StarkCompliancePlus Site Map

• Home
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• Stark in 30 seconds - section details below
• StarkAction - section details below
• StarkTools - section details below
• Updates - section details below
• Support - section details below
  
  
• Medical practices
  • Internal - section details below
  • External - section details below
• Compensation Systems - section details below
• Specialty suites
  • Cardiology - section details below
  • Orthopedics - section details below
• Hospital suite - section details below
• Academic suite - section details below
• e-health - section details below
• Antikickback - section details below
• Other Exceptions - section details below
  

Stark in 30 seconds

• Stark in 30 seconds
• History of the Stark Law
• Stark Law Full Text
• What the Stark law prohibits
• Stark penalties and violations
  • Denial of payment
• Policy basis for the Stark law
• Other laws and self-referral prohibitions
• Stark Law enforcement and compliance
• Complying with Stark
  
  
  • Definition of physician
  • Definition of immediate family member 
  • Definition of financial relationships 
  • Definition of ownership/investment interests 
  • Definition of compensation arrangements 
  • Definition of direct financial relationships 
  • Definition of indirect financial relationships 
  • Definition of indirect ownership/investment interests 
  • Definition of indirect compensation arrangements 
  • New Stand in the Shoes Provision 
  • Definition of Entity 
  • Definition of Referrals 
  • Definition of designated health services
  • Stark law exceptions
    
    
• Using StarkCompliance Plus
  
  
  • A physician or physician-owned medical practice
  • An academic faculty practice plans or academic medical center 
  • A hospital
  • Another type of provider or other organization
    

StarkAction

• StarkAction - What do you want to do? 
• Who are you or who do you “represent” (e.g., who do you work for)
  
  
  • Physicians and Physician-owned Medical Practices 
  • Faculty Practice Plans and Academic Medical Centers 
  • Hospitals 
  • Other Organizations / Providers

Tools

• Tools and other Stark resources
• Fair Market Value Calculator
• Designated Health Services Code look-up tool 
• Practice assessment tools 
• Compensation System Modeling 
• Physician Compensation Per Hour 
• Tools - 75% encounters test worksheet 
• Tools - Substantially All Services Test 
• Technical resources
  

Updates

• StarkCompliance Bulletins / Updates

Support

• Support - Log-in problems / questions
  

Medical practices

• Stark Internal / External Practice Relationships
  
  
  • Internal Practice Relationships
    
    
    • Learn how to comply with the in-office ancillary services or physician services exceptions to enable a medical practice to furnish and receive reimbursement for ancillary services.
      
      
      • Introduction to the in-office ancillary exception
      • In-office ancillary services exception requirements
        
        
        • The Service Restrictions
          
          
          • Special topics related to the Services Restriction
          • Parenteral and enteral nutrients, equipment and supplies
          • DME that may be provided through a group practice under the Stark law
          • Special requirements for providing DME through a group practice
          • Infusion pumps
          • Compliance checklist for the Services Restriction
            
            
        • Performance and Supervision Test
          
          
          • Performance by the referring physician.
          • Performance by “member” physicians in the group.
          • Supervision by physicians in the group practice.
          • Level of supervision required
          • Special topics related to the Performance and Supervision Test
          • Independent contractor physicians in the group practice
          • Diagnostic test interpretations and reassignment issues
          • Supervision by independent contractor physicians
          • Compliance checklist for the Performance and Supervision Test
            
            
        • Building or Site-of-Service Test
          
          
          • The same-building option – in general
          • Specific same-building options and requirements
            
            
            • Primary/full time facility in same building option
            • Primary building for the patient
            • Part time facility with physician presence when service is furnished
              
              
          • The centralized building option.
            
