It is the policy of [PROVIDER] that [PROVIDER] and its employees shall not knowingly and willfully solicit or receive any remuneration directly or indirectly, overtly or covertly, in cash or in kind:
- In return for referring an individual to a person for furnishing ( or arranging for the furnishing) of any item or service for which payment may be made in whole or in part under a federal health care program, or
- In return for purchasing, leasing, ordering, or arranging for, or recommending purchasing, leasing, or ordering any good, facility service, or item for which payment may be made, in whole or in part under a federal health care program.
Furthermore, [PROVIDER] and its employees shall not offer or transfer remuneration to any individual eligible for benefits under federal or state health care programs (including Medicare or Medicaid) that [PROVIDER] and its employees know or should know is likely to influence the individual to order or receive from a particular provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, by a federal or state health care program.
Providers may wish to include the following suggested elements in their corporate compliance policy:
- [PROVIDER] and its employees shall not offer or provide any gift, hospitality, or entertainment of more than nominal value to any Medicare and Medicaid beneficiary. Examples of permissible items include pens, T-shirts, water bottles, etc., valued at less than [CHOOSE DOLLAR AMOUNT], as long as such items are not offered or provided to influence health care decisions by a beneficiary, family member, or responsible party;
- [PROVIDER] and its employees shall not offer waivers of coinsurance or deductible amounts as part of any advertisement or solicitation;
- [PROVIDER] and its employees shall not routinely waive coinsurance or deductible amounts, and shall only waive such amounts after determining in good faith that the resident is in financial need, or after making reasonable efforts to collect the cost-sharing amounts from the resident;
- [PROVIDER] and its employees shall not participate in any arrangement with a health care plan that effectively requires [PROVIDER] and its employees to forgo certain Medicare cost-sharing amounts; and
- [PROVIDER] and its employees shall not participate in any arrangement with a health care plan that requires [PROVIDER] and its employees to waive charges for copayments and deductibles when Medicare is the primary payer and the applicable Medicare reimbursement is higher than the plan fee schedule amount.
To comply with the federal anti-kickback and physician self-referral (stark) laws, all agreements between [PROVIDER] and a hospital, home health agency, hospice, managed care organizations or alliance, or other entity that involves the referral or transfer of any residents to or by [PROVIDER] shall be reviewed by legal counsel or his or her designee prior to execution. Similar state laws may also apply and should be reviewed so that all such leases comport with state law as well.
Note: the following provisions are base on federal law. Providers should also examine state law and included any necessary language.
Providers may wish to include the following suggested elements in their corporate compliance policy. Any such agreement:
- Shall be in writing;
- Shall be negotiated only by legal counsel and/or the [facility administrator, owner(s) or their designees;
- Shall be approved by legal counsel or his or her designee prior to execution;
- Shall be signed by all parties;
- Shall specify all of the obligations of the parties;
- Shall specify the fee or payment, if any, which shall be set at fair market value for the items and services provided;
- Shall, when taken as a whole, be reasonable in its entirety;
- Shall not take into consideration the value or volume of referrals provided by or to [PROVIDER] except as is specifically permitted by the “safe harbors” found at 42 C.F.R. Part 1001.952;
- Shall not involve free or discounted goods or services or goods or services below fair market value to induce a referral to or by [PROVIDER]except as specifically permitted by the “safe harbors”; and
- Shall not involve any referral or transfer of any resident to or by [PROVIDER] to induce the other party to refer or obtain referrals of residents from [PROVIDER].