BUL4602 Fall-2011 Lecture 7, Reading 3

BUL4602 Fall-2011 Lecture 7, Reading 3 - 42 USC 1395nn NB...

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42 USC 1395nn NB: This unofficial compilation of the U.S. Code is current as of Jan. 2, 2006 (see http://www.law.cornell.edu/uscode/uscprint.html). - 1 - TITLE 42 - THE PUBLIC HEALTH AND WELFARE CHAPTER 7 - SOCIAL SECURITY SUBCHAPTER XVIII - HEALTH INSURANCE FOR AGED AND DISABLED Part E - Miscellaneous Provisions § 1395nn. Limitation on certain physician referrals (a) Prohibition of certain referrals (1) In general Except as provided in subsection (b) of this section, if a physician (or an immediate family member of such physician) has a financial relationship with an entity specified in paragraph (2), then— (A) the physician may not make a referral to the entity for the furnishing of designated health services for which payment otherwise may be made under this subchapter, and (B) the entity may not present or cause to be presented a claim under this subchapter or bill to any individual, third party payor, or other entity for designated health services furnished pursuant to a referral prohibited under subparagraph (A). (2) Financial relationship specified For purposes of this section, a financial relationship of a physician (or an immediate family member of such physician) with an entity specified in this paragraph is— (A) except as provided in subsections (c) and (d) of this section, an ownership or investment interest in the entity, or (B) except as provided in subsection (e) of this section, a compensation arrangement (as defined in subsection (h)(1) of this section) between the physician (or an immediate family member of such physician) and the entity. An ownership or investment interest described in subparagraph (A) may be through equity, debt, or other means and includes an interest in an entity that holds an ownership or investment interest in any entity providing the designated health service. (b) General exceptions to both ownership and compensation arrangement prohibitions Subsection (a)(1) of this section shall not apply in the following cases: (1) Physicians’ services In the case of physicians’ services (as defined in section 1395x (q) of this title) provided personally by (or under the personal supervision of) another physician in the same group practice (as defined in subsection (h)(4) of this section) as the referring physician. (2) In-office ancillary services In the case of services (other than durable medical equipment (excluding infusion pumps) and parenteral and enteral nutrients, equipment, and supplies)— (A) that are furnished— (i) personally by the referring physician, personally by a physician who is a member of the same group practice as the referring physician, or personally by individuals who are directly supervised by the physician or by another physician in the group practice, and (ii) (I) in a building in which the referring physician (or another physician who is a member of the same group practice) furnishes physicians’ services unrelated to the furnishing of designated health services, or (II) in the case of a referring physician who is a member of a group practice, in another building which is used by the group practice— (aa) for the provision of some or all of the group’s clinical laboratory services, or
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