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COMPLIANCE ROAD TRIP. “Navigating Labs to Make Informed Decisions”. David W. Gee and Kristen R. Blanchette David Wright Tremaine LLP [email protected] [email protected]. 1. % BASED CONTRACT MARKETING. COMPLIANCE ROAD TRIP. 2. IN-OFFICE PHLEBOTOMISTS. ST. - PowerPoint PPT Presentation
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COMPLIANCE ROAD TRIP
“Navigating Labs to Make Informed Decisions” David W. Gee and Kristen R.
BlanchetteDavid Wright Tremaine LLP
COMPLIANCE ROAD TRIP
1. % BASED CONTRACT MARKETING
2. IN-OFFICE PHLEBOTOMISTS
3. MOBILE PHLEBOTOMISTS
4. LEASING SPACE FROM DOCTORS
5. LAB PRICING PRACTICES
ST.
AVE.
BLVD.
RD.
WAY
1. % BASED CONTRACT MARKETING
FEDERAL PROHIBITED
Why? AKS and No Safe Harbor
CAPROHIBITED
Why? Medi-Cal AKS
BUT: May be PERMITTED by PORA Safe Harbor Unless Medicare or Medi-Cal Involved
YIELDAHEAD
ST.
REFERENCES
1. % BASED CONTRACT MARKETING
FEDERAL 42 U.S.C. § 1320-a-7(b)
[AKS] 42 C.F.R. § 1001.952 [Safe
Harbors] 42 U.S.C. § 1320-a-7b (b)(3)
(B); 42 C.F.R. § 1011.952(i) [Bona Fida Employees]
42 C.F.R. § 1001.952 (d) [Pers. Svs./ and Mgmt.]
CA Cal. Bus. & Prof. Code §
650(a) [CA AKS – PORA] Cal. Welf. & Inst. Code §
14107.2 (a) + (b) [Medi-Cal AKS]
Cal. Welf. & Inst. Code § 14107.2 (c) [Medi-Cal AKS Safe Harbor]
ST.
REFERENCES
1. % BASED CONTRACT MARKETING
FEDERAL CASE LAW U.S. v. Polin, 194 F.3d 863 (7th Cir. 1999) U.S. v. Starks, 157 F. 3d 833 (11th Cir.
1998) Joint Tech. v. Weaver, CIV-11-846-M (W.D.
Okla. 1/23/14) Zimmer v. NuTech Medical, 54 F. Supp. 2d
(N.D.Ind.1999) Nursing Home Con. v. Quantum Health
Services, 926 F. Supp. 835 (E.D. Ark. 1996) Modern Med. Labs v. Smith-Kline Beecham
Clinical Labs, 1994 U.S. Dist. LEXIS 11525 (N.D. Ill. 8/16/94)
CA CASE LAW People v. Duz-Mor Diagnostic
Laboratory, 68 Cal.App.4th 654, 671 (1998)
People v. Palma, 40 Cal.App.4th 1559 (Cal. Ct. App. 1995)
People v. Guiamelon, 205 Cal.App.4th 383, 413, 140 Cal.Rptr.3d 584 (2012)
ST.
REFERENCES
1. % BASED CONTRACT MARKETING
FEDERAL SETTLEMENTS OIG - Kickback and Physician Self-
Referral (08-21-2014) [Zimmer-Deptula (ZDI) paid $123K]
OIG - Kickback and Physician Self-Referral (10-21-2013) [FCA case; two owners of DME co. agreed to be excluded for 20 yrs]
OIG Archives - Kickback and Physician Self-Referral (02-15-2005) [ TLC paid $130K to resolve CMP liability]
CA LEGIS. COUNSEL OPINION
California Legislative Counsel Bureau Opinion # 1128674, “Clinical Laboratory Referral Practice” (Apr. 20, 2012) (adresses the legality under both federal and state law of a commission-based contract marketing arrangement)
ST.
2. IN-OFFICE PHLEBOTOMISTS
FEDERAL PERMITTED, IF
Solely collecting and processing lab specimens
CAPROHIBITED
Why? LFS has provided guidance on this issue
AVE.