            
          • Special topics related to the Building or Site-of-Service Test
            
            
            • Designated health services are furnished
            • "Physician services” under the Stark law
            • Anti-markup tests
            • Diagnostic test interpretations and reassignment issues
            • Supervision by independent contractor physicians
            • Shared facilities
            • Home-care physician services
            • Mobile facilities
            • Prohibitions on shared centralized facilities
            • Compliance checklist related to the same-building option 
            • Compliance checklist related to the centralized building compliance option
            • Summary of the Building or Site-of-Service Test implications
            • Examples of the application of the same building and centralized building options
              
              
        • Billing Test
          
          
          • Billing by the performing or supervising physician
          • Billing by the group practice in which the physician is a member physician
          • Billing by an entity wholly-owned by the physician or group practice
          • Billing by agent under assignment
          • Billing agent exception
          • Exceptions to the prohibition on reassignment
          • Special topics related to the Billing Test 
            
            
            • Global billing arrangements
            • Compliance checklist for the Billing Test
            • Billing Test examples
              
              
        • Group Practice Requirement
          
          
          • Two Physician and Single Legal Entity requirements
            
            
            • Special topics related to the Two Physicians and Single Legal Entity Requirements
              
              
              • One owner group practices with multiple physicians
              • Informal "groups"
              • Entities recognized by state law
              • Multi-entity arrangements involving multiple “groups”
              • Group practices in multiple states
              • Multiple groups under common ownership or control
              • Captive professional corporation and "friendly physician" arrangements
              • Foundation models;
              • Faculty practice plans as “group practices”
              • Practical implications of the requirements
              • Group practice examples
                
                
          • Full Range of Services Test
            
            
            • Application to member physicians 
            • Full range of patient care services
            • “Substantially” the full range of services
            • Compliance checklist for the Full Range of Services Test
              
              
          • Substantially All Services Test
            
            
            • Special topics related to the Substantially All Services Test
              
              
              • Measurement
              • Counting of services to hospitals or other organizations
              • Health Care Professional Shortage Areas and Rural areas
              • Start-up group practices
              • Addition of new members
              • Billing requirement
              • Compliance checklist for the Substantially All Services Test
              • Example of the Substantially All Services Test
                
                
          • Distribution of Income and Expenses Requirement
            
            
            • Special topics related to the Distribution of Income and Expenses Requirement
              
              
              • Third-party assistance with the Distribution of Income and Expenses requirement
              • Compliance checklist for the Distribution of Income and Expenses Requirement
                
                
          • Unified Business Test
            
            
            • Special topics related to the Unified Business Test
              
              
              • Potential unified business arrangements
              • Distinctions between local and centralized autonomy and decision-making in medical groups
              • Compliance checklist for the Unified Business Test
                
                
    • Understand the application of the Stark law’s compensation test to physicians and group practices.
      
      
      • Compensation Test
        
        
        • Designated health services under the Stark law.
        • Referrals under the Stark law
        • Personally performed services and referrals
        • Basic rule regarding referrals
        • Technical component referrals and personal performance
        • Referrals and personal performance of other items/services
        • Summary of implications for group practice compensation plans
        • Personal performance and referral examples
        • “Directly” related to the “volume or value” of referrals
        • Fair market value confusion
          
          
        • Overall profits and productivity bonus compensation methodologies
          
          
          • Special topics related to profit shares and productivity bonuses
            
            
            • Basic requirements -- overall profits and productivity bonus methods
            • Funds subject to the methodology
            • Ability to pool and redistribute revenues within the group
            • Examine and explore overall profit shares distribution methods including available safe harbor profit share distribution methods consisting of:
              
              
              • Method 1 – Overall profits on per capita basis
              • Method 2 – Overall profits based on nondesignated health services
              • Method 3 – Overall profits involving less than 5% of revenues
              • Other overall profits methods
                
                
            • Productivity bonuses
            • Understand available safe harbor productivity methods involving:
              
              
              • Method 4 – Productivity bonuses based on patient encounters or RVUs
              • Method 5 – Productivity bonuses based on the “allocation of compensation”
              • Method 6 – Productivity bonuses involving less than 5% of revenues
              • Other productivity bonus methods 
                
                
            • Summary – Overall profits and productivity bonuses 
            • Practical implications 
            • Learn about:
              
              
              • Example -- “individualistic” compensation system models, including those involving cost accounting methods 
              • Example – Team oriented compensation models 
              • Example -- Allocation to divisions, locations or other groupings of physicians in the group practice 
              • Example -- Allocation of designated health service revenues to pay expenses and combined methods
              • Special issues -- Financial credit for services performed by nonphysician providers
                
                
            • Remaining Uncertainties -- Compensation Test
              
              
    • Learn about compensation plans and review examples of plans that are crafted to promote compliance with the Stark law’s compensation test.
      
