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In its ongoing efforts to decrease regulatory burdens, the US Centers for Medicare and Medicaid Services (CMS) has turned its attention to a law that, with the exception of physical therapy and a few other treatments and procedures, bars physicians from referring patients to services in which the physician has a financial interest. The CMS call for feedback—an effort largely focused on how the law might be loosened up—comes at a time when APTA and other organizations are voicing support for a bill that would do nearly the opposite by eliminating the exemptions allowing for self-referral for physical therapy and other services.

The CMS Request for Information (RFI) is part of an initiative dubbed the "Regulatory Sprint to Coordinated Care." According to CMS, the focus of the initiative is on "identifying regulatory requirements or prohibitions that may act as barriers to coordinated care, assessing whether those regulatory provisions are unnecessary obstacles to coordinated care, and issuing guidance or revising regulations to address such obstacles and, as appropriate, encouraging and incentivizing coordinated care."

According to the RFI, CMS is setting its sights on the Stark Law because of its potential to bump up against new models of care delivery by seemingly prohibiting systems that could be interpreted as forms of self-referral.

"CMS is aware of the effect the physician self-referral law may have on parties participating or considering participation in integrated delivery models, alternative payment models, and arrangements to incent improvements in outcomes and reductions in cost," CMS states. "We are particularly interested in your thoughts on issues that include, but are not limited to, the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law."

The RFI includes 20 questions soliciting ideas on topics ranging from what additional exceptions to the Stark Law might be considered to how CMS could track physician overuse of self-referral. APTA is reviewing the RFI, and will collaborate with the APTA Private Practice Section and other stakeholders to provide comments by the August 24 deadline. The association also provides a template letter for individuals to submit comments directly to CMS via its regulatory issues webpage (scroll down to second bullet under "APTA's Current Regulatory Advocacy Efforts").

The general aim of the RFI would seem to run counter to APTA's own efforts to toughen up the rules against self-referral. Last year, the association joined fellow members of the Alliance for Integrity in Medicare in support of a bill in the US House of Representatives that seeks to eliminate self-referral exemptions for so-called "in-office ancillary services"—physical therapy, anatomic pathology, advanced imaging, and radiation oncology. The idea of eliminating the loopholes is also supported by AARP. To date, the legislation has not been scheduled for House committee review.

"APTA supports efforts to ease the regulatory and administrative burdens faced by health care providers, but those efforts need to be weighed against possible effects on patient choice and access to care," said Justin Elliott, APTA's vice president of government affairs. "Our response to this RFI will take great care to help CMS understand the possible unintended consequences of creating more ways around self-referral without other safeguards in place."


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