PENNSYLVANIA - REFERRALS

I. CONSULTING PHYSICIANS FROM ANOTHER STATE

1. May a physician request a consultation from a physician licensed in another State?

Yes. A person authorized to practice medicine or surgery or osteopathy without restriction by any other state may, upon request by a Pennsylvania-licensed medical doctor, provide consultation regarding the treatment of a patient under the care of the medical doctor provided that the consultant works directly with the doctor who is treating the patient and does not him or herself treat the patient or administer care in any form.

63 P.S. § 422.16

2. What are the regulations governing the referral of patients by a physician to health care facilities in which the physician has a financial interest?

A. The Pennsylvania’s Workers’ Compensation Act.

The Pennsylvania’s Workers’ Compensation Act prohibits provider self-referral involving workers’ compensation of patients for a specified list of ancillary health services if the provider has a financial interest with the person or in the entity that receives the referral. Those ancillary health services include:

1. laboratory;

2. physical therapy;

3. rehabilitation;

4. chiropractic,;

5. radiation oncology,

6. psychometric;

7. home infusion therapy;

8. diagnostic imaging; and

9. goods or services.

The penalty for violating the self-referral ban under the Pennsylvania’s Workers’ Compensation Act is non-payment by the workers compensation insurance company for the service.

77 P.S. § 531

B. Referral Standards.

Pennsylvania has also developed regulations that incorporate all present and future Federal regulations under the Anti-kickback Statute and the exceptions to the Federal self-referral law known as the “Stark Law.” (See "Medicare and Medicaid Anti-Kickback Law and Self-Referral Law"). Thus, if a referral is acceptable under the Federal Stark Law, it would be acceptable under State law.

34 PA ADC § 127.301

C. Disclosure.

Pennsylvania requires disclosure to patients where a financial interest exists in the entity or with the person to which a referral is made. More specifically, physicians must, prior to referral of a patient to any facility or entity engaged in providing health-related services, tests, pharmaceuticals, appliances or devices, disclose to the patient any financial interest of the practitioner or ownership by the practitioner in the facility or entity.

In making any referral, a physician may render any recommendations he or she considers appropriate, but must advise the patient of his freedom of choice in the selection of a facility or entity.

A physician who violates Pennsylvania’s disclosure requirement will be liable for a civil monetary penalty of up to $1,000.

35 P.S. § 449.22

Copyright © Kern Augustine Conroy and Schoppmann, P.C. Used with permission.

Updated 2008