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50 Focused Physician Arrangement Compliance Questions

Richard P. Kusserow | April 2022

The following is a list of questions Compliance Officers can use to assess compliance with legal requirements for physician arrangements. These questions provide a rough guide to conducting an arrangements review to ensure alignment with the Anti-Kickback Statute and Physician Referral (Stark) Laws. The questions are in three categories: (a) Prior to Agreement; (b) Arrangement Agreement; and (c) Agreement Compliance. 

Prior to Agreement

  1. Are there adequate policies/procedures for establishing a physician arrangement?
  2. How was the process documented for justifying a contracted arrangement?
  3. Was a medical necessity evaluation performed to justify contracting for the services?
  4. What is the basis for determining medical necessity for the position?
  5. Is the medical necessity determined the same way as for full-time employed physicians?
  6. Who is responsible for determining medical necessity?
  7. What role did the Chief Medical Officer play in deciding to engage a part-time physician?
  8. What process was followed to select a part-time physician?
  9. Was the physician selection process documented in detail?
  10. How was the position opportunity publicized to the physician community?
  11. Who made the selection decision for the physicians engaged?
  12. Was a history of referring patients to the hospital a factor in the selection?
  13. Were referrals a factor in making the selection decision?
  14. Was marketing or business development involved in making the hiring decision?
  15. What representations were made to leadership and the board concerning the selection?

Arrangement Agreement

  1. Is the duration of the agreement at least one year?
  2. Is the agreement current and not expired, lapsed, or terminated?
  3. Does the agreement cover all services to be furnished by the physician?
  4. How was Fair Market Value (FMV) determined?
  5. Is there a standardized process for documenting FMV determination?
  6. When was the last time a FMV assessment was performed?
  7. Was the standard for commercially reasonable services established?
  8. Was the commercial reasonableness analysis completed and documented?
  9. Did the Agreement cover all identifiable specified items or services to be performed?
  10. Was the compensation set in advance of physician selection and objectively verifiable?
  11. Were there any changes in the agreement after it was put into effect?
  12. Do contracts include how services are to be delivered and the hours needed to do it?
  13. Is the work described in the contract bona fide, consistent with the medical needs identified?
  14. Are there any provisions in the agreement related to referrals or volume of business?
  15. Are all the essential contractual terms and conditions addressed?
  16. Who approved (signed) the agreement?
  17. Have all physician arrangement contracts been reviewed and signed off by legal counsel?
  18. Was the agreement signed by the parties?
  19. Is there more than one agreement with the physician?

Agreement Compliance

  1. Have parties in the contract been screened against the Department of Health and Human Services Office of Inspector General LEIE?
  2. Have physician arrangements been made part of ongoing monitoring and auditing?
  3. Is there a committee or other identified parties overseeing arrangement compliance?
  4. Has the contracted work performed been evaluated?
  5. Is the work performed being paid for at an acceptable level of FMV?
  6. Are there measurable performance standards required before payments are made?
  7. Are there internal controls for accounting and documentation of physician services?
  8. Are there any other contracts and relationships between the parties?
  9. What verifies that all work has been documented before payments are made?
  10. Who is reviewing and approving the numbers of hours worked for payment?
  11. Is there a separate file to support and document each physician arrangement?
  12. Is a process in place to mandate that all contracts be stored in a contract database?
  13. Are all contracts centrally located in one database for ongoing monitoring?
  14. Are all focused arrangements identified and maintained in a single database?
  15. Is there a Focused Arrangements Tracking System that tracks and monitors all agreements?
  16. Are payments made under physician arrangements audited?

For more information on this topic, contact Richard Kusserow at rkusserow@strategicm.com.

About the Author

Richard P. Kusserow established Strategic Management Services, LLC, after retiring from being the DHHS Inspector General, and has assisted over 2,000 health care organizations and entities in developing, implementing and assessing compliance programs.

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