      
      • Compensation Systems
        
        
        • Introduction – The Stark Law Group Practice Compensation Test
        • Safe Harbor-Type Methods
        • Overall Profits Methods
        • Productivity Bonus Methods
        • Compliance Documentation and Verification Requirements
        • Additional Considerations Regarding Group Practice Compensation Systems 
        • Effective Compensation Plans and Compliance with Technical Legal Requirements 
        • Information System Capabilities 
        • Identification of Designated Health Services 
        • Revenues, Receipts and Other Financial Management and Cash Flow Issues 
        • Capitation 
        • Funds Flow Examples 
        • Compensation system examples
          
          
          • Example A – Individualistic Overall Profit Share Method, Per Capita Distribution
          • Example B – Team-Oriented Overall Profits Model, Per Capita Distribution
          • Example C – Individualistic Overall Profit Shares Method, Percent of Non-DHS Revenues Distribution 
          • Example D – Team-Oriented Overall Profits Model, Percent of Non-DHS Revenues Distribution Method
          • Example E – Individualistic Overall Profits Model, Less than 5% Distribution Method 
          • Example F -- Individualistic Productivity Bonus Model, Encounters for Allocation 
          • Example G – Team-Oriented Productivity Bonus Model Using Encounters Methodology
          • Example H -- Individualistic Productivity Bonus Model, Work RVU Allocation Method
          • Example I – Team-Oriented Productivity Bonus Model, Work RVUs Allocation Method
          • Example J -- Individualistic Productivity Bonus Model, Percentage of Compensation Allocation Method 
          • Example L -- Individualistic Productivity Bonus Model, Less than 5% Distribution Method 
          • Example M -- Individualistic Overall Profits Model, Work RVUs Distribution
            
            
    • Explore how a group practice can develop new ancillary services that can be furnished by the practice.
      
      
  • External Practice Relationships
    
    
    • Assess financial and referral relationships that physicians and/or their medical practices have with hospitals and other DHS Entities (e.g., recruitment support received from a hospital, office leases and service arrangements including medical directorships with hospitals and other providers, investments in hospitals, ambulatory surgical centers or other organizations and others).
      
      
      • Support for physician recruitment and/or retention (Physician recruitment and retention)
        
        
        • Direct Recruitment Requirements 42 CFR § 411.357(e)(1).
          
          
          • Relocation bright lines
            
            
        • Indirect recruitment into established medical practice 42 CFR § 411.357(e)(4)
          
        • Special topics related to the recruitment exception
          
          
          • Geographic area served by the hospital 
          • Residents, physicians with less than one year of practice and certain others eligible to benefit from recruitment support. 
          • Application to FQHCs and Rural Health Clinics. 
          • Costs that may be included as actual additional incremental costs. 
          • Special rules actual additional incremental cost rules where recruitment is to rural areas and HPSAs. 
          • Policy objectives. 
          • Non-compete and other reasonable practice restrictions. 
          • Limitation on application to inner-city areas and academic medical centers.
            Recruitment of non-physician practitioners. 
          • Retention payments in underserved areas (42 CFR § 411.357(t))
            
            
            • Bona fide written offer.
            • Written certification from physician.
              
              
      • Leases of office space and equipment (Space and equipment leases)
        
        
        • Space and equipment rental
          
          
        • Rental of Office Space Exception (42 CFR 411.357(a)) 
        • Rental of equipment 
        • Special topics related to space and/or equipment leases
          
          
          • Compensation terms under space and equipment leases 
          • Early termination of lease arrangements
            
            
            • Additional information on modifying compensation during the term of an agreement 
              
              
          • Holdover tenancies and leases 
          • Exclusive use requirements applicable to space leases 
          • Equipment lease arrangements involving indirect compensation arrangements 
            
            
            
            • Indirect compensation arrangements (42 CFR § 411.357(p))
              
              
              • Indirect Compensation Arrangements Requirements.
                
