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Differential Valuations and the Anti-kickback Statute

Monday, April 3rd, 2017

Ambulatory Surgery Case Demonstrates Differential Value Theory of Renumeration

ASC Fraud and Abuse RemunerationA relatively recent case involving buy-in terms in an ambulatory surgery center demonstrates how different valuations for referral sources and non-referral sources can be evidence of remuneration under the Medicare Anti-Kickback Statute (42 U.S.C. § 1320a-7b(a)-(b)).  The case also demonstrates how the initial investment terms that favor referral sources can foreclose reliance on safe harbor regulations.

The case involved an ambulatory surgery center management company what purchased an interest in an ambulatory surgery center.  The company then offered shares of the company for investment to physicians who were in a position to refer surgical cases to the surgery center.  The physician investment was structured to meet the terms of the safe harbor regulations for ambulatory surgery center investments (“ASC Safe Harbors”).  The ASC Safe Harbors provide protection from remuneration that is received by a referring physician as a return on investment as long as the physician meets certain minimum practice revenue and surgical volume requirements. Physician investors must generally receive at least 1/3 of their practice income from the provision of surgical procedures and perform at least 1/3 of their surgical procedures in the center in which they hold an investment interest.

The problem with the way that the investment interest was structured was the different valuation that applied to the purchase that was made by the management company and the investment offer made to the referring physicians.  The management company purchased its investment at a much higher price than was offered to the physicians.  The differential valuation violated a threshold requirement of the safe harbor regulations that prohibits the initial investment interest to be based, in whole or in part, on the volume or value of referrals that the investor might make to the entity.  It was very difficult for the parties to justify the different value applied to physician investment.  The only apparent difference appeared to be that the physician investors were the referral sources for the surgery center.

This case specifically involved an ambulatory surgery center investment but the concept of differential valuation could apply in other situations involving the Anti-Kickback Statute.  Different values paid to or received from referral sources and non-referral sources can suggest that at least one of the reasons for the differential is the volume or value of potential referrals.  This points out a general area of risk assessment for all health care providers.  Areas where different pricing is applied to referral sources and non-referral sources could signify a potential violation of the Anti-Kickback Statute.

Ambulatory Surgery Center Exclusions – ASC Safe Harbor Compliance

Monday, February 13th, 2017

Excluding Non-performing Positions from a Physician Owned Surgery Center

Many surgery centers are eventually faced with decisions about how to treat investing physicians who do not perform as many procedure procedures in the surgery center as others.  Under-performing physicians can create political issues in ASCs because investors who perform more surgeries or higher value procedures at the center feel that the other investors are taking a ride on their efforts. Over time, higher producers may start to view those with lower surgery levels as “dead wood”. This dynamic is a perfect set up for violating the anti-kickback statute which specifically prohibits basing investment offering on the actual or expected volume or value of referrals.

​The anti-kickback statute standards that apply to surgery centers are somewhat counter-intuitive. The safe harbors that protect ASC investment interests actually require an investor to make certain levels of referral in order to receive the benefits of the safe harbor. This is different from other types of services which consider additional referrals to be suspect.

​The conditions included in the ambulatory surgery center safe harbors act as a proxy for determining when an investing referrer actually uses the ASC as a natural extension of his or her office practice. If the investor does not meet the Safe harbor threshold they may still use the ASC is a natural extension of their office. The Safe harbor merely provides absolute protection if the thresholds are met.

Where the specific requirements of the safe harbor is not met, the referring physician may still be using the facility as an extension of his or her medical practice. It might just be that the nature of the practice does not support as many referrals as other types of practices.  This does not necessarily mean that the lower volume provider presents any additional risk of violating the anti-kickback statute than a provider that comes closer to meeting the safe harbor standards.

Depending on the practice type, the lower level of referrals might very well still be indicative that the physician uses the facility as an extension of his or her practice.  This may not be what the higher referring physicians wish to hear.   In reality, they may feel that lower volume providers are taking a ride on their higher profitability that is created by there more lucrative practice.  In these cases, strict adherence to the one-third tests for multi specialty ambulatory surgery centers can support the positions of the high-volume surgeons to the detriment of the lower volume surgeons who still realistically create very little risk under the anti-kickback statute. However it becomes convenient that those who are responsible for more income being produced by the ASC can rely upon the number of procedures and percentage of income tests to exclude physicians who legitimately use the ASC is an extension of practice from participation but who have lower surgical volumes.

