Documenting Documenting Compliant and Fair ?· Documenting Documenting Compliant and Fair Compliant…

  • View
    213

  • Download
    0

Embed Size (px)

Transcript

  • Documenting Documenting Compliant and Fair Compliant and Fair Market Value Physician Financial Market Value Physician Financial ArrangementsArrangements

    Robert A. Wade, Esq.PartnerPartnerKrieg DeVault4101 Edison Lakes ParkwaySuite 100Mishawaka IN 46545Mishawaka IN 46545Telephone: (574) 485-2002Fax: (574) 277-1201

    bwade@kdlegal combwade@kdlegal.com

    KD_4901978

  • Learning ObjectivesLearning Objectives

    This session will provide you with the knowledge to:

    g jg j

    This session will provide you with the knowledge to: Assemble documentation to support physician financial

    arrangementsg Document a financial arrangement with a referring physician Determine legal requirements for fair market value and

    i l blcommercial reasonableness

    2

  • Why Why IsIs Documenting Fair Market Value and Documenting Fair Market Value and Commercial Reasonableness Important? Commercial Reasonableness Important?

    Fines and Penalties incl ding 3 times the

    pp

    Fines and Penalties, including 3 times the amount paid by Medicare/Medicaid for service, $10 000 fine per payment etc$10,000 fine per payment, etc.

    Exclusion from Medicare/Medicaid Programs.Programs.

    Intermediate Sanctions. Imprisonment Imprisonment.

    3

  • Thi ll illThis really will not happen to me, will it?

    The government has better things to worry about than one

    t t b tcontract between a hospital and physician, right?

    4

  • Tell That To The Parties Involved In The Tell That To The Parties Involved In The Following CasesFollowing CasesFollowing CasesFollowing Cases

    Metropolitan Health, Grand Rapids, Michigan Rapid City Regional Hospital, Rapid City, South p y g p p y

    Dakota McLaren Regional Medical Center, Flint,

    Michigan Baptist Medical Center, Kansas City, Missouri Saint Joseph Regional Medical Center, South

    Bend, Indiana

    5

  • Excerpt from the Petition to Enter a Plea involving Excerpt from the Petition to Enter a Plea involving Saint Joseph Regional Medical Center: Saint Joseph Regional Medical Center:

    From in or around 1991 through 1993 it knowingly and willfully offered

    J p gJ p g

    From in or around 1991 through 1993, it knowingly and willfully offeredand provided financial benefits, including a $350,000 loan guarantee,a lease of medical facility space for radiology services at an inflatedrate, monthly practice enhancement payments, and medical chartrate, monthly practice enhancement payments, and medical chartcoding to Drs. Peter D. Farr and Howard M. Addis and offered otherthings of value to Drs. Peter D. Farr and Howard M. Addis forpurposes including Saint Josephs Medical Center, an affiliate ofp p g pHorizon, receiving patient referrals, including referrals of Medicaidand Medicare patients, from these two doctors. Horizon intentionallyoffered and provided these items to Drs. Farr and Addis while Horizonknew, on a collective basis, that it was contrary to law and a violationof a legal duty to enter into and to maintain the financial arrangementsthat it did with Drs. Farr and Addis;

    6

  • Fair Market Value and Commercial Fair Market Value and Commercial Reasonableness are important factors in: Reasonableness are important factors in:

    Anti-Kickback Statute Stark Act Intermediate Sanctions

    7

  • AntiAnti--Kickback Statute Kickback Statute (42 U.S.C. (42 U.S.C. 1320a1320a--7b7b))(42 U.S.C. (42 U.S.C. 1320a1320a 7b7b))

    U d th AKS it i ill l t Offer, pay, solicit, or receive remuneration; Directly or indirectly;

    Under the AKS it is illegal to:

    Directly or indirectly; In cash or in kind; In exchange for: In exchange for:

    Referring an individual; or Furnishing or arranging for a good or

    i dservice; and Payment may be made by Medicare

    or Medicaid.or Medicaid.

    8

  • What Is Remuneration?What Is Remuneration?

    E t l B d S h th i h i ki d

    What Is Remuneration?What Is Remuneration?

    Extremely Broad Scope, whether in cash or in kind, and whether made directly or indirectly, including:

    Kickbacks; Bribes; Rebates; Gifts; Gifts; Above or below market rent or lease payments; Discounts; Furnishing of supplies, services or equipment either free,

    above or below market; Above or below market credit arrangements; and Waivers of payments due.

