and entity; receivables; 537 criminal actions; and 262 civil actions The report is accessible on the OIG Web site.… Continue Reading

Stark DHS Includes Nuclear Medicine

The final rule from the Medicare Physician Fee Schedule revises the Stark definition of designated health services (DHS) to include diagnostic and therapeutic nuclear medicine services. Since this change will impact existing relationships, this portion of the rule has a delayed effect date, i.e. January 1, 2007. Fee Schedule: Nuclear Medicine: DHS (CMS’s discussion on … Continue Reading