Rewards Exception to Beneficiary Inducement CMPL

Rewards Exception to Beneficiary Inducement CMPL

The Office of the Inspector General of the US Department of Health and Human Services recently passed a regulation providing an exception to certain prohibitions under the Civil Monetary Penalties Law (CMPL). This exception allows pharmacies and other healthcare providers to offer certain access incentives or remunerations to Medicare beneficiaries that had previously been prohibited, but only if those incentives meet specific qualifications.

What Is the CMPL?

The CMPL allows the Office of the Inspector General (OIG) to collect civil monetary penalties for a variety of reasons, including violations of the Anti-Kickback Statute (AKS) and other laws. This law essentially prohibits pharmacies, physicians, hospitals, and other organizations involved in healthcare from offering remuneration for services covered by Medicare or state-run healthcare programs that would influence a beneficiary’s choice of practitioners, providers, etc.

In other words, if offering an incentive or reward for seeking or accepting certain healthcare services would cause a patient covered by Medicare to seek out a specific physician (like the one offering the incentive), that would be subject to a civil monetary penalty (CMP).

The Exception

The exception recently introduced to the CMPL offers a few safe harbors for remuneration, but only if it meets certain criteria. These are:

  • The incentive or remuneration would not influence the beneficiary’s choice of doctors, physicians, etc.
  • The remuneration or incentive must have a low risk of harm to the beneficiary, i.e. it should not encourage them to seek care they do not need or drive up healthcare (Medicare) costs.
  • The incentive must remove socioeconomic, geographic, mobility, educational, or other barriers that would otherwise impede their seeking out needed care.

For instance, an example offered by the OIG involves providing child care for beneficiaries attending smoking cessations programs. This would remove a socioeconomic barrier—the cost of child care—that might otherwise prohibit the beneficiary from seeking these services that would likely benefit his or her health (i.e. cessation of smoking). On the other hand, if they were offering movie tickets as a reward, that would in no way remove a barrier to seeking care.

Compliance

The Retailer Rewards exception can provide numerous opportunities to healthcare providers to assist their patients that they might not have had otherwise. However, measures must be properly implemented to ensure full compliance with healthcare law. An experienced health law attorney can help with that process.

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