Two Representatives have introduced the Promoting Integrity in Medicare Act of 2019 (PIMA), which if passed, will limit the number of exceptions permitted under Stark Law. Physicians are currently permitted to refer patients for certain in-office ancillary services, such as radiology and lab tests. PIMA would render many of these services non-ancillary unless determined to be necessary.
PIMA would exclude certain non-ancillary services from the Stark Law’s in-office ancillary services and doctor service exceptions, increasing penalties for physicians who violate the law. Services performed in multi-group health care practices, in rural areas, and as part of Medicare shared savings programs would not be subject to the new PIMA exceptions.
Understanding Stark Law
Stark Law was enacted to prevent abusive and wasteful billing of ancillary services to Medicare. It prohibits doctors from referring patients using Medicare to any providers with which they have a financial relationship; this can involve any investment or ownership held by the physician or their immediate family members. While the Stark Law does not pose the threat of criminal charges, violators are subject to civil actions brought by the Office of the Inspector General. Every billed service that violates Stark Law can cost the referring physician $15,000 plus three times the total amount of the government’s overpayment.
Stark Law Exceptions
Stark Law includes numerous exceptions, which allow physicians to make referrals for federally covered medical services including:
- Services performed in-office, including diagnostic tests
- Services provided at fair market value
- Services involving indirect compensation arrangements between a doctor and entity
- Services paid for with non-monetary compensation up to $300 a year
PIMA would define non-ancillary services as:
- Advanced diagnostic imaging studies
- Anatomic pathology studies
- Physical therapy services
- Radiation therapy services
- Any service performed during an office visit that is not generally considered to be necessary
PIMA Violations and Penalties
Under PIMA, physicians who violate these exceptions involving non-specified ancillary services would face penalties. Any physician billing for a service or not providing a refund for any service excluded from coverage under PIMA could face a civil penalty of up to $25,000 per service. Doctors who knowingly scheme to refer patients to any entity that would put them in violation of PIMA would be subject to penalties upwards of $150,000.
Philadelphia Physician Lawyers at Sidney L. Gold & Associates, P.C. Represent Health Care Professionals Facing Stark Law Violations
The Philadelphia physician lawyers at Sidney L. Gold & Associates, P.C. understand the unique challenges facing today’s physicians. We will help you ensure compliance with Stark Law to protect your career and your patients. To discuss your health care law matter today, call us at 215-569-1999 or contact us online. Located in Philadelphia, we represent clients throughout Bucks County, Chester County, Delaware County, and Montgomery County.