Optional_2023 Board Resources

controls referrals made by another person or entity. 17 With limited exceptions pertaining to pathologists, radiologists, and radiation oncologists, ‘referral’ is defined by regulation as either of the following: 18 (i) . . . the request by a physician for, or ordering of, or the certifying or recertifying of the need for, any designated health service for which payment may be made under Medicare Part B, including a request for a consultation with another physician and any test or procedure ordered by or to be performed by (or under the supervision of) that other physician, but not including any designated health service personally performed or provided by the referring physician . . . . (ii) a request by a physician that includes the provision of any designated health service for which payment may be made under Medicare, the establishment of a plan of care by a physician that includes the provision of such a designated health service, or the certifying or recertifying of the need for such a designated health service, but not including any designated health service personally performed or provided by the referring physician. The term “consultation” is defined 19 as limited to circumstances where the following conditions are satisfied: (1) The physician’s opinion or advice regarding evaluation or management or both of a specific medical problem is requested by another physician; (2) The request and need for the consultation are documented in the patient's medical record; and CMS has stated that when a physician sends a patient “to a specialist who assumes responsibility for furnishing the appropriate treatment,” it does not qualify as a “consultation” and it is not a “referral” that implicates the Stark referral prohibition. 20 (b) Financial Relationship . A financial relationship under the Stark law exists when a physician (or an immediate family member) has a direct or indirect ownership or investment interest or a direct or indirect compensation arrangement with the entity that furnishes designated health services. While ownership or investment interests are more straightforward, compensation arrangements reach any type of remuneration flowing to or form a referring physician and the DHS entity: (3) After the consultation is provided, the physician prepares a written report of his or her findings, which is provided to the physician who requested the consultation.

17 42 C.F.R. § 411.351. 18 Id . 19 Id. 20 See 63 FR 1659, 1693 (Jan. 9, 1998) (quoting 57 FR 8588, 8595 (Mar. 11, 1992).