                
                
          • Other limited exceptions involving payments made by a physician where the payments meet no other exception.
            
            
        • Service arrangements
          
          
        • Bona fide employment relationships exception (42 CFR § 411.357(c)) 
        • Personal service arrangements exception (42 CFR 411.357(d)(1)) 
        • Fair-market-value compensation exception (42 CFR § 411.357(l) 
        • Payments by a Physician 
        • Special topics related to the personal service and employment exceptions
          
          
          • Personal service arrangements exception special requirements related to compensation 
          • Set in advance requirement 
          • Master lists under the personal services arrangement 
          • Termination provisions and personal service arrangements 
          • Foundation model integrated delivery systems 
          • Compensation arrangements under the employment exception
          • Use of the employment exception rather than other exceptions 
          • No set-in advance requirements with employment exception
          • Supervision services under the employment exception 
          • Qualitative and other measures under the employment exception
          • Additional information on modifying compensation during the term of an agreement
        
        
      • Service arrangements including medical directorships with hospitals and other DHS entities
        
        
      • Medical practice acquisition transactions
        
        
      • Physician investments in hospitals
        
        
      • Physician joint venture investments in ambulatory surgical centers and other DHS entities (such as freestanding imaging centers, rehabilitation facilities, CORFs or other organizations
        
        
        • Implants in an ambulatory surgical center exception (42 CFR § 411.355(f)) 
        • EPO and other dialysis-related outpatient prescription drugs furnished in or by an ESRD facility 42 - CFR 411.3545(g)
        • Preventive screening tests, immunizations and vaccines (42 CFR § 411.355(h)) 
        • Eyeglasses and contact lenses following cataract surgery (42 CFR 411.355(i))
          
          
      • Exceptions that are only available in rural areas
        
        
        • Ownership/investment interests in rural providers (42 CFR § 411.356(c)(1)) 
        • Exception for intra-family referrals in rural areas (42 CFR 411.355(j))
          
          
      • Relationships with academic medical centers and practice plans
        
        
      • Investments in public companies that furnish DHS
        
        
      • Access to and use of health information technology, electronic health records, electronic prescribing and similar technology from other organizations
        
        
      • Incidental benefits and support that physicians might receive from hospitals and other organizations (such as medical staff benefits, referral services and similar arrangements, obstetrics malpractice subsidies)
        
        
      • Relationships with third party payers such as pre-paid plans, risk sharing arrangements, and physician incentive plans
        
        
      • Arrangements that comply with certain safe harbors to the antikickback statute
        
        
      • Other relationships that physicians may have with DHS entities, such as charitable donations made by physicians to such entities and the like
        
        
      • Non-monetary compensation exception
        
        
        • Medical staff incidental benefits (42 CFR § 411.357(m))
          
          
          • Organizations with bona fide medical staffs. 
          • Adjustment
            
            
        • Professional courtesy (42 CFR § 411.357(s))
        • Nonmonetary compensation up to $300 in value (42 CFR § 411.357(k))
          
          
          • History and additional details
            
            
        • Compliance training (42 CFR § 411.357(o))
          
          
      • Payer Compensation Arrangements - Introduction
        
        
        • Physician Incentive Plan Exception. 42 C.F.R. § 411.357(d)(2).
        • Risk-sharing arrangements (42 CFR § 411.357(n))
          
          
      • Prepaid plan own and compensation exception
        
        
        • Prepaid plans exception -- services furnished by an organization (or its contractors or subcontractors) to enrollees (42 CFR § 411.355(c))
          
          
      • Public Company Exceptions
        
        • Publicly traded securities exception (42 CFR § 411.356(a)).
        • Mutual funds exception (42 CFR § 411.356(b))

