Archive for May, 2016

Stark Law Changes Effective in 2016

By Richard D. Sanders, Esq.


On October 30, 2015, the Centers for Medicare and Medicaid Services (“CMS”) revealed the 2016 Medicare Physician Fee Schedule (the “Final Rule”), which included significant changes to the Physician Self-Referral Law (the “Stark Law”). The Stark Law generally prohibits physician referrals for designated health services payable by Medicare or Medicaid to an entity with which such physician (or an immediate family member) has a financial relationship, unless an exception applies.

The purpose of this Final Rule is to accommodate healthcare delivery and payment system reform, reduce burdens, facilitate compliance, and issue new exceptions to the Stark Law. These new regulations became effective on January 1, 2016, with the exception of the definition of “ownership or investment interest” as it relates to the level of physician ownership in physician-owned hospitals, which will become effective on January 1, 2017.

New Stark Exceptions

Assistance to Compensate a Non-physician Practitioner

In an attempt to address changes to the healthcare delivery and payment systems, alarming primary care workforce shortage projections, and the increasing demand for primary care services (particularly in rural and underserved areas), the Final Rule includes a new exception that permits remuneration from a hospital, federally qualified health center (“FQHC”), or rural health clinic (“RHC”) to a physician in order to assist the physician in employing a non-physician provider in the geographic area served by the hospital, FQHC or RHC. The specific limitations and requirements of this new exception can be found under 42 C.F.R. § 411.357(x).

Timeshare Arrangements

The Final Rule also includes an exception to the Stark Law for “timeshare” arrangements in which a hospital or local physician practice may arrange with a specialist from another community to provide services in a space owned by a hospital or practice on a limited or as-needed basis. CMS acknowledged the utility of timeshare arrangements whereby an individual could use another person or entity’s premises, equipment, personnel, items, supplies or physician services under a license rather than under a traditional lease. Further details regarding this arrangement can be located at 42 C.F.R. § 411.357(y).

Modifications to Existing Stark Law Exceptions, Policies, Definitions and Other Changes

Writing Requirement

CMS clarified in its Final Rule that the existing writing requirement in many Stark Law exceptions does not require an arrangement to be in a single “formal” written contract. Rather, the writing requirement can be satisfied by showing a collection of documents evidencing the course of conduct between the parties. To further clarify this policy, CMS replaced the terms “agreement,” “lease,” “written contract,” and “contract,” with the terms “arrangement” and “writing.” Moreover, when parties use a collection of documents to satisfy the writing requirement, a signature is required on a contemporaneous writing(s) sufficient to document the arrangement.

Term Requirement

Certain Stark Law exceptions (i.e., rental of office space, rental of equipment, and personal services arrangements) require a term of at least one year. CMS clarified that a formal written contract or other document with an explicit term provision is not required to satisfy the “term” element. Instead, the term requirement can be satisfied so long as the arrangement clearly establishes that a business relationship will last for at least one year. On the other hand, an arrangement that actually lasts for one year will satisfy this requirement. CMS further provides that “Parties must have contemporaneous writings establishing that the arrangement lasted for at least one year, or be able to demonstrate that the arrangement was terminated during the first year and that the parties did not enter into a new arrangement for the same space, equipment, or services during the first year.”

Signature Requirement & Temporary Noncompliance

The Final Rule allows an entity ninety (90) days to obtain required signatures, regardless of whether the noncompliance was purposeful or inadvertent. In order to utilize this temporary noncompliance period, the arrangement must satisfy all other requirements of the applicable exception. However, an entity can only use this temporary noncompliance period to satisfy the signature requirement once every three (3) years for the same referring physician.

Holdover Arrangements

Previously, expired arrangements under the Rental of Office Space Exception, Rental of Equipment Exception and Personal Services Exception were permitted for up to six (6) months if the arrangement satisfies the requirements of an exception upon its expiration, and the arrangement continues to comply with the same terms and conditions after the stated expiration. Under the Final Rule, indefinite holdovers are permitted provided the arrangement: (1) satisfies all of the elements of the applicable exception at the time of the stated expiration; (2) continues under the same terms and conditions as the original agreement; and (3) continues to comport with all of the elements of the applicable exception during the course of the holdover.

Definition of Remuneration

The Final Rule revised the definition of “remuneration” under the Stark Law to make it clear that the provision of items, devices, or supplies that are used solely to collect, transport, process, or store specimens for the entity providing the items, devices, or supplies, or to order or communicate the results of tests or procedures for such entity does not constitute remuneration.