These types of cases run significant risk of being challenged under the anti-kickback statute by excluded investors or governmental enforcement agencies.  Great care must be taken in surgery centers that contain this dynamic to assure that frustrations of higher volume producers do not lead to actions that create regulatory risk for the surgery center.

Many operating agreements that govern the rules relating to ambulatory surgery center ownership actually create legal compliance risk.  It is critical that the procedures for excluding providers be established in advance, are uniformly followed, and do not raise any inference that additional referrals are being required in order to maintain an investment interest. Efforts to bring investors closer to compliance with safe harbor standards can easily be “turned inside out” and be re-characterized as requiring additional referrals.

Once investors own interests in an ambulatory surgery center, it is very difficult to force redemption without creating a lot of legal risk.  ASCs that use the failure to meet safe harbor standards as a reason to exclude investors run substantial risk.  The ASC Safe Harbor provisions exist to protect arrangements from further scrutiny where they contain elements that the federal government has indicated are reflective of there being a lower level of risk of abuse.  The safe harbors were never intended to be used as a tool to replace a complete risk analysis presented by investors who do not meet all of the terms of the safe harbor.  In this respect, the ASC Safe Harbors are different from other safe harbor provisions under the anti-kickback statute.  The primary difference involves that fact that the safe harbor actually requires certain levels of referrals to be made to the ASC.

With other safe harbors, structuring an arrangement to come close to a safe harbor can be a valid risk mitigation approach.  This is not the case with the ASC safe harbor because requiring investors in an ASC to come closer to the referral threshholds in the ASC Safe Harbor actually invoke the referral prohibition.  Forcing this doctor out of the ASC for simply not meeting the safe harbor creates a violation.

Ambulatory Surgery Center National Legal Practice ASC Compliance Issues

Monday, January 30th, 2017

Ambulatory Surgery Center Compliance Legal Practice

Ruder Ware has developed an active practice counseling ambulatory surgery center providers and has served as special counsel in several cases involving ambulatory surgery center exclusions.  The firm’s health care and compliance attorneys are knowledgeable on the numerous legal and regulatory requirements that are applicable to ASCs.  The regulations applicable to these entities are complex and nuanced.  The consequences of failing to comply or with taking improper steps to exclude providers can be very costly.

Some of the issues that our health care practice has recently addressed include the following:

  • Counseling ASC’s on the application of the Stark law, Anti-Kickback Statute, and ASC safe harbor issues.
  • Advising and representing providers on issues relating to conditions of participation and governmental surveys.
  • Representing organizations in preparing and submitting self-disclosure to the government.
  • Development of ASC investment entities.
  • Establishment of ASC compliance programs
  • Decisions regarding exclusion of “under-performing” providers.
  • Structuring exclusion provisions to minimize risk of violating regulations or enhancing the risk of litigation.
  • Sale and purchase of surgery centers.
  • ASC licensure and governmental approval.
  • Compliance with patient confidentiality and privacy laws.
  • Risk assessment, audits, compliance work plans, staff compliance training.
  • Contractual relationships with outside parties.

Ambulatory Surgery Center Lawyers – Ambulatory Surgery Center Lawyers

Ambulatory Surgery Center Attorney

John H. Fisher has practiced health care law for over 25 years.  One of John’s significant areas of expertise involves the regulatory and business aspects of ambulatory surgery centers.  Over the years, John has represented numerous clients on legal and compliance issues related to ambulatory surgery centers.  John consults as a subject matter expert and provider legal backup to other attorneys and law firms from around the country on issues relating to ambulatory surgery centers.  Some of John’s more recent ASC related projects include:

  •  Representation of an ASC in connection with the exclusion of non-complying owners.
  • Representation of excluded providers in litigation and settlement.
  • Creating operating documents that comply with ambulatory surgery center safe harbors and other applicable regulatory requirements.
  • Creation of policies and procedures required to gain certification as an ASC.
  • Consultation with local litigation attorneys regarding regulatory issues relevant to ASC litigation.
  • Consultation with ASCs on establishment of compliance programs and identification of related risk areas.
  • Assisting ASC providers in addressing detected deviations in operating and compliance requirements.

