ROWAN UNIVERSITY POLICY
Title: General Statement on Agreements with Referral Sources
Subject: Office of Compliance & Corporate Integrity (OCCI)
Policy No: OCCI: 2013: C04
Issuing Authority: Rowan President & RowanSOM Dean
Responsible Authority: RowanSOM Chief Compliance and Privacy Officer
Reviewed: July 2, 2012
Amended: July 1, 2013
Last Reviewed: Jan 6, 2015
To provide guidance as to Rowan University's School of Medicine (RowanSOM) policy on the entering into financial arrangements with physicians and other potential referral sources, as defined below, and to ensure compliance with Stark Law, the Federal Anti-kickback statute and with the regulations, directives and guidance related to those statutes.
Under the direction of the President, the Dean, General Counsel, and the Chief Compliance and Privacy Officer shall ensure compliance with this policy. The Dean, Associate Deans, Clinical Chairs and Executive Director shall implement this policy.
This policy applies to all RowanSOM operating units, including but not limited to hospitals, physician practices, and outpatient centers. The policy applies to any agreement or financial relationship involving, i) a physician or, as set forth below, a non-physician referral source, or ii) a physician's immediate family members (herein and in this policy, all may be referred to as "Referral Sources").
A. "Approving Authority" - For purposes of this policy, the approving authority for an operating unit is the president of the unit or the dean of the school.
B. "Immediate Family Members" - Is defined by law as spouse; natural or adoptive parent, child, or sibling; stepparent, stepchild, stepbrother or stepsister; father-in law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law; grandparent or grandchild; and the spouse of a grandparent or grandchild.
C. "Physician" - A doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor.
D. "Potential Referral Sources" - Physicians, hospitals, long-term acute care centers, nursing homes, clinics, physician group practices, therapists and other individuals and entities who are in a position to influence referrals.
E. "Subject Agreements and Financial Relationships" - Subject Agreements and Financial Relationships include, but are not limited to, physician recruiting agreements, management services agreements, professional service agreements, employment agreements, other agreements for the provision of services or supplies (whether medically related or not), and medical office building leases, leases of equipment and staff.
A. 42 U.S.C. § 1320a-7b; 42 C.F.R. § 1001.952(a)-(v); 42 U.S.C. § 1395nn; 42 C. F. R. § 411.350 et. seq.;
B. 60 Fed. Reg. 41914 (Aug. 14, 1995); 63 Fed. Reg. 1659 (Jan. 9, 1998);
C. 66 Fed. Reg. 856 (Jan. 4 2001); 69 Fed. Reg. 16054 (March 26, 2004); Corporate Integrity Agreement Between the Office of Inspector General of the Department of Health and Human Services and the University of Medicine and Dentistry of New Jersey, September 25, 2009.
A. RowanSOM will from time to time promulgate various policies as to financial relationships between RowanSOM Operating Units and (i) physicians and (ii) other potential referral sources. Compliance with the policies is required in all contracts with physicians and other referral sources.
C. The Office Compliance and Corporate Integrity will educate responsible parties on the laws, regulations and policies applicable to Subject Agreements with Potential Referral Sources, will monitor and review such Subject Agreements, will ensure that fair market value documentation attached to Subject Agreements reflects fair market value for the services rendered and will assist the responsible dean or chief executive officer with remediating such Subject Agreements when potential violations of Section VI of this policy are detected.
D. Execution Timing: The Subject Agreement must be fully executed before any services are provided and before payment is made or received.
E. Compliance with Subject Agreement terms: In all arrangements with Potential Referral Sources, payments must be consistent with the terms of the Subject Agreement and performance of all of the terms of the Subject Agreement is required. For example, monies owed by a physician under a lease agreement must be paid in accordance with the terms of the documents. Accurate and complete records of all time and effort must be maintained by the facility, clinical unit or department. The RowanSOM Operating Unit must accurately track remuneration paid or received pursuant to an agreement. The Office Compliance and Corporate Integrity is responsible for conducting annual probe sample reviews for time and effort reporting and remuneration tracking.
By Direction of the President:
Signature on file
RowanSOM Chief Compliance and Privacy Officer