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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| INTRODUCED BY DeLUCA, MUNDY, BARBIN, D. COSTA, BELFANTI, CALTAGIRONE, FRANKEL, GEORGE, HARKINS, JOSEPHS, KOTIK, MATZIE, MILLER, M. O'BRIEN, PASHINSKI, SIPTROTH, SOLOBAY, THOMAS, WHITE AND YOUNGBLOOD, MAY 19, 2010 |
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| REFERRED TO COMMITTEE ON INSURANCE, MAY 19, 2010 |
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| AN ACT |
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1 | Providing for prohibition on health care provider self-referral. |
2 | The General Assembly of the Commonwealth of Pennsylvania |
3 | hereby enacts as follows: |
4 | Section 1. Short title. |
5 | This act shall be known and may be cited as the Prohibition |
6 | on Health Care Provider Self-referral Act. |
7 | Section 2. Definitions. |
8 | The following words and phrases when used in this act shall |
9 | have the meanings given to them in this section unless the |
10 | context clearly indicates otherwise: |
11 | "Compensation arrangement." An arrangement involving |
12 | remuneration, direct or indirect, between a provider or a member |
13 | of a provider's immediate family, and a person or entity. |
14 | "Designated health service." The following goods or |
15 | services: |
16 | (1) clinical laboratory services; |
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1 | (2) physical therapy, occupational therapy or speech |
2 | language pathology; |
3 | (3) chiropractic; |
4 | (4) radiation oncology; |
5 | (5) psychometric services; |
6 | (6) home health services; or |
7 | (7) diagnostic imaging. |
8 | "Financial interest." An ownership or investment interest or |
9 | a compensation arrangement. |
10 | "Health care provider." A person, corporation, facility or |
11 | institution licensed or otherwise authorized by the |
12 | Commonwealth to provide health care services, including, but not |
13 | limited to, a physician, coordinated care organization, |
14 | hospital, health care facility, dentist, nurse, optometrist, |
15 | podiatrist, physical therapist, psychologist, chiropractor or |
16 | pharmacist and an officer, employee or agent of the person |
17 | acting in the course and scope of employment or agency related |
18 | to health care services. |
19 | "Immediate family member." Husband or wife; birth or |
20 | adoptive parent, child or sibling; stepparent, stepchild, |
21 | stepbrother or stepsister; father-in-law, mother-in-law, son-in- |
22 | law, daughter-in-law, brother-in-law or sister-in-law; |
23 | grandparent or grandchild; and spouse of a grandparent or |
24 | grandchild. |
25 | "Ownership or investment interest." A direct or indirect |
26 | ownership or investment interest through equity, debt or other |
27 | means that includes an interest in an entity that holds an |
28 | ownership or investment interest in any entity that furnishes |
29 | designated health services. An ownership or investment interest |
30 | includes, but is not limited to, stock, stock options, |
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1 | partnership shares, limited liability company memberships, as |
2 | well as loans, bonds or other financial instruments that are |
3 | secured with an entity's property or revenue or a portion of |
4 | that property or revenue. |
5 | "Referral." |
6 | (1) The term shall include: |
7 | (i) The request by a health care provider for, or |
8 | ordering of, or the certifying or recertifying of the |
9 | need for any designated health service, including a |
10 | request for a consultation with another health care |
11 | provider and any test or procedure ordered by or to be |
12 | performed by, or under the supervision of, that other |
13 | health care provider, but not including any designated |
14 | health service personally performed or provided by the |
15 | referring provider. A designated health service is not |
16 | personally performed or provided by the referring health |
17 | care provider if it is performed or provided by any other |
18 | person, including, but not limited to, the referring |
19 | health care provider's employees, independent contractors |
20 | or group practice members. |
21 | (ii) A request by a health care provider that |
22 | includes the provision of any designated health service, |
23 | the establishment of a plan of care by a health care |
24 | provider that includes the provision of such a designated |
25 | health service or the certifying or recertifying of the |
26 | need for such a designated health service, but not |
27 | including any designated health service personally |
28 | performed or provided by the referring health care |
29 | provider. A designated health service is not personally |
30 | performed or provided by the referring health care |
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1 | provider if it is performed or provided by any other |
2 | person, including, but not limited to, the referring |
3 | health care provider's employees, independent contractors |
4 | or group practice members. |
5 | (2) The term shall not include a request by a |
6 | pathologist for clinical diagnostic laboratory tests and |
7 | pathological examination services by a radiologist for |
8 | diagnostic radiology services and by a radiation oncologist |
