CMS proposes to tighten fraud and abuse rules

Why This Topic Matters

These proposals could affect common clinical and business arrangements across specialties that rely on imaging, testing, referrals, and shared service models. Understanding the scope of the changes helps organizations assess compliance risk and operational impact.

Article Sections

1. Broadened anti-markup provisions

   Discusses proposed changes to anti-markup policy and the types of professional and technical service arrangements that may be affected. The section also notes the provider groups most likely to be impacted.

2. Redefining 'entity'

   Covers CMS’s proposed revision to the meaning of an entity under Stark-related rules and its effect on certain physician-hospital and joint venture structures. The section addresses broader concerns about arrangements involving referred services.

3. Unit-of-service arrangement restrictions

   Reviews proposed limits on unit-based payment arrangements tied to equipment and facility use. The section explains the general compliance concerns CMS associates with these structures.

4. Predetermined percentage pay arrangements

   Summarizes proposed limitations on percentage-based payment formulas in physician arrangements. The section focuses on the general direction of CMS’s proposed restrictions.

5. IDTFs

   Describes proposed updates affecting independent diagnostic testing facilities, including space sharing, subleasing, and supervision-related requirements. The section highlights changes that could affect practice operations.

6. Other proposals

   Lists additional proposed fraud and abuse changes addressing insurance subsidies, ownership or investment interests, compensation relationships, and timing issues for noncompliant financial relationships.