Geographic Area Served by FQHCs and RHCs

According to the Physician Recruitment Exception, remuneration may be provided by a hospital to a physician in order to induce the physician to relocate his or her medical practice to the geographic area served by the hospital and become part of the hospital’s medical staff. This exception was also expanded to include FQHCs and RHCs. The term “geographic area served by the hospital” is partially defined as “the lowest number of contiguous postal zip codes from which the hospital draws at least 75 percent of its inpatients.” However, this definition did not provide guidance as to the geographic areas in which a FQHC or RHC can recruit a physician. As a result, the Final Rule added a new definition to clarify this discrepancy by defining the geographic area served by a FQHC or RHC as “the lowest number of contiguous or noncontiguous zip codes from which the FQHC or RHC draws at least 90 percent of its patients, as determined on an encounter basis.”


In all, CMS made some very significant changes to the Stark Law (including the addition of two new exceptions) which should offer healthcare providers greater clarity and flexibility under certain arrangements.

Richard D. Sanders is an attorney in Atlanta who specializes in corporate and regulatory matters for physicians. He can be reached at or (404) 806-5575.

Georgia Academy of Family Physicians 2016 Student and Resident Awards

Congratulations to the 2016 recipients of the T.A. Sappington Award. This prestigious award is given to student members who have demonstrated their commitment to family medicine by choosing to attend a Georgia Family Medicine Residency Program.

This year we recognize:

Afua Akhi-Gbade from the Medical College of Georgia at Augusta University who plans to attend the Emory University Family Medicine Residency Program in Atlanta.

Natalie Britt from Mercer University School of Medicine, Savannah who will attend the Memorial Health Family Medicine Residency Program in Savannah.

Kayla Dziuba from the Philadelphia College of Osteopathic Medicine in Suwanee who is planning to attend the Floyd Family Medicine Residency Program in Rome.

Monique Merritt from the Morehouse School of Medicine who will attend the Morehouse Family Medicine Residency Program in East Point.

Best of luck to the Sappington winners as they transition to residency programs in Georgia!

Congratulations goes out to Edward Agabin, MD, who was voted to be the Georgia Academy Resident of the Year for his strong leadership abilities and dedication to family medicine at Augusta University, Medical College of Georgia Family Medicine Residency Program. According to Dr. Julie Dahl-Smith, Dr. Agabin has excelled in leadership as well as clinical abilities. He is very active in both policy-making and residency recruitment. He was elected Chief Resident by his peers, and served as a primary voting member of the Graduate Education Committee and Electronic Health Records Residency Advisory Committee as well as serving as an Alternate Delegate for the GAFP Congress of Delegates in 2015. Attending physicians have referred to him as “efficient, thorough, and knowledgeable.” In addition to being extremely competent, he is also kind, compassionate, and empathetic, developing great rapport with the patients and staff. Truly an outstanding resident!

The Resident of the Year receives an engraved plaque along with a pair of tickets to the President’s event during the Georgia Academy’s Annual Meeting in November, where he will be recognized.

This year, the Georgia Academy Keith Ellis Award winner for Chief/Co-Chief Resident goes to Naheed Lakhani, MD from the Emory University Family Medicine Residency Program in Atlanta. Her Program Director, Dr. Teresa Lianne Beck states that Dr. Lakhani’s organizational, teaching and mentoring skills have been invaluable to the residency program in creating and maintaining call schedules and managing the logistical, interpersonal and professionalism issues inherent to any residency training program. Her lead role in residency recruitment was a key factor in helping Emory achieve another successful recruiting season. Her teaching and mentoring of medical students and fellow residents has made a significant impact on the quality of training that their students and residents receive. She has played key roles helping revive the Tar Wars program at Emory and organize free health screenings and preventive health education for the local community.

Dr. Lakhani has earned the respect and admiration of her patients, support staff, fellow residents and faculty. Her hard work, dedication and positive attitude is reflected daily in the way she approaches her personal and professional life. She has demonstrated exceptional leadership, clinical and academic excellence throughout her residency training.

The Keith Ellis award winner receieves a free trip to our annual meeting this November along with registration and attendance at the President’s event where she will be recognized.

#StopAFIBinGA – Georgia’s Family Physicians Launch AFIB Social Media Awareness Campaign

The Georgia Academy is launching a twitter war against strokes and atrial fibrillation and we ask that you join in the fun! The GAFP’s twitter account @gafamilydocs will be tweeting out reminders for patients and clinicians related to AFIB and stroke awareness on the 5th, 15th, and 25th of the month for the next year.

