OIG’s Message to Surgeons: “Hands Off Anesthesia Fees! “
Last month’s OIG’s advisory opinion strongly condemned surgeons for asking anesthesia providers for kickbacks. OIG Advisory Opinion No. 12-06 concluded that both of the increasingly popular fee-splitting models (management fees & company model) “could potentially generate prohibited remuneration under the anti-kickback statute and that the OIG could potentially impose administrative sanctions.”
Under the Fee-for-service model, an ASC bills the anesthesia provider a per-patient management fee for such “management services” as pre-op nursing assessments, office space and equipment storage. The OIG said this arrangement would implicate the anti-kickback statute because the fee that the anesthesia group would pay would be for some of the same services that the ASC facility fee is intended to cover. The ASC would essentially be paid twice for the same services, said the OIG.
Under the Company model, an ASC forms and owns a separate anesthesia shell company that bills for anesthesia services, hires the anesthetists at a negotiated rate either as independent contractors or as employees, bills for anesthesia services and then shares in the profits generated by the anesthesia service fees. The OIG ruled that the physician owners’ investment in the anesthesia company wouldn’t be protected by the ASC safe harbor, saying that the company model “is designed to permit the centers’ physician-owners to do indirectly what they cannot do directly: to receive compensation, in the form of a portion of the anesthesia services revenues, in return for their referrals to the anesthesia provider.”
Healthcare attorneys say the negative OIG advisory opinion gives anesthesia practices solid footing to refuse to pay a “franchise fee” to ASCs and surgical centers. As anesthesia providers celebrate not having to fork over part of their fees to surgeons any longer, surgery center owners used to drinking from 3 revenue streams ( facility fees, procedural fees and anesthesia services fees) will have to learn to get by on just 2.
HHS Issues Advisory Opinion on the “Company Model”
ASA was pleased to see that the Department of Health and Human Services Office of Inspector General (HHS-OIG) issued an Advisory Opinion (No. 12-06) on a “company model” arrangement and expressed the view that it could violate the federal anti-kickback statute. ASA has repeatedly brought this issue to the attention of the HHS-OIG and in February of this year sent formal communication to Inspector General Levinson outlining ASA’s concerns with the “company model.”
Under the “company model,” referring physicians, who typically also own the facility where surgical procedures are performed, form a separate anesthesia company in order to share in anesthesia revenue.
This Advisory Opinion was issued in response to a request submitted by an anesthesia practice (the “Requestor”) regarding two different proposed arrangements, both of which represented a departure from the current practice between the Requestor and the Centers.
Under Proposed Arrangement A, the Requestor would begin paying the Centers a per-patient fee, excluding Federal health care program patients, for “Management Services” such as paying for space in the referring physician’s facility and paying for the services of Center personnel to transfer billing documentation to the anesthesiologists’ billing office.
Under Proposed Arrangement B, the physician-owners would establish anesthesia companies and engage the Requestor as an independent contractor to provide anesthesia services, paying the Requestor a negotiated rate.
The HHS-OIG concluded that both arrangements posed regulatory concern.
- With regard to Proposed Arrangement A, the OIG stated:
Based on the facts presented here, we think there is risk that the Requestor would be paying the Management Services fees with regarding to non-Federal health care program patients to induce the Centers’ referral of all of its patients, including Federal health care program beneficiaries.
- With regard to Proposed Arrangement B, the OIG concluded:
Based on the facts presented here, it appears that Proposed Arrangement B is designed to permit the Centers’ physician-owners to do indirectly what they cannot do directly; that is, to receive compensation, in the form of a portion of the Requestor’s anesthesia services revenues, in return for their referrals to the Requestor. This conclusion is consistent with, and supported by, the Requestor’s representation that it is under competitive pressures to enter into the Proposed Arrangements to stem the loss of its business.
Significantly, under the “company model” (Proposed Arrangement B), even though the regulatory “safe harbors” might protect the payments to the Requestor (the anesthesiologists), the safe harbors would not protect the distribution of profits to the referring physicians.