Ambulatory Surgery Centers – Federal Settlement Highlights Safe Harbor Requirements

Monday, September 29th, 2014

ASC Investments Safe HarborsA Tennessee based ambulatory surgery center company has agreed to pay damages to a former employee who filed a suit alleging that physician investments in local surgery center entities violated the Anti-kickback Statute.  The case highlights some of the unique kickback issues that are present in ambulatory surgery center structure.  Specifically, the case demonstrates how investment terms that are intended to assure compliance with the safe harbor regulations under the Medicare Anti‑Kickback Statute (42 U.S.C. § 1320a-7b(a)-(b)) can create evidence of non-compliance if the initial terms of the offering relate, in whole or in part, to the volume or value of expected referrals from the investor in the ASC venture.

In order to comply with safe harbor requirements, ASCs must generally require investing physicians to use the facility as an extension of their medical practices.  However, if the terms of the investment are based on the volume or value of referrals, those same requirements become evidence that referrals are being required in exchange for remuneration.  In the Tennessee case, the ASC management company purchased controlling interests in local surgery center entities at a high multiple of earnings.  Physicians who were referral sources were offered investments at less than 1/3 of the value that was applicable to the non-referring management company.  That differential in value was evidence of “remuneration” under the Anti-kickback Statute and also indicated that investment terms were more advantageous based on expected referrals.

Structuring ambulatory surgery center investments to comply with Anti-kickback requirements is an extremely complex task.  Indications of compliance can become evidence of non-compliance depending on initial investment terms.  Cases such as the Tennessee case illustrate the problems that can occur when safe harbor requirements are not complied with and when decisions on investment or exclusion are made based on past or anticipated referrals.  The Tennessee case also illustrates how these issues come to light.  The Tennessee case was filed as a whistleblower case by a former administrator of one of the local surgery centers who walked away with a settlement in the millions of dollars.

We have published a more complete analysis of the Tennessee case which you can access through the following link   ASC-Investment-Federal-Case

Ambulatory Surgery Center Advisory Opinions

Saturday, December 7th, 2013

Ambulatory Surgery Center Advisory Opinions

Physician Ownership In Ambulatory Surgery Centers

ambulatory Surgery Center OIG Advisory Opinions

Some OIG Advisory Opinions provide useful guidance on the application of the Anti-Kickback Statute to physician ownership in ambulatory surgery centers.

In OIG Advisory Opinion 03-05, the OIG found that a joint venture between a multi-specialty physician group and a hospital to operate an ambulatory surgery center could violate the Anti-Kickback Statute.  The OIG noted that the investing physicians represented specialties that were likely sources of referrals to each other, and most did not meet either the one-third source of ASC income test or the test that one-third of their procedures would be performed at their ASC.  The OIG concluded that few of the investors would actually use the surgery center on a regular basis.

The OIG seemed to focus its concern in 03-05 on the possible cross referrals created by the investment.  Where providers perform only nominal amount so procedures but refer a significant number of cases to other providers who end up in the ASC, there can be an illegal referral incentive.  However, before basing a divesture decision on service levels, an ASC should examine referral patterns to determine whether the return on investment is a significant inducement.  If a physician investor makes relatively few referrals to other investors, the cross-referral inducement would not appear to create a significant justification necessitating divesture.

The request in OIG Advisory Opinion 07-05 asked the OIG to consider a hospital’s proposed investment in an existing ASC.  The hospital proposed to purchase the shares of stock from the orthopedic surgeons who owned the ASC.  The OIG expressed concern that over a number of aspects of this arrangement.

In OIG Advisory Opinion 07-13, the OIG determined that an arrangement among a hospital subsidiary, ophthalmologists and optometrists to own a single specialty ASC could potentially violate the Anti-Kickback Statute.  The optometrist investors in the ASC, unlike the ophthalmologist investors, performed no procedures in the ASC and were in a position to benefit from their referrals to the ophthalmologists in the form of profit distributions from the ASC.  The OIG noted in particular the lack of any “discernible safeguards to minimize the significant risk” of the optometrists’ receipt of payment for their referrals.  The OIG also noted that although the ASC was an extension of the ophthalmologists’ office practices, the same was not true for the optometrists who performed no procedures using ASC facilities.