    9

  • Three Necessary ElementsThree Necessary ElementsThree Necessary ElementsThree Necessary Elements

    Intentional Act

    Direct or

    of Remuneration

    Direct or Indirect Payment of Remuneration

    To Induce the Referral of

    10Patients or Business

  • PENALTYPENALTY

    Finednot more than $25,000 or imprisoned for not more p

    than five (5) years

    or bothor both

    11

  • Fair Market Value RequiredFair Market Value Requiredin Following Safe Harborsin Following Safe Harborsgg

    Employment Personal Services and Management Contracts Office Space Leasing Equipment Leasing

    12

  • Stark ActStark Act

    42 U.S.C. 42 U.S.C. 1395 1395 nnnn42 U.S.C. 42 U.S.C. 1395 1395 nnnn

    Under the Stark Act, a physician is prohibited from making a referral:to an entity; to an entity;

    for the furnishing of a designated health service;for which payment may be made under for which payment may be made under Medicare or Medicaid;

    if the physician (or an immediate familyif the physician (or an immediate family member);

    has a financial relationship with the entity.

    13

  • Stark ActStark Act

    Designated Health Service Entity includes: 1) Entity that bills Medicare) y2) Entity that performs DHS

    14

  • Stand in the Shoes

    Pre-Phase III View Phase III View

    Physician

    $Physician

    Organization

    Group $ Direct

    $ HospitalIndirect

    15

    Hospital

  • Stark ActStark Act42 U.S.C. 42 U.S.C. 1395 1395 nnnn

    St k E ti R i i F i M k t

    Stark Exceptions Requiring Fair Market Value/Commercial Reasonableness: Personal Service ArrangementsPersonal Service Arrangements Rental of Office Space Rental of Equipment Employment Isolated Transactions Fair Market Value Fair Market Value Indirect Compensation

    Arrangement

    16

  • 17

  • Intermediate SanctionsIntermediate Sanctions

    If a tax-exempt organization engages in an excess benefits transaction with a disqualified person, the tax-exempt organizations directors and managers, and the disinterested person, could be subject to a tax of 25% on the excess benefit If the excess benefit is not paid backthe excess benefit. If the excess benefit is not paid back or reversed, the organization's officers and managers, and the disqualified person could be subject to a 200% tax on the excess benefit.

    18

  • Intermediate SanctionsIntermediate SanctionsDisqualified PersonDisqualified Personq fq f

    A disqualified person is an officer, director, trustee, highly-compensated or high-level employee, d t t j t j ddepartment or project manager, major donor or anyone who has been in a position to exert substantial influence over the organization within gthe prior five years

    19

  • Intermediate SanctionsIntermediate SanctionsExcess BenefitExcess BenefitExcess BenefitExcess Benefit

    An excess benefit is one that exceeds fair market value for the benefit received by themarket value for the benefit received by the tax exempt organization, or is not comparable (commercially reasonable) tocomparable (commercially reasonable) to similar benefits paid by similar tax-exempt organizations.

    20

  • WHAT IS FAIR MARKET VALUE?WHAT IS FAIR MARKET VALUE?

    $I want

    MORE!Fair

    market l i$ $value is fine!

    21

  • What do you mean by FMV?What do you mean by FMV?y yy y

    In the healthcare context there are In the healthcare context, there areessentially 3 basic views on the meaningof FMV:

    Person on the street perspective Professional appraisal perspective Legal/regulatory perspective

    Unfortunately, these 3 basic views frequently conflictconflict.

    Parties can get dazed and confused when these 3 competing views meet to complete a transaction.p g p

    2222

  • The Street View of FMV The Street View of FMV

    What everyone is getting paid in the marketWh t th h it l d th t t i What the hospital down the street is payingIncremental cost plus a profit margin Incremental cost plus a profit margin

    Whats in a survey bookWh t it th t t t th t ti What its worth to one party to the transaction

    2323

  • Professional Appraisal ViewProfessional Appraisal Viewof FMVof FMV

    The price, expressed in terms of cash equivalents, at which property would change h d b t h th ti l illi d blhands between a hypothetical willing and able buyer and a hypothetical willing and able seller, acting at arms length in an open andacting at arm s length in an open and unrestricted market, when neither is under a compulsion to buy or sell and when both have p yreasonable knowledge of the relevant facts.(International Glossary of Business Valuation Terms)

    2424

  • Professional Appraisal View of FMVProfessional Appraisal View of FMV

    B d th h th ti l t i l b t Based on the hypothetical-typical buyer concept FMV contrasts with investment value or strategic value Determination of FMV is based on 3 approaches toDetermination of FMV is based on 3 approaches to

    value: Cost IncomeIncome Market

    Formal body of knowledge and professional standards governing the appraisal practice for real estate andgoverning the appraisal practice for real estate and business valuation (BV)

    No current body of knowledge or standard