A 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