REFERENCES
2. IN-OFFICE PHLEBOTOMISTS
FEDERAL CMS Commentary to Final
Stark II Regs., 66 Fed. Reg. 856, 948-49 (Jan. 4, 2001)
OIG Special Fraud Alert: Special Arrangements for the Provision of Clinical Lab Services, 59 Fed. Reg. 65372 (Dec. 19, 1994)
CA Legis. Counsel of CA, Clinical
Lab Personnel: Placement in Physician’s Offices - #2433 (Feb. 29, 1996)
Memo re: Legal opinions re: phleb. issues from Karen Nickel, Ph.D., Chief, LFS (July 11, 1997) [AKS]
AVE.
3. MOBILE PHLEBOTOMISTS
FEDERAL NO GUIDANCE
(besides authority re: phlebs)
CACAUTION: LFS – NO
“Roving phlebs” WHY? Prohibited
by Bus. & Prof. Code § 650
BLVD.
REFERENCES
3. MOBILE PHLEBOTOMISTS
FEDERAL 42 C.F.R. § 493.1242 (2)
CA Memo re: Legal opinions re:
phleb. issues from Karen Nickel, Ph.D., Chief, LFS (July 11, 1997) AKS]
Regs related to phleb: Cal. Bus. & Prof. Code § 1242, § 1242.6, § 1246
BLVD.
4. LEASING SPACE FROM DOCTORS
FEDERAL PERMITTED,
SUBJECT TO: Stark Law AKS Safe Harbor
CA PERMITTED,
SUBJECT TO: PORA
RD.
REFERENCES
4. LEASING OFFICE SPACE FROM DOCTORS
FEDERAL 42 C.F.R. 10001.952(b)
[AKS Space Rental Safe Harbor]
42 U.S.C. § 1395nn (e) (1)(A); 42 C.F.R. § 411.357(a) [Stark Law Space Safe Harbor Exception]
OIG Special Fraud Alert (Feb. 2000) (listing requirements)
CA Cal. Bus. & Prof. Code §
650.01 (PORA) Cal. Bus. & Prof. Code §
650.02(b)(2) (exception to PORA re: leases)
RD.
5. LAB PRICING PRACTICES
FEDERAL WHAT YOU NEED TO
KNOW: Medicare Usual
Charge Rule Discounting Rules
and AKS
CAWHAT YOU NEED TO
KNOW: Anti-Markup Rules Disclosure Rules Direct Billing Medi-Cal Lowest
Charge Rule
WAY
REFERENCES
5. LAB PRICING PRACTICES
FEDERAL 42 U.S.C. §1320a-7(b)(6)(A)
[Medicare Usual Charge Rule] Ltr. from K. McAnaney, Chief,
OIG (April 26, 2000) [Medicare Usual Charge Rule]
OIG Advisory Opinion 99-13
CA Cal. Bus. & Prof. Code § 655.5
(anti-markup and disclosure req.)
Cal. Bus. & Prof. Code § 655.7 (direct billing)
22 C.C.R. § 515501(a) (Medi-Cal “Lowest Charge Rule”)
Hunter Labs v. Quest (settled in 2011)
AB 1494
WAY
COMPLIANCE ROAD TRIPSUMMARY
1. % BASED CONTRACT MARKETING FEDERAL & CA PROHIBITED (BUT SEE CA PORA)
3. MOBILE PHLEBOTOMISTSFEDERAL = NO GUIDANCE
CA = PROHBITED (per LFS guidance)
4. LEASING OFFICE SPACE FROM DOCTORSFEDERAL = PERMITTED, subject to Stark AND AKS
CA = PERMITTED, subject to PORA
5. LAB PRICING PRACTICESSEE RULES FOR FEDERAL & CA
ST.
AVE.
BLVD.
RD.
WAY
1. IN-OFFICE PHLEBOTOMISTSFEDERAL = PERMITTED (key word: “solely”)
CA = PROHIBITED (per LFS guidance)
AVE.
QUESTIONS?
David W. Gee & Kristen R. BlanchetteDavid Wright Tremaine LLP