OIG Advisory Opinion 08-08 presents a good example of a single-specialty ASC joint venture that did not meet the technical safe harbor requirements but was structured in a manner that reduced the risk of prohibited remuneration.  In that ruling, 14 of the orthopedic surgeon investors in the joint venture ASC were not affiliated with the hospital and met the one-third test because at least one-third of their income was earned by performing ASC-qualified surgical procedures.  The other four investing surgeons, however, did not meet the one-third test, because of the nature of the surgeries they performed required a hospital setting.

 

Ambulatory Sugery Center Radiologist Rules – Proposed Simplified By CMS

Friday, February 15th, 2013

CMS Proposed Rule Would Simplify Ambulatory Surgery Center Radiologist Requirements 

Merging Physician Specialty PracticesOn February 7, 2013, the Center for Medicare/Medicaid Services (“CMS”) released a proposed rule that contains regulatory provisions to promote program efficiency, transparency and burden reduction.  The proposed rule proposes reforming certain Medicare regulations that CMS has identified as unnecessary, obsolete or excessively burdensome on health care providers and suppliers. 

One significant rule that CMS is proposing be abandoned is the requirement that Ambulatory Surgery Centers (“ASC”) meet the full hospital requirements for radiology services.  The full requirement must correctly be met by ASCs even though ASCs are only permitted to provide radiologic services that are integral to the performance of surgical services provided at the ASC. 

CMS concluded in the proposed regulations that some of the hospital conditions of participation requirements which are applicable to ASCs are unduly burdensome and create unnecessary costs.  Particularly, this CMS is proposing that the requirement to have a radiologist supervise the provision of radiologic services be deleted from the ASC conditions of participation.  CMS states that the requirement was overly aggressive since ASCs did not provide radiologic services that are required for interpretation or diagnosis.  CMS cites the cost of privileging radiologists and paying radiologist fees for oversight of radiology studies that are limited to services that are integral to surgical procedure.

The proposed revision would keep the governing body of the ASC responsible for determining if there are any procedures being performed at the ASC, which would require review by a radiologist.  The surgeon performing the procedure would be expected to be privileged and trained the use of imaging as an integral part of the procedure.  However, the use of radiology in connection with surgical procedures does not require the services of a radiologist in most cases.

The revised requirements would permit supervision of radiologic services used in an ASC by a doctor of medicine or osteopathy who is not a radiologist but is a general member of the ASC’s medical staff.  CMS welcomes comments on these proposed regulations.

The Ruder Ware Health Care Industry Focus Group has done a great deal of work structuring Ambulatory Surgery Centers to comply with regulatory requirements.  Please feel free to contact us with any questions regarding the structure or operation of your Ambulatory Surgery Center.

Anesthesia Company Model Advisory Opinion 12-06

Monday, February 11th, 2013

Anesthesia Company Models and Advisory Opinion 12-06

Anesthesia Advisory OpinionAs previously reported on this blog, the Department of Health and Human Services issued advisory opinion 12-06 in June 2012.  This advisory opinion has an impact on many relationships between physician groups, ambulatory surgery centers and providers of anesthesia services.

Generally, the advisory opinion addressed the permissibility of the “company model.”  Under the company model, a physician group who provides surgical services will establish a separate company and provide ownership interest to an anesthesia group.  This structure is created in order for the surgery group to take advantage of some of the revenues from anesthesia services.  The jointly held entity is the billing provider for the anesthesia component of the care.

Advisory opinion 12-06 addressed the company model and found that such a model was potentially a violation of the Medicare Anti-Kickback Statute.  However, the advisory opinion did not go so far as to say that all anesthesia models were impermissible.  Each circumstance must be looked at under its specific facts.  It is often possible to structure these arrangements to take advantage of an Anti-Kickback Statute Safe Harbor or to otherwise minimize the risk to an acceptable level.

There has been a lot of talk in the industry following the release of advisory opinion 12-06.  Many sources are saying that this advisory opinion completely abolished the ability of a surgery group to be involved in anesthesia service revenues.  It is important that providers have a clear understanding of the true implications of advisory opinion 12-06 and the structures that are still permissible without creating unacceptable risk under the Anti-Kickback Statute.

Ruder Ware health care has advised physician practices and anesthesia groups regarding the structuring of permissible arrangements.  We have also represented providers and payors with respect to other types of anesthesia billing and contract matters.  If you have questions regarding advisory opinion 12-06, or any other legal issue pertaining to health care law, please contact us through the contact information on this blog.

