50 Questions to Ask When Assessing Physician Compliance Arrangements
The following is a list of questions Compliance Officers can use to assess compliance with legal requirements for physician arrangements. These questions provide a rough guide to conducting an arrangements review to ensure alignment with the Anti-Kickback Statute and Physician Referral (Stark) Laws. The questions are in three categories: (a) Prior to Agreement; (b) Arrangement Agreement; and (c) Agreement Compliance.
Prior to Physician Arrangement Agreement
- Are there adequate policies/procedures for establishing a physician arrangement?
- How was the process documented for justifying a contracted arrangement?
- Was a medical necessity evaluation performed to justify contracting for the services?
- What is the basis for determining medical necessity for the position?
- Is the medical necessity determined the same way as for full-time employed physicians?
- Who is responsible for determining medical necessity?
- What role did the Chief Medical Officer play in deciding to engage a part-time physician?
- What process was followed to select a part-time physician?
- Was the physician selection process documented in detail?
- How was the position opportunity publicized to the physician community?
- Who made the selection decision for the physicians engaged?
- Was a history of referring patients to the hospital a factor in the selection?
- Were referrals a factor in making the selection decision?
- Was marketing or business development involved in making the hiring decision?
- What representations were made to leadership and the board concerning the selection?
Physician Arrangement Agreement
- Is the duration of the agreement at least one year?
- Is the agreement current and not expired, lapsed, or terminated?
- Does the agreement cover all services to be furnished by the physician?
- How was Fair Market Value (FMV) determined?
- Is there a standardized process for documenting FMV determination?
- When was the last time a FMV assessment was performed?
- Was the standard for commercially reasonable services established?
- Was the commercial reasonableness analysis completed and documented?
- Did the Agreement cover all identifiable specified items or services to be performed?
- Was the compensation set in advance of physician selection and objectively verifiable?
- Were there any changes in the agreement after it was put into effect?
- Do contracts include how services are to be delivered and the hours needed to do it?
- Is the work described in the contract bona fide, consistent with the medical needs identified?
- Are there any provisions in the agreement related to referrals or volume of business?
- Are all the essential contractual terms and conditions addressed?
- Who approved (signed) the agreement?
- Have all physician arrangement contracts been reviewed and signed off by legal counsel?
- Was the agreement signed by the parties?
- Is there more than one agreement with the physician?
Physician Compliance
- Have parties in the contract been screened against the Department of Health and Human Services Office of Inspector General LEIE?
- Have physician arrangements been made part of ongoing monitoring and auditing?
- Is there a committee or other identified parties overseeing arrangement compliance?
- Has the contracted work performed been evaluated?
- Is the work performed being paid for at an acceptable level of FMV?
- Are there measurable performance standards required before payments are made?
- Are there internal controls for accounting and documentation of physician services?
- Are there any other contracts and relationships between the parties?
- What verifies that all work has been documented before payments are made?
- Who is reviewing and approving the numbers of hours worked for payment?
- Is there a separate file to support and document each physician arrangement?
- Is a process in place to mandate that all contracts be stored in a contract database?
- Are all contracts centrally located in one database for ongoing monitoring?
- Are all focused arrangements identified and maintained in a single database?
- Is there a Focused Arrangements Tracking System that tracks and monitors all agreements?
- Are payments made under physician arrangements audited?
For more information on this topic, contact Richard Kusserow at [email protected].