9 | for radiation therapy or ancillary services necessary for, |
10 | and integral to, the provision of radiation therapy, if: |
11 | (i) the request results from a consultation |
12 | initiated by another whether the request for a |
13 | consultation was made to a particular pathologist, |
14 | radiologist or radiation oncologist or to an entity with |
15 | which the pathologist, radiologist or radiation |
16 | oncologist is affiliated; and |
17 | (ii) the tests or services are furnished by or under |
18 | the supervision of the pathologist, radiologist or |
19 | radiation oncologist or under the supervision of a |
20 | pathologist, radiologist or radiation oncologist, |
21 | respectively, in the same group practice as the |
22 | pathologist, radiologist or radiation oncologist. |
23 | (3) A referral may be in any form, including, but not |
24 | limited to, written, oral or electronic. |
25 | "Secretary." The Secretary of Health of the Commonwealth. |
26 | Section 3. Unprofessional conduct. |
27 | (a) Referrals.-- |
28 | (1) It is unlawful for a health care provider to refer a |
29 | person for a designated health service if the provider or an |
30 | immediate family member of the provider has a financial |
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1 | interest with the person or entity that receives the |
2 | referral. |
3 | (2) It is unlawful for a health care provider to enter |
4 | into an arrangement or scheme, such as a cross-referral |
5 | arrangement, which the health care provider knows or should |
6 | know has a principal purpose of assuring referrals of |
7 | designated health services by a health care provider to a |
8 | particular entity which, if the provider directly made |
9 | referrals to such entity, would be in violation of this act. |
10 | (b) Limitation on billing.--No claim for payment may be |
11 | presented by an entity to any individual, third-party payer or |
12 | other entity for a designated health service furnished pursuant |
13 | to a referral prohibited under this section. |
14 | (c) Denial of payment.-- |
15 | (1) Except as provided in paragraph (2), no payment may |
16 | be made by any payer for a designated health service that is |
17 | furnished pursuant to a prohibited referral. |
18 | (2) Payment may be made to an entity that submits a |
19 | claim for a designated health service if the entity did not |
20 | have actual knowledge of, and did not act in reckless |
21 | disregard or deliberate ignorance of, the identity of the |
22 | provider who made the referral of the designated health |
23 | service to the entity. |
24 | (d) Exceptions.--The provisions of subsections (a), (b) and |
25 | (c) do not apply to the following: |
26 | (1) Referrals permitted under all present and future |
27 | Safe Harbor regulations promulgated under the Medicare and |
28 | Medicaid Patient and Program Protection Act (section 1128B(b) |
29 | (1) and (2) of the Social Security Act (49 Stat. 620, 42 |
30 | U.S.C. § 301 et seq.) currently published at 42 CFR 1001.952 |
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1 | (relating to exceptions)). |
2 | (2) Referrals permitted under all present and future |
3 | exceptions to the Stark amendments to the Medicare Act |
4 | (section 1877 of the Social Security Act) and all present and |
5 | future regulations promulgated thereunder, currently |
6 | published at 42 CFR Pt. 411 Subpt. J (relating to financial |
7 | relationships between physicians and entities furnishing |
8 | designated health services). |
9 | (3) Referrals permitted by the secretary through |
10 | regulations upon a determination that the referrals do not |
11 | pose a risk of program or patient abuse. |
12 | (e) Prohibition.--An individual, third-party payor or other |
13 | entity may not deny payment to a health care provider involved |
14 | in a transaction or referral described in subsection (d). |
15 | Section 4. Penalties. |
16 | (a) Requiring refunds for certain claims.--If a person |
17 | collects amounts billed in violation of section 3(a), he shall |
18 | be liable to the individual, payer or other entity for and shall |
19 | refund on a timely basis to the individual, payer or other |
20 | entity the collected amounts. |
21 | (b) Civil penalty for improper claims.--A person that |
22 | presents or causes to be presented a bill or a claim for a |
23 | service that he knows is for a service for which payment may not |
24 | be made under section 3(a) or for which a refund has not been |
25 | made under subsection (a) or otherwise violates this act shall |
26 | be subject to a civil penalty of not more than $15,000 for each |
27 | service. |
28 | (c) Civil penalty for circumvention schemes.--A provider or |
29 | other entity that enters into an arrangement or scheme, such as |
30 | a cross-referral arrangement which the provider or entity knows |
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1 | or should know has a principal purpose of assuring referrals by |
2 | the provider to a particular entity which, if the provider |
3 | directly made referrals to such entity, would be in violation of |
4 | this section, shall be subject to a civil penalty of not more |
5 | than $100,000 for each arrangement or scheme. |
6 | Section 20. Effective date. |
7 | This act shall take effect in 60 days. |
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