The Department of Health and Human Services Office of the Inspector General (OIG) has issued an Advisory Opinion (Opinion) in connection with a hospital’s gainsharing arrangement (Arrangement) with a designated group of neurosurgeons who perform spinal fusion surgeries at the hospital. According to the Opinion, the OIG would not impose sanctions because the Arrangement, when viewed in its entirety, is not designed or likely to induce the neurosurgeons to (i) reduce or limit medically necessary services to their Medicare or Medicaid patients, or (ii) increase referrals to the hospital. This Opinion is the latest in a line of earlier advisory opinions to “bless” gainsharing arrangements that meet certain criteria for minimizing the risk of fraud and abuse. Continue Reading OIG Reaffirms Permissibility of Certain Gainsharing Arrangements
In a fraud alert released today, the OIG warns that physician compensation arrangements, such as medical directorship compensation, may potentially violate the anti-kickback statute. The fraud alert reiterates the “one purpose” doctrine (a compensation arrangement may violate the anti-kickback statute if even one purpose is to compensate a physician for past or future referrals of Federal health care program business). While this concept is hardly headline news to providers or health law attorneys, the OIG issued the fraud alert after recently reaching settlements with 12 individual physicians who entered into “questionable” arrangements. The fraud alert cites a variety of issues that made these arrangements questionable, including taking into account the volume or value of referrals, payments that were inconsistent with fair market value for services to be performed and failure of physicians to actually perform the services. Some of the arrangements included payment by an affiliated health care entity of the physicians’ front office staff, constituting improper remuneration to the physicians. The fraud alert notes that the OIG determined that the “physicians were an integral part of the scheme and subject to liability under the Civil Monetary Penalties Law.”
Medical directorship and other arrangements with physicians often make good sense and reflect bona fide physician services that further the goals of coordination of care, improvement of quality, and cost savings. This fraud alert serves as a not-so-gentle reminder to remember the basics in structuring, documenting and monitoring these arrangements to assure initial and ongoing compliance with the anti-kickback statute. It also highlights that the OIG will not hesitate to pursue individual physicians in these cases.