Compensation Systems

Compensation Systems introduction

• Introduction – The Stark Law Group Practice Compensation Test
• Safe Harbor-Type Methods
• Overall Profits Methods
• Productivity Bonus Methods
• Compliance Documentation and Verification Requirements
• Additional Considerations Regarding Group Practice Compensation Systems 
• Effective Compensation Plans and Compliance with Technical Legal Requirements 
• Information System Capabilities 
• Identification of Designated Health Services 
• Revenues, Receipts and Other Financial Management and Cash Flow Issues 
• Capitation 
• Funds Flow Examples 
• Compensation system examples
  
  
  • Example A – Individualistic Overall Profit Share Method, Per Capita Distribution 
  • Example C – Individualistic Overall Profit Shares Method, Percent of Non-DHS Revenues Distribution 
  • Example M -- Individualistic Overall Profits Model, Work RVUs Distribution 
  • Example E – Individualistic Overall Profits Model, Less than 5% Distribution Method 
  • Example F -- Individualistic Productivity Bonus Model, Encounters for Allocation 
  • Example H -- Individualistic Productivity Bonus Model, Work RVU Allocation Method 
  • Example J -- Individualistic Productivity Bonus Model, Percentage of Compensation Allocation Method 
  • Example L -- Individualistic Productivity Bonus Model, Less than 5% Distribution Method 
  • Example B – Team-Oriented Overall Profits Model, Per Capita Distribution 
  • Example D – Team-Oriented Overall Profits Model, Percent of Non-DHS Revenues Distribution Method 
  • Example G – Team-Oriented Productivity Bonus Model Using Encounters Methodology 
  • Example I – Team-Oriented Productivity Bonus Model, Work RVUs Allocation Method

Specialty suites

• Specialty suites overview
  
  
  • Cardiology practice suite
    
    
    • Designated health services commonly furnished by cardiology practices
    • Common Stark law exceptions used by cardiology practices to furnish designated health services
      
      
      • The Service Restrictions
      • The Performance and Supervision Test
        
        
        • Performance by the referring physician
        • Performance by “member” physicians in the group.
        • Supervision by physicians in the group practice.
        • Special topics related to the Performance and Supervision Test
          
          
          
          • Independent contractor physicians in the group practice
          • Diagnostic test interpretations and reassignment issues
          • Supervision by independent contractor physicians
          • Compliance checklist for the Performance and Supervision Test
            
            
      • The Building or Site-of-Service Test
        
        
        • The same-building option – in general
        • Specific same-building options and requirements
          
          
          Primary/full time facility in same building
          • Part-time primary facility for patient 
          • Part-time facility for physician or the medical practice
          • Part-time facility for physician or the medical practice
            
            
            
        • The centralized-building option
        • Special topics related to the Building or Site-of-Service Test
          
          
          
      • The Billing Test
        
        
        • Billing by the performing or supervising physician
        • Billing by the group practice in which the physician is a member physician
        • Billing by an entity wholly-owned by the physician or group practice
        • Billing by agent under assignment
        • Exceptions to the prohibition on reassignment
        • Special topics related to the Billing Test
          
          
          
          • Global billing arrangements
          • Provider-based and “under-arrangement” situations
          • Compliance checklist for the Billing Test
          • Billing Test examples
            
            
            
      • Group Practice Requirements
        
        
        • Two Physicians and Single Legal Entity Requirements
        • Full Range of Services Test
        • Substantially All Services Test
        • Distribution of Income and Expenses Requirement
        • Unified Business Test
        • Physician Patient Encounters Test
        • Compensation Test
          
          
          
    • Designated health service delivery models in cardiology practices
      
      
      
      • The Antikickback Law
      • Medicare Reimbursement Requirements
      • State Laws
      • Tax-Exempt Organization Requirements
      • Third-party payer reimbursement, credentialing and related requirements
      • Other issues/Considerations
        
        
        
    • Cardiology-group physician compensation plans
    • Common external designated health service relationships
      
      
      
      • External service, lease and similar arrangements
      • Ownership in external designated-health-service entities
        
        
        
        
  • Orthopedics practice suite
    
    
    
    • Designated health services commonly furnished through orthopedic surgical practices
    • Common Stark law exceptions used by orthopedic practices to furnish designated health services
      
