Physician Referral and Feedback 2025

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1877 [42 U.S.C. 1395nn] (a) Prohibition of certain referrals. (B) the entity may not present or cause to be presented a claim under this title or bill to any individual, third party payor, or other entity for designated health services furnished pursuant to a referral prohibited under subparagraph (A).
A medical peer review is a performance assessment. Through this process, peers evaluate other physicians clinical performances. Teams of multiple physicians are assembled, often by administrative committees and ethics committees, to review the patient charts and activities of a particular physician.
What Are Stark Law Violation Examples? To give an example, lets say a physician invests in a freestanding lab diagnostics center and refers their patients, with Medicare, to that lab center for bloodwork. Whether or not they intended to benefit from the referrals, the physician would appear to violate the law.
In order for a relationship to implicate Stark, five basic elements must be present: (1) a physician must make (2) a referral for the furnishing of (3) designated health services payable by Medicare (4) to an entity (5) with which he/she (or an immediate family member) has a financial relationship.
In 2022, CMS updated Stark law policy regarding physician compensation plans. Physician compensation plans where productivity is above the 75th percentile could trigger review, and compensation should be consistent with the services performed by the practitioner.
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The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive designated health services payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.
A referral is an order from a primary care physician (PCP) that allows a patient to see and receive care from a specialist. PCPs use referrals when patients need: Expertise the PCP cant provide. Specialized treatment.

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