Source: http://complianceland.com/ao/html/ao97_4.html
Timestamp: 2019-03-23 16:30:02
Document Index: 720004368

Matched Legal Cases: ['§1320', '§ 1320', '§ 1320', 'art 1008', '§ 413', '§308']

Advisory Opinion No. 97-4 (September 5, 1997)
The anti-kickback statute, 42 U.S.C. §1320a-7b(b), makes it a criminal offense knowingly and willfully to offer, pay, solicit, or receive any remuneration to induce the Although the Special Fraud Alert addressed charge-based providers, we 4 expressly stated that the Special Fraud Alert should not be interpreted to legitimize routine waiver of Medicare copayments with respect to providers paid under prospective payment or cost-based systems. referral of business that may be paid for by a Federal health care program. Specifically, the statute provides that Whoever knowingly and willfully offers or pays [or solicits or receives] any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person -- to refer an individual to a person for the 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 to purchase, lease, order, or arrange for or recommend 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, shall be guilty of a felony. 42 U.S.C. § 1320a-7b(b). In other words, the statute prohibits payments made purposefully to induce referrals of business paid for by a Federal health care program. The statute ascribes liability to both sides of an impermissible "kickback" transaction. The statute has been interpreted to cover any arrangement where one purpose of the remuneration was to obtain money for the referral of services or to induce further referrals. United States v. Kats, 871 F.2d 105 (9th Cir. 1989); United States v. Greber, 760 F.2d 68 (3d Cir.), cert. denied, 474 U.S. 988 (1985). “Remuneration” for purposes of the anti-kickback statute includes the transfer of any thing of value, in cash or in-kind, directly or indirectly, covertly or overtly. We have said previously that providers who routinely waive Medicare Copayments may be held liable under the anti-kickback statute. See Special Fraud Alert, 59 Fed. Reg. 242 (1994). When providers forgive financial obligations for reasons other than 4 genuine financial hardship of the particular patient, they unlawfully may be inducing the patient to purchase items or services in violation of the anti-kickback statute’s proscription against offering or paying something of value as an inducement to generate business payable by a Federal health care program. Thus, except in those special cases of financial hardship, providers must make a good faith effort to collect Medicare Copayments. One indicator of a suspect waiver is the failure to collect Medicare Copayments for a specific group of Medicare patients for reasons unrelated to indigency. Here, the Proposed Arrangement is suspect because it would effectively waive the Medicare Copayment for the specific group of Medicare patients covered by the Company X complementary coverage, if Company X continues to deny payment. Moreover, an inference can be drawn that the Proposed Arrangement’s waiver of the Medicare Copayment for reasons unrelated to individualized financial hardship may unlawfully induce patients to purchase services from Center B that are reimbursable by Medicare. For these reasons, the Proposed Arrangement may be subject to sanction under the anti-kickback statute, 42 U.S.C. § 1320a-7b(b). III. LIMITATIONS The limitations applicable to this opinion include the following: • This advisory opinion is issued only to Company A, which is the Requestor of this opinion. This advisory opinion has no application, and cannot be relied upon, by any other individual or entity. • This advisory opinion may not be introduced into evidence in any matter involving an entity or individual that is not a Requestor to this opinion. • This advisory opinion is applicable only to the statutory provisions specifically noted above. No opinion is herein expressed or implied with respect to the application of any other Federal, state, or local statute, rule, regulation, ordinance, or other law that may be applicable to the Arrangement. • This advisory opinion will not bind or obligate any agency other than the U.S. Department of Health and Human Services. • This advisory opinion is limited in scope to the specific arrangement described in this letter and has no applicability to other arrangements, even those which appear similar in nature or scope. This opinion is also subject to any additional limitations set forth at 42 C.F.R. Part 1008. The OIG will not proceed against the Requestor with respect to any action taken in good faith reliance upon this advisory opinion as long as all of the material facts have been fully, completely, and accurately presented, and the arrangement in practice comports with the information provided. The OIG reserves the right to reconsider the questions and issues raised in this advisory opinion and, where the public interest requires, modify or terminate this opinion. In the event that this advisory opinion is modified or terminated, the OIG will not proceed against the Requestor with respect to any action taken in good faith reliance upon this advisory opinion, where all of the relevant facts were fully, completely, and accurately presented and where such action was promptly discontinued upon notification of the modification or termination of this advisory opinion. Sincerely, D. McCarty Thornton Chief Counsel to the Inspector General
1 Center B contends that Company X’s denial of the facility fee copayment is 1 contrary to Medicare payment principles. In support of this view, it has submitted an Order from the Wayne County (Michigan) Circuit Court in the matter of Greater Lansing Ambulatory Surgery Center Company et al. v. Blue Cross and Blue Shield of Michigan, No. 96-635927-CZ (March 1, 1997).
2The statute, as amended, contains three further exceptions, not applicable here, 2 for: (i) certain permissible waivers specified in section 1128B(b)(3) of the Social Security Act or in regulations issued by the Secretary; (ii) certain differentials in coinsurance and deductible amounts as part of a benefit plan design; and (iii) certain incentives given to individuals to promote the delivery of preventive care.
3 See, e.g., 42 C.F.R. § 413.80; Prov. Reimb. Man., Part I, §§308, 310.