2013 Ambulatory Surgery Center Rates Proposes By CMS

Tuesday, July 17th, 2012

CMS Increases Ambulatory Surgery Center Rates, Adds 16 New Procedures for 2013

Ambulatory surgery centers will receive an across-the-board 1.3% rate increase under the 2013 propose Medicare ASC rates. The proposed rate adjustments were released by the Center for Medicare and Medicaid services on July 12, 2012.

CMS has also proposed the addition of 16 new procedures to the list of procedures that are payable in an ambulatory surgery center beginning January 1, 2013.

View the proposed rate changes on the CMS site.  Ambulatory Surgery Center Rates 2013

Ambulatory Surgery Centers – ASC Safe Harbor Compliance

Tuesday, January 17th, 2012

Ambulatory Surgery Center – Anti-kickback Issues and Safe Harbor Regulation Compliance

More and more procedures are being performed in Ambulatory Surgical Centers. The CMS has recently expanded the procedures that it considers to be safely performed in an ASC. Clearly, the trend is to move many procedures to an outpatient facility unless the health care needs of the patient clearly require an inpatient presence. One of the primary sources of capital for these new ASC ventures is the physicians who are involved in performing procedures in the ASC or sending business to the ASC.

From a purely business point of view, it makes sense to have investors who have a direct financial interest in seeing that the business succeeds. However, from the point of view of the party paying for the care, this same financial interest can lead to an increased and arguably unnecessary levels of procedures performed in the facility.  For this reason, the Medicare and Medicaid program, and many states, have enacted the Anti-kickback Statutes and other anti-referral laws that prohibit, or at least limit, the financial interests that a referring provider can have with an organization where there is any control over the referral flow to that entity.

 Anti-Kickback Statute Prohibition

The Federal Anti-Kickback Statute proscribes the offering, payment, solicitation or receipt of any remuneration in exchange for a patient referral or referral of other business for which payment may be made by any Federal health care program. Violations of the Anti-Kickback Statute is a federal felony and can result in substantial prison time and criminal monetary penalties. Violation of the Anti-Kickback Statute can also serve as a basis for imposition of Civil Monetary Penalties. Enforcement of the Federal Anti-kickback Statute has been on the rise since the mid-1980s. Today, the federal government has made health care fraud one of its top priorities. We are hearing about new prosecutions on an almost daily basis as the government ramps up its enforcement through the creation of the HEAT program.

ASC Ownership and the Federal Anti-Kickback Statute

When we look at a typical Ambulatory Surgical Center venture, the primary concern is when the physicians (or hospital) who make referrals to the entity and provide services in the entity receive remuneration from the entity. This normally will involve remuneration in the form of a return on an investment interest. We are not concerned with the reimbursement applicable to the physician’s personally performed service.  What raises the issue is the physician receiving a portion of the technical component related to the use of the Ambulatory Surgery Center where the physician is in the position to make or influence referrals.  The referring physician may purchase an ownership or investment interest in the company that is set up to operate the ASC. The ASC can be set up with capital contributions from a number of physicians or it may involve a hospital sponsored ASC that seeks capital investment from physicians.

 Regardless of the exact structure, the Anti-kickback Statute will come into play to govern the structure and ongoing operation of the ASC. The ASC venture must be structured from the start to comply with the Anti-Kickback Statute. It must also be monitored on an ongoing basis to assure that it does not fall out of compliance with the Anti-Kickback Statute.

 ASC Safe Harbors – The Four ASC Types Qualifying For Safe Harbor Protection

 The ASC Safe Harbor regulations identify four types of Ambulatory surgery center structures that can meet safe harbor protection.  These four types of ASCs include Surgeon-Owned ASCs, Single Specialty ASCs, Multi-Specialty ASCs and Hospital/Physician ASCs.  Each category has different requirements that must be met in addition to the threshold requirements identified above that are applicable to all ASCs to meet the safe harbor.

