US doctors face curbs on referrals
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7278.72 (Published 13 January 2001) Cite this as: BMJ 2001;322:72
Doctors may no longer refer Medicare patients to organisations in which they have a financial interest, according to new US Department of Health and Human Services regulations.
The department issued a new regulation that will bar physicians from referring Medicare patients to healthcare organisations, such as hospitals, radiology centres, physical and occupational therapy groups, as well as pharmacies and medical equipment suppliers, in which they or their families have a financial interest.
The rule, effective from 4 January 2002, is designed to eliminate conflict of interest inherent in self referral practices as well as to decrease abuse of Medicare funds; it applies to referrals of Medicare patients only.
Medicare is the US government's federally financed health insurance plan that supplies healthcare coverage to over 39 million Americans over the age of 65, as well to disabled people and patients dependent on renal dialysis.
The new regulation grew out of a 1989 law that prohibited doctors from referring patients to clinical laboratories in which they or family members had a financial interest. In 1995 Congress voted to extend this law to prohibit referrals to 10 other categories of healthcare services if a financial relation existed between the doctor or the doctor's family and the service.
This revised ban covers physical and occupational services, radiology services, parenteral and enteral nutrients, equipment, prosthetics, orthotics, home health services, outpatient prescription drugs, and inpatient and outpatient hospital services. It also bans profit from medical billing for these prohibited referrals.
Implementing and interpreting this rule may prove difficult. Under the rule, for instance, doctors in group or multispecialty practices may face difficulties referring patients to others in their group. Getting prescriptions filled in house, or x ray examinations performed at an affiliated centre may be regarded as illegal self referrals.
Certain exemptions will apply for certain services provided in the doctor's office and for managed care plans and academic faculty practices with affiliations to their medical centres.