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PRINTER'S NO. 180
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
214
Session of
2021
INTRODUCED BY DeLUCA AND PISCIOTTANO, JANUARY 22, 2021
REFERRED TO COMMITTEE ON HEALTH, JANUARY 22, 2021
AN ACT
Providing for prohibition on health care provider self-referral.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Short title.
This act shall be known and may be cited as the Prohibition
on Health Care Provider Self-referral Act.
Section 2. Definitions.
The following words and phrases when used in this act shall
have the meanings given to them in this section unless the
context clearly indicates otherwise:
"Compensation arrangement." An arrangement involving
remuneration, direct or indirect, between a provider or a member
of a provider's immediate family and a person or entity.
"Designated health service." The following goods or
services:
(1) clinical laboratory services;
(2) physical therapy, occupational therapy or speech
language pathology;
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(3) chiropractic;
(4) radiation oncology;
(5) psychometric services;
(6) home health services; or
(7) diagnostic imaging.
"Financial interest." An ownership or investment interest or
a compensation arrangement.
"Health care provider." A person, corporation, facility or
institution licensed or otherwise authorized by the
Commonwealth to provide health care services, including a
physician, coordinated care organization, hospital, health care
facility, dentist, nurse, optometrist, podiatrist, physical
therapist, psychologist, chiropractor or pharmacist and an
officer, employee or agent of the person acting in the course
and scope of employment or agency related to health care
services.
"Immediate family member." Husband or wife, birth 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 spouse of a grandparent or
grandchild.
"Ownership or investment interest." A direct or indirect
ownership or investment interest through equity, debt or other
means that includes an interest in an entity that holds an
ownership or investment interest in an entity that furnishes
designated health services. An ownership or investment interest
includes, stock, stock options, partnership shares, limited
liability company memberships and loans, bonds or other
financial instruments that are secured with an entity's property
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or revenue or a portion of that property or revenue.
"Referral." As follows:
(1) The term includes:
(i) The request by a health care provider for, or
ordering of, or the certifying or recertifying of the
need for a designated health service, including a request
for a consultation with another health care provider and
a test or procedure ordered by or to be performed by, or
under the supervision of, that other health care
provider, but not including a designated health service
personally performed or provided by the referring health
care provider. A designated health service is not
personally performed or provided by the referring health
care provider if it is performed or provided by another
person, including the referring health care provider's
employees, independent contractors or group practice
members.
(ii) A request by a health care provider that
includes the provision of a designated health service,
the establishment of a plan of care by a health care
provider that includes the provision of the designated
health service or the certifying or recertifying of the
need for the designated health service, but not including
a designated health service personally performed or
provided by the referring health care provider. A
designated health service is not personally performed or
provided by the referring health care provider if it is
performed or provided by another person, including the
referring health care provider's employees, independent
contractors or group practice members.
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(2) The term does not include a request by a pathologist
for clinical diagnostic laboratory tests and pathological
examination services by a radiologist for diagnostic
radiology services and by a radiation oncologist for
radiation therapy or ancillary services necessary for, and
integral to, the provision of radiation therapy, if:
(i) the request results from a consultation
initiated by another whether the request for a
consultation was made to a particular pathologist,
radiologist or radiation oncologist or to an entity with
which the pathologist, radiologist or radiation
oncologist is affiliated; and
(ii) the tests or services are furnished by or under
the supervision of the pathologist, radiologist or
radiation oncologist or under the supervision of a
pathologist, radiologist or radiation oncologist,
respectively, in the same group practice as the
pathologist, radiologist or radiation oncologist.
(3) A referral may be in any form, including written,
oral or electronic.
"Secretary." The Secretary of Health of the Commonwealth.
Section 3. Unprofessional conduct.
(a) Referrals.--
(1) A health care provider may not refer a person for a
designated health service if the health care provider or an
immediate family member of the health care provider has a
financial interest with the person or entity that receives
the referral.
(2) A health care provider may not enter into an
arrangement or scheme, such as a cross-referral arrangement,
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which the health care provider knows or should know has a
principal purpose of assuring referrals of designated health
services by a health care provider to a particular entity
which, if the health care provider directly made referrals to
the entity, would be in violation of this act.
(b) Limitation on billing.--A claim for payment may not be
presented by an entity to an individual, third-party payer or
other entity for a designated health service furnished under a
referral prohibited under this section.
(c) Denial of payment.--
(1) Except as provided in paragraph (2), a payment may
not be made by a payer for a designated health service that
is furnished under a prohibited referral.
(2) Payment may be made to an entity that submits a
claim for a designated health service if the entity did not
have actual knowledge of, and did not act in reckless
disregard or deliberate ignorance of, the identity of the
health care provider who made the referral of the designated
health service to the entity.
(d) Exceptions.--The provisions of subsections (a), (b) and
(c) shall not apply to the following:
(1) Referrals permitted under the Safe Harbor
regulations promulgated under section 1128B(b)(1) and (2) of
the Social Security Act (49 Stat. 620, 42 U.S.C. § 1320a-7b)
currently published at 42 CFR 1001.952 (relating to
exceptions).
(2) Referrals permitted under the exceptions to the
Stark amendments to the Medicare Act (42 U.S.C. § 1395nn) of
the Social Security Act and the regulations promulgated
thereunder, currently published at 42 CFR Pt. 411 Subpt. J
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(relating to financial relationships between physicians and
entities furnishing designated health services).
(3) Referrals permitted by the secretary through
regulations upon a determination that the referrals do not
pose a risk of program or patient abuse.
(e) Prohibition.--An individual, third-party payer or other
entity may not deny payment to a health care provider involved
in a transaction or referral described in subsection (d).
Section 4. Penalties.
(a) Requiring refunds for certain claims.--If a person
collects amounts billed in violation of section 3(a), the person
shall be liable to the individual, payer or other entity for the
collected amounts and shall refund on a timely basis to the
individual, payer or other entity the collected amounts.
(b) Civil penalty for improper claims.--A person that
presents or causes to be presented a bill or a claim for a
service that the person knows is for a service for which payment
may not be made under section 3(a) or for which a refund has not
been made under subsection (a) or otherwise violates this act
shall be subject to a civil penalty of not more than $15,000 for
each service.
(c) Civil penalty for circumvention schemes.--A health care
provider or other entity that enters into an arrangement or
scheme, such as a cross-referral arrangement which the health
care provider or entity knows or should know has a principal
purpose of assuring referrals by the health care provider to a
particular entity which, if the health care provider directly
made referrals to the entity, would be in violation of this act,
shall be subject to a civil penalty of not more than $100,000
for each arrangement or scheme.
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Section 5. Effective date.
This act shall take effect in 60 days.
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