Join twitter (it’s easy and fun) and help us outreach to thousands of Georgians who are unaware of their cardiac, stroke and atrial fibrillation risk. The GAFP thanks Pfizer in their support to #StopAFIBinGA

Upcoming Tweets:


  • May is National Stroke Awareness Month. Did you know 10% of all strokes are from#AtrialFibrillation? #StrokeMonth #StopAFIBinGA @natlstrokeassoc @wsbtv
  • Know the signs: unhealthy eating, smoking, drinking & lack of exercise are #stroke risk factors you can control. #StrokeMonth #StopAFIBinGA
  • #AtrialFibrillation is a leading cause of strokes, but most #afib patients don’t know they are at risk. #StrokeMonth #StopAFIBinGA @natlsrokeassoc



What You Need to Know from the AAFP- AAFP Launches MACRA Ready Web Page to Aid Family Physicians

 AAFP launches MACRA Ready Web page to aid family physicians

AAFP President Wanda Filer, M.D., announced the official launch of the Academy’s member communication and education initiative to help physicians prepare for new payment models under the Medicare Access and CHIP Reauthorization Act. Filer told attendees of a town hall event at the AAFP’s 2016 Leadership Conference that the MACRA Ready Web page is “designed to help simplify the transition and provide the guidance that you will need to realize the benefits of MACRA and value-based payments.”

AAFP News (5/6)

CMS officials discuss MACRA at AAFP forum

The AAFP hosted a town hall meeting during its Annual Chapter Leader Forum in which about 300 family physicians and chapter executives had the opportunity to discuss the Medicare Access and CHIP Reauthorization Act with CMS officials. CMS Acting Administrator Andy Slavitt, who participated via conference call, said making sure regulations are flexible and practice-driven and let physicians customize performance measures are among CMS’ goals during the rule-making process. He urged physicians to provide feedback during the public comment period, which ends on June 27.

AAFP News (5/10)

Article gives physicians guidance on 60-day overpayment rule

A report in the journal Family Practice Management offers guidance to family physicians on the new CMS 60-day overpayment rule, which says Medicare overpayments not paid back to the government within 60 days of being identified will be considered a false claim. The AAFP opposed parts of the regulation during the approval process, and President Wanda Filer, M.D., said most errors linked to Medicare billing and payments are inadvertent and not fraudulent.

AAFP News (5/4)

Task force says evidence is insufficient to recommend celiac screening

The US Preventive Services Task Force’s first draft recommendation statement on celiac disease said there is insufficient evidence to weigh the benefits and harms of screening asymptomatic patients. USPSTF member Alex Krist, M.D., said physicians should use their clinical judgment to decide if patients need screening. The AAFP is reviewing the draft recommendation.

AAFP News (5/5)

NCCL delegates support increased diversity in family medicine

Resolutions supporting research and advocacy to encourage more physicians from diverse backgrounds to become family physicians were adopted by delegates at the 2016 National Conference of Constituency Leaders. Delegates also adopted a resolution asking the AAFP to study workplace violence and recommended ways to address the issue.

AAFP News (5/9)

Take Advantage of TWO Webinars this May and Earn Free CME!

Join GAFP for a DPH Webinar on May 20th at 12pm!

DPH Webinar: Developmental Screening

May 20, 2016

12:00 pm – 1:00 pm

This program will be presented by Jennifer Zubler, MD. Dr. Zubler is board certified in pediatrics and worked for 10 years in a private pediatric practice in Atlanta, Georgia. She has a special interest in developmental delays and works as a pediatric consultant to the “Learn the Signs. Act Early.” team. In addition, she helps run a developmental and behavioral pediatric clinic in Atlanta.

Reserve your seat now at:

CME Information:

AMA Credit: The Georgia Academy of Family Physicians is accredited by the Medical Association of Georgia to provide continuing medical education for physicians.  The GAFP designates this live educational activity for a maximum of 1 AMA PRA Category 1 credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Registration is now open for the Georgia Clinical

Transformation Team’s May webinar:

Incorporating Behavioral Health into the Primary Care Practice

Registration: Please follow this link to register.

Date & Time: Wednesday, May 25 – 12:30-1pm ET – Incorporating Behavioral Health into the Primary Care Practice

Webinar Objectives:

Incorporating Behavioral Health into the Primary Care Practice


  • Identify which screening tools are practical to use in primary care
  • Learn how to interpret screening results
  • Identify successful workflows to accomplish screening and accurate coding for reimbursement

This webinar is part of a monthly series of 30-minute webinars focused on quality improvement in your practice brought to you by the Georgia Clinical Transformation Team (GCT2). GCT2 partners include Alliant Quality, American Cancer Society, DCH Medicaid, GA-HITEC, GAFP, GAPHC, Georgia Chapter of ACP, Georgia DPH, GHA, GPHA, HomeTown Health, and MAG.


Adrienne Mims, MD, MPH, FAAFP, AGSF

Vice President, Chief Medical Officer, MedicareQuality Improvement

Alliant Quality

All interested stakeholders are welcome, so please feel free to share this information. If you have any questions, please contact Angela Flanigan at or 404-321-7445.

CME Information:

AMA Credit: The Georgia Academy of Family Physicians is accredited by the Medical Association of Georgia to provide continuing medical education for physicians.  The GAFP designates this live educational activity for a maximum of .50 AMA PRA Category 1 credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.