PRACTICE MANAGEMENT
Integrated Private Practice
Jordan Saint John and Stephen D . Bittinger
False Claims Act
The federal False Claims Act (“ FCA ”) prohibits the knowing presentation of false claims to the government 8 . While every healthcare practice must avoid submitting claims known to be false to any FHP , an integrated practice can create particular opportunities to run afoul of this law , especially where a non-physician owns the MSO and is submitting claims on behalf of the physician ’ s practice .
The FCA allows private persons to file a false claims suit in their own name and in the government ’ s stead . This is known as a qui tam action , and is designed to bring to light wrong-doing that only an insider would know about . The government may decide to intervene , taking over the action as its own after examining the complaint and supporting evidence . While a qui tam action is a powerful tool for genuine whistle blowers , this law is sometimes invoked in retaliation , often by a disgruntled ex-employee terminated for good cause . Even where meritless , such actions are a tremendous burden on a healthcare practice .
Physician Self-Referral (“ Stark ”)
Self-referral is the practice of referring patients to healthcare entities in which the referring provider has a financial interest . Due to the inherent conflict this creates between the provider ’ s financial considerations and his / her medical judgment regarding the patient , such referrals are prohibited by most states and under federal law . The federal physician self-referral law is known as the “ Stark ” law , after the bill ’ s initial sponsor , California
Congressman Pete Stark 9 . Stark specifically prohibits self-referral by physicians regarding eleven “ designated ” healthcare services that are reimbursable by Medicare or Medicaid . However , state self-referral laws may be even broader , perhaps applying to all healthcare providers , or entailing even more healthcare services , or involving any healthcare payer .
An integrated practice , unless properly structured , could implicate federal and / or state self-referral laws . Each scenario needs to be carefully evaluated on a state by state basis .
Finally , states have laws governing the scope of practice and supervision of mid-level medical practitioners ( e . g . NP , PA , PT ). Scope of practice refers to the services a licensed practitioner is authorized to provide . For example , a chiropractor looking to expand services to offer to his / her patients might choose to develop a pain management and physical therapy practice . The diagnosis and treatment of chronic pain due to causes beyond spinal subluxations would involve medical diagnosis and treatment that can often be provided by a mid-level provider ( e . g . NP or PA ). Depending on applicable state law , a NP may function largely autonomously in some states , giving injections and even prescribing medications , but must usually have a collaboration and supervision agreement in place with a supervising physician that provides for regular oversight , education , and training .
Such an arrangement usually means that the physician is off-site but immediately accessible by phone or email to help with questions or concerns . This can become a secondary income stream for the physician and will usually pass regulatory muster if the physician ’ s compensation for this arrangement is determined to be legally compliant in advance .
However , such services must be billed under the practice , with the rendering mid-level NPI accurately billed in accordance with each payer ’ s policy . For Medicare / Medicaid , mid-level rendered services may be billed under the physician ’ s NPI as “ incident to ”
25 TODAY ’ S PRACTICE : CHANGING THE BUSINESS OF MEDICINE