Bill Text: PA HB319 | 2011-2012 | Regular Session | Introduced

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Bill Title: Providing for prohibition on health care provider self-referral.

Spectrum: Strong Partisan Bill (Democrat 11-1)

Status: (Introduced - Dead) 2011-01-31 - Referred to HEALTH [HB319 Detail]

Download: Pennsylvania-2011-HB319-Introduced.html

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PRINTER'S NO. 274
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 319 Session of2011
INTRODUCED BY DeLUCA, D. COSTA, CALTAGIRONE, FABRIZIO, GEORGE, HARHART, HARKINS, JOSEPHS, KIRKLAND, KOTIK, WHITE AND YOUNGBLOOD, JANUARY 31, 2011
REFERRED TO COMMITTEE ON HEALTH, JANUARY 31, 2011
AN ACT
Providing for prohibition on health care provider self-referral.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Prohibition
on Health Care Provider Self-referral Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Compensation arrangement." An arrangement involving
remuneration, direct or indirect, between a provider or a member
of a provider's immediate family, and a person or entity.
"Designated health service." The following goods or
services:
(1) clinical laboratory services;
(2) physical therapy, occupational therapy or speech
language pathology;
(3) chiropractic;
(4) radiation oncology;
(5) psychometric services;
(6) home health services; or
(7) diagnostic imaging.
"Financial interest." An ownership or investment interest or
a compensation arrangement.
"Health care provider." A person, corporation, facility or
institution licensed or otherwise authorized by the
Commonwealth to provide health care services, including, but not
limited to, a physician, coordinated care organization,
hospital, health care facility, dentist, nurse, optometrist,
podiatrist, physical therapist, psychologist, chiropractor or
pharmacist and an officer, employee or agent of the person
acting in the course and scope of employment or agency related
to health care services.
"Immediate family member." Husband or wife; birth or
adoptive parent, child or sibling; stepparent, stepchild,
stepbrother or stepsister; father-in-law, mother-in-law, son-in-
law, daughter-in-law, brother-in-law or sister-in-law;
grandparent or grandchild; and spouse of a grandparent or
grandchild.
"Ownership or investment interest." A direct or indirect
ownership or investment interest through equity, debt or other
means that includes an interest in an entity that holds an
ownership or investment interest in any entity that furnishes
designated health services. An ownership or investment interest
includes, but is not limited to, stock, stock options,
partnership shares, limited liability company memberships, as
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well as loans, bonds or other financial instruments that are
secured with an entity's property or revenue or a portion of
that property or revenue.
"Referral."
(1) The term shall include:
(i) The request by a health care provider for, or
ordering of, or the certifying or recertifying of the
need for any designated health service, including a
request for a consultation with another health care
provider and any test or procedure ordered by or to be
performed by, or under the supervision of, that other
health care provider, but not including any designated
health service personally performed or provided by the
referring provider. A designated health service is not
personally performed or provided by the referring health
care provider if it is performed or provided by any other
person, including, but not limited to, the referring
health care provider's employees, independent contractors
or group practice members.
(ii) A request by a health care provider that
includes the provision of any designated health service,
the establishment of a plan of care by a health care
provider 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 health care
provider. A designated health service is not personally
performed or provided by the referring health care
provider if it is performed or provided by any other
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person, including, but not limited to, the referring
health care provider's employees, independent contractors
or group practice members.
(2) The term shall not include a request by a
pathologist for clinical diagnostic laboratory tests and
pathological examination services by a radiologist for
diagnostic radiology services and by a radiation oncologist
for radiation therapy or ancillary services necessary for,
and integral to, the provision of radiation therapy, if:
(i) the request results from a consultation
initiated by another whether the request for a
consultation was made to a particular pathologist,
radiologist or radiation oncologist or to an entity with
which the pathologist, radiologist or radiation
oncologist is affiliated; and
(ii) the tests or services are furnished by or under
the supervision of the pathologist, radiologist or
radiation oncologist or under the supervision of a
pathologist, radiologist or radiation oncologist,
respectively, in the same group practice as the
pathologist, radiologist or radiation oncologist.
(3) A referral may be in any form, including, but not
limited to, written, oral or electronic.
"Secretary." The Secretary of Health of the Commonwealth.
Section 3. Unprofessional conduct.
(a) Referrals.--
(1) It is unlawful for a health care provider to refer a
person for a designated health service if the provider or an
immediate family member of the provider has a financial
interest with the person or entity that receives the
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referral.
(2) It is unlawful for a health care provider to enter
into an arrangement or scheme, such as a cross-referral
arrangement, which the health care provider knows or should
know has a principal purpose of assuring referrals of
designated health services by a health care provider to a
particular entity which, if the provider directly made
referrals to such entity, would be in violation of this act.
(b) Limitation on billing.--No claim for payment may be
presented by an entity to any individual, third-party payer or
other entity for a designated health service furnished pursuant
to a referral prohibited under this section.
(c) Denial of payment.--
(1) Except as provided in paragraph (2), no payment may
be made by any payer for a designated health service that is
furnished pursuant to a prohibited referral.
(2) Payment may be made to an entity that submits a
claim for a designated health service if the entity did not
have actual knowledge of, and did not act in reckless
disregard or deliberate ignorance of, the identity of the
provider who made the referral of the designated health
service to the entity.
(d) Exceptions.--The provisions of subsections (a), (b) and
(c) do not apply to the following:
(1) Referrals permitted under all present and future
Safe Harbor regulations promulgated under the Medicare and
Medicaid Patient and Program Protection Act (section 1128B(b)
(1) and (2) of the Social Security Act (49 Stat. 620, 42
U.S.C. § 301 et seq.) currently published at 42 CFR 1001.952
(relating to exceptions)).
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(2) Referrals permitted under all present and future
exceptions to the Stark amendments to the Medicare Act
(section 1877 of the Social Security Act) and all present and
future regulations promulgated thereunder, currently
published at 42 CFR Pt. 411 Subpt. J (relating to financial
relationships between physicians and entities furnishing
designated health services).
(3) Referrals permitted by the secretary through
regulations upon a determination that the referrals do not
pose a risk of program or patient abuse.
(e) Prohibition.--An individual, third-party payor or other
entity may not deny payment to a health care provider involved
in a transaction or referral described in subsection (d).
Section 4. Penalties.
(a) Requiring refunds for certain claims.--If a person
collects amounts billed in violation of section 3(a), he shall
be liable to the individual, payer or other entity for and shall
refund on a timely basis to the individual, payer or other
entity the collected amounts.
(b) Civil penalty for improper claims.--A person that
presents or causes to be presented a bill or a claim for a
service that he knows is for a service for which payment may not
be made under section 3(a) or for which a refund has not been
made under subsection (a) or otherwise violates this act shall
be subject to a civil penalty of not more than $15,000 for each
service.
(c) Civil penalty for circumvention schemes.--A provider or
other entity that enters into an arrangement or scheme, such as
a cross-referral arrangement which the provider or entity knows
or should know has a principal purpose of assuring referrals by
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the provider to a particular entity which, if the provider
directly made referrals to such entity, would be in violation of
this section, shall be subject to a civil penalty of not more
than $100,000 for each arrangement or scheme.
Section 20. Effective date.
This act shall take effect in 60 days.
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