2. Self Referrals 1 Flashcards
What is the main prohibition outlined in Self-Referrals Section 139.3?
It is unlawful for a physician to refer a person for specific healthcare services if the physician or their immediate family has a financial interest in the entity receiving the referral.
List the services mentioned in Section 139.3 that cannot be referred by a physician with a financial interest.
The services include: clinical laboratory diagnostic nuclear medicine radiation oncology physical therapy physical rehabilitation psychometric testing home infusion therapy outpatient surgery diagnostic imaging goods or services or pharmacy goods.
What are the financial interests that disallow a physician from making referrals according to Section 139.3?
A physician is prohibited from making referrals if they or an immediate family member has a financial interest in the person or entity that receives the referral.
Define ‘diagnostic imaging’ as per Section 139.3.
‘Diagnostic imaging’ includes but is not limited to all X-ray computed axial tomography magnetic resonance imaging nuclear medicine positron emission tomography mammography and ultrasound goods and services.
Who qualifies as ‘immediate family’ according to Section 139.3?
‘Immediate family’ includes the spouse and children of the physician as well as the parents.
What is the overarching principle of the law outlined in Section 139.3 regarding physician referrals?
The overarching principle is to prevent conflicts of interest and ensure that referrals are made based solely on patient need rather than financial gain.
What legal division is referenced in Section 139.3 regarding payment for services?
The payment for services is referenced under Division 4 commencing with Section 3200.
Explain the implications of Section 139.3 on medical-legal referrals.
Section 139.3 prohibits referrals for both treatment and medical-legal purposes if the referring physician has a financial interest in the entity being referred.
What types of healthcare practices are affected by the provisions of Section 139.3?
The provisions affect practices that involve clinical laboratory services diagnostic imaging therapy services outpatient surgeries and other specified healthcare and pharmacy services.
What is the definition of ‘physician’ as mentioned in the document?
‘Physician’ means a physician as defined in Section 3209.3.
Who are included in the definition of ‘family members’ for the purpose of this regulation?
Family members include the spouses and children of the physician.
What does ‘financial interest’ include according to the provided text?
‘Financial interest’ includes ownership interest debt loan lease compensation remuneration discount rebate refund dividend distribution subsidy or other forms of direct or indirect payment between a licensee and a person or entity to whom the physician refers a person for goods or services.
What constitutes an indirect relationship between a physician and the referral recipient?
An indirect relationship includes but is not limited to arrangements whereby a physician has an ownership interest in any entity that leases property to the referral recipient.
What happens if a financial interest is transferred for the purpose of avoiding the prohibition of this section?
Any financial interest transferred by a physician to or otherwise established in any person or entity for the purpose of avoiding the prohibition of this section shall be deemed a financial interest.
Can a financial interest be in forms other than money?
Yes a financial interest can be in forms other than money including any other form of direct or indirect payment.
Is the physician’s financial interest limited only to direct payments?
No a financial interest encompasses both direct and indirect payments.
What kind of transactions might raise financial interest concerns in a physician’s practice?
Transactions that might raise concerns include ownership stakes in referring entities leases and compensation agreements associated with referrals.
In what scenarios can family members of a physician create a financial interest conflict?
Family members of a physician can create a financial interest conflict if they have ownership or financial arrangements connected to the goods or services the physician refers patients to.
What is the significance of Section 3209.3 in defining a physician?
Section 3209.3 provides the formal legal definition of ‘physician’ which must be understood to apply the regulations and restrictions laid out in the document.
What is the definition of a ‘physician’s office’ according to the text?
A ‘physician’s office’ is defined as either of the following: A) An office of a physician in solo practice. B) An office in which the services or goods are personally provided by the physician or by employees in that office or personally by independent contractors in that office in accordance with other provisions of law. It is required that employees and independent contractors shall be licensed or certified when that licensure or certification is required by law.
What are the criteria for an ‘office of a group practice’?
An ‘office of a group practice’ is defined as an office or offices in which two or more physicians are legally organized as a partnership professional corporation or not-for-profit corporation licensed according to subdivision a of Section 1204 of the Health and Safety Code. The following criteria must be met: A) Each physician who is a member of the group provides substantially the full range of services that the physician routinely provides including medical care consultation diagnosis or treatment through the joint organization.
What legal organization forms can constitute a group practice according to the definition provided?
A group practice can be legally organized as a partnership professional corporation or not-for-profit corporation.
According to the text what must employees and independent contractors have when providing services in a physician’s office?
Employees and independent contractors must be licensed or certified when such licensure or certification is required by law.
What types of services must physicians provide in a group practice?
In a group practice each physician must provide substantially the full range of services they routinely offer including medical care consultation diagnosis or treatment.