      
      
      • The Service Restrictions
      • The Performance and Supervision Test
        
        
        • Performance by the referring physician
        • Performance by “member” physicians in the group.
        • Supervision by physicians in the group practice.
        • Special topics related to the Performance and Supervision Test
          
          
          
          • Independent contractor physicians in the group practice
          • Diagnostic test interpretations and reassignment issues
          • Supervision by independent contractor physicians
          • Compliance checklist for the Performance and Supervision Test
            
            
      • The Building or Site-of-Service Test
        
        
        • The same-building option – in general
        • Specific same-building options and requirements
          
          
          
          • Primary/full time facility in same building
          •  Part-time primary facility for patient 
          •  Part-time facility for physician or the medical practice
          •  Part-time facility for physician or the medical practice
            
            
            
        • The centralized-building option
        • Special topics related to the Building or Site-of-Service Test
          
          
          
      • The Billing Test
        
        
        • Billing by the performing or supervising physician
        • Billing by the group practice in which the physician is a member physician
        • Billing by an entity wholly-owned by the physician or group practice
        • Billing by agent under assignment
        • Exceptions to the prohibition on reassignment
        • Special topics related to the Billing Test 
          
          
          
          • Global billing arrangements
          • Provider-based and “under-arrangement” situations
          • Compliance checklist for the Billing Test
          • Billing Test examples
            
            
            
      • Group Practice Requirements
        
        
        • Two Physicians and Single Legal Entity Requirements
        • Full Range of Services Test
        • Substantially All Services Test
        • Distribution of Income and Expenses Requirement
        • Unified Business Test
        • Physician Patient Encounters Test
        • Compensation Test
          
          
          
    • Designated health service delivery models in orthopedic practices
      
      
      • The Antikickback Law
      • Medicare Reimbursement Requirements
      • State Laws
      • Tax-Exempt Organization Requirements
      • Third-party payer reimbursement, credentialing and related requirements
      • Other issues/Considerations
        
        
    • Orthopedic group practice physician compensation plans
    • Common external relationships and applicable exceptions
      
      
      
      • External service, lease and similar arrangements
      • Ownership in external designated-health-service entities
        

Hospital suite

• Hospital Internal and External Relationships
  
  
  • Hospital Hospital ownership exception
    
    
    • Hospitals in Puerto Rico exception
    • Ownership in a Whole Hospital
    • MedPac and CMS guidance and advisory opinions related to specialty hospitals.
      
      
      • Final CMS Report on Specialty Hospitals

Academic suite

• Academic Medical Center Financial Relationships - Entry Portal
  
  
  • Academic medical centers exception (42 CFR 411.355(e))
    
    
    • Referring physician requirements.
    • Compensation received by referring physician requirements.
    • Academic medical center requirements.
    • Academic medical center defined. 
    • Implications of exception
      

e-health

• Overview
• Comparison to other Stark exceptions
• Technology covered
• Standards and interoperability
• Donors and recipients
• Selection criteria
• Limits on value and cost-sharing obligations
• Duration of exceptions and sunset provisions
• Community-wide health information systems (42 CFR § 411.357(u))
• Other requirements

Antikickback

• Overview
• Antikickback law and State laws
• Interrelationship between Stark and federal antikickback law
• Antikickback statute safe harbors
  
  
  • Space rental (42 C.F.R. § 1001.952(b))
  • Equipment rental (42 C.F.R. § 1001.952(c)
  • Personal services and management contracts (42 C.F.R. § 1001.952(d))
  • Practitioner recruitment. (42 C.F.R. § 1001.952(n))
  • Investments in group practices (42 C.F.R. § 1001.952(p))
  • Electronic prescribing items and services (42 C.F.R. § 1001.952(x))
  • Electronic health records items and services. (42 C.F.R. § 1001.952(y))
  • Stark exceptions that directly mirror antikickback safe harbors
  • Exceptions for arrangements that meet antikickback safe harbors (42 CFR § 411.357(s) and (r))
  • False Claims Act
    

Other Exceptions

• Other Exceptions