§ 43-1B-4 - Prohibited actions; civil penalties; grounds for disciplinary action - Georgia Statutes

O.C.G.A. 43-1B-4 (2010)
43-1B-4. Prohibited actions; civil penalties; grounds for disciplinary action

Except as provided in this Code section:

(1) A health care provider may not refer a patient for the provision of designated health services to an entity in which the health care provider has an investment interest. This prohibition includes any consideration paid as compensation or in any manner which is a product of, or incident to, or in any other way related to any membership, proprietary interest, or co-ownership with an individual, group, or organization to whom patients, clients, or customers are referred or to any employer-employee or independent contractor relationship including, without limitation, those that may occur in a limited partnership, profit-sharing arrangement, or other similar arrangement with any person licensed under this title to whom these patients are referred;

(2) A board shall encourage the use by licensees of the declaratory statement procedure to determine the applicability of this Code section or any rule adopted pursuant to this Code section as it applies solely to the licensee. The board shall determine the name of any entity in which a health care provider investment interest has been approved pursuant to this Code section and the board shall adopt rules providing for periodic quality assurance and utilization review of such entities;

(3) No claim for payment may be presented by a health care provider or an entity to any individual, third-party payor, or other entity for a service furnished pursuant to a referral prohibited under this Code section, and, further, a third-party payor may request annually and receive from the health care provider a copy of the disclosure form provided for in subsection (a) of Code Section 43-1B-5;

(4) If the health care provider or entity collects any amount that was billed in violation of this Code section, the health care provider or entity shall refund such amount on a timely basis to the payor or individual, whichever is applicable;

(5) Any person who presents or causes to be presented a bill or a claim for service that such person knows or should know is for a service for which payment may not be made under paragraph (3) of this Code section and for which a refund has not been made under paragraph (4) of this Code section shall be subject to a civil penalty of not more than $15,000.00 for each such service;

(6) Any health care provider or other entity that enters into an arrangement or scheme, such as a cross-referral arrangement, which the health care provider or entity knows or should know has a principal purpose of assuring referrals by the health care provider to a particular entity which, if the health care provider directly made referrals to such entity, would be in violation of this Code section shall be subject to a civil penalty of not more than $50,000.00 for each such circumvention arrangement or scheme;

(7) Any health care provider or entity that divides fees or agrees to divide fees received for a designated health service with any health care provider or entity solely for referring a patient shall be subject to a civil penalty of not more than $15,000.00 for each such service. The board shall develop rules regarding the prohibition of fee division and charging of fees solely for referral of a patient; and

(8) A violation of this Code section by a health care provider shall constitute grounds for disciplinary action to be taken by the health care provider's respective board, including the potential for license revocation.