  • Surgeon-Owned ASCs

 Owners in a surgeon owned ASC can only include general surgeons or surgeons in the same surgical specialty.  The surgeons must be in a position to make referrals to the ASC and to perform surgical procedures in the ASC on the patients that they refer.  Each surgeon owner must meet a source of income test for the previous fiscal year or 12 month period.  Each surgeon must derive at least one-third of their total medical practice income from performing surgical procedures that require an ASC or Hospital surgical setting.  This does not require all of these procedures to be performed in the ASC in which they are an investor.  However, when the surgeons annual revenues are calculated at least one-third of the physicians medical practice revenues from all sources must be derived from the surgeon’s performance of procedures that are listed as Medicare covered services in an ASC.  The surgical services can be performed in an ASC or in a hospital outpatient department and are not limited to the procedures actually performed in the surgeon owned ASC.

  • Single-Specialty ASC

This safe harbor permits physicians within the same specialty, whether or not they are surgeons, to invest in an ASC to which they refer their patients and perform surgical procedures on their patients in the ASC.  Group practices composed of a single specialty may also own and refer to their own ASC.

 Multi-Specialty ASCs

This safe harbor permits physicians who are in a variety of specialties to form an ASC and make referrals to the ASC.  Physician investors in multi-specialty ASCs must meet the one-third practice revenue test described above in relation to surgeon owned ASCs.  However, unlike surgeon-owned ASCs, physicians in multi-specialty ASCs must actually perform one-third of their ASC procedures in the ASC in which they hold an investment interest.  This has become referred to as the “one-third/one-third” test.  The reasoning behind this requirement is that in these types of ASCs, the physicians are actually using the ASC as an extension of their medical office and this does not create significant incentives to generate referral revenues for other investors.  Group practices composed exclusively of physicians who meet the one-third/one-third test may also invest in multi-specialty ASCs.

  • Hospital/Physician ASC

Under this safe harbor, at least one hospital must be an investor in the Ambulatory Surgery Center.  The remainder of the investors must be physicians (or group practices) who meet the requirements for a surgeon-owned ASC. There are a number of additional requirements that must be met by physician/hospital ASCs.

Hospital Physician Owned ASC Safe Harbor Provisions

In a previous post, I discuss the requirements for a Hospital/Physician Owned Ambulatory Surgery Center to meet the ASC safe harbor requirements. Under the Hospital/Physician ASC safe harbor, at least one hospital must be an investor in the Ambulatory Surgery Center.  The remainder of the investors must be physicians (or group practices) who meet the requirements for a surgeon-owned ASC. There are some additional requirements that must be met by physician/hospital ASCs.

The ASC may not use an operating room, recovery room, or other space of the hospital unless it is properly leased from the hospital to the ASC under a lease agreement that meets the requirements of the safe harbor for space rental.  Likewise, any equipment provider by the hospital or services provided by the hospital must be pursuant to an agreement that complies with the equipment rental and/or services safe harbor provisions.

The hospital cannot be in a position to make or influence referrals to the ASC.  This excludes physicians who are employees of the hospital from becoming investors in the Ambulatory Surgery Center.  The hospital is also prohibited from including costs associated with the ASC in its Medicare cost report.

Summary

             The Anti-kickback Statute must be considered in any ambulatory surgical venture where potential referral sources could potentially receive remuneration of any kind.  The Anti-kickback Statute and safe harbors will have a large influence on the structure of most ASC ventures.  At the same time, the Anti-kickback Statute is not the only legal issue that must be considered when structuring ASCs.  In some cases, the Stark Law may be a consideration.  Even though ASC services are not “designated health services” under Stark, the ACS might provide other types of services that are covered by Stark.  Reimbursement issues may also have an impact on structure.  Where a hospital is involved, tax exempt tax issues will also play a role.

             For more information regarding Ambulatory Surgery Center structure and other health care law issues, contact John Fisher in the Ruder Ware Health Care Industry Focus Group.

Outpatient Surgery Article On Using A Safe Surgery Checklist

Tuesday, December 20th, 2011

Use if Safe Surgery Checklist – Implementing Safe Surgery Checklist

As discussed in previous posts, ASCs and hospital outpatient departments must begin using a Safe Surgery Checklist by January 1, 2012.  Certification will need to be made that the checklist was used throughout 2012.  The regulations contain little detail on what it actually means to “use” a Safe Surgery Checklist.  I have seen a variety of opinions on this issue ranging from simply posting it in the operating room through documenting each checklist item in the medical chart.

A relatively recent article in Outpatient Surgery online magazine may provide some level of guidance for providers who are struggling for an answer on the level of “use” that is required.  Check out the article on Safe Surgery Checklist integration

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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