Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny

Christopher BeckhamSenior Manager, PYA

R. Ross Burris IIIShareholder, Polsinelli PC

Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny

2016 AHLA Physicians and Hospital Law Institute, Austin, TX

Prepared for AHLA Physicians and Hospital Law Institute

2016 | Austin, TX

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Program Agenda

1

2

3

Trends and Forces Driving Affiliation ActivityExamination of Recent Cases

Discussion of Recent OIG Fraud Alerts

Best Practices for Providers and Provider Organizations

4

Trends and Forces Driving Affiliation Activity

• Forces Driving Affiliation• Triple Aim• Types of Affiliation• Regulatory Considerations

Section 1


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▪ Decreasing Medicare reimbursement▪ Business complexities

▪ Insurers that are dominant in markets may dictate rates▪ Healthcare reform

▪ Pay for performance▪ Bundled payments▪ ACOs

▪ Overhead and cost of doing business▪ High malpractice insurance premiums▪ Pressure to adopt expensive electronic health records (EHR)

▪ Practice demographics – aging partners/new partners▪ Medical students graduating with large debt often prefer

employment▪ Market Factors

Forces Driving Affiliation


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Alignment – the “Triple Aim”


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Bundled Payments

Partial Capitation

Global Payment

Fee forService

Shared Savings

Reactive Focused Predictive

Visitor

Symptomatic

Acute Needs

Services & Supplies

Unit-Based

No Financial Risk

Patient

Episode

Most Common Conditions

Packaged Treatments

Efficiency-Based

Partial Financial Risk

Person

Overall Health

Community Health Characteristics

Manage Well Being

Outcome-Based

Full Financial Risk

Delivery System Reform


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Shifting from Volume to Value

As Figure 1 [above] illustrates, healthcare leaders must gauge the speed at which this transition will occur in their markets. Leaders need both a strategy to ensure their organization’s survival during this transition period and a strategy to change the provider culture to match the requirements of value-based payments.

The switch from volume- to value-based payments is occurring…but in market-specific ways and at different speeds.


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Value Creation

Quality Efficiency “Value”

“The old ways we did things – appoint medical directors, enter into co-management agreements or joint ventures – now they’re just small pieces of the big picture of creating value. They may still exist, but they’re inefficient.” – Alan S. Kaplan, MD, MMM

The CMS Definition of Value


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New Programs Impacting Revenue

▪Hospital Readmission▪DRG Modifier▪HAC Reduction▪Hospital Value-Based

Purchasing▪Chronic Care Management

Fees

▪EHR Incentives▪Medicare ACOs▪PQRS▪Value-Based Payment

Modifier▪CAHPS▪Physician Compare


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Healthcare Reform Is Here to Stay

“Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018.”

“Our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.”

Source: HHS Secretary Sylvia Burwell (January 30, 2015)


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Physician Practice OwnershipMGMA Survey Respondents

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

31%29%

44%

52%55%

53% 52%

60%57%

85%

61% 63%

49%

42%38%

42%39%

34%31%

14%

Hospital/IDS Owned Physician Owned

Source: MGMA Cost Survey Respondents, 2006-2015.

14 Years Ago (2000)

MGMA

AMGA

76% 21%

54% 39%


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Hospital Employment of PhysiciansSurvey Results Suggest Employment Will Remain

Does your hospital/system plan to employ a greater percentage of physicians in the next 12-36 months?

Percentage of Hospitals (82%) and Health Systems (80%) reporting employment as an alignment mechanism.

Sources: HealthLeaders Intelligence Report, September 2013 and September 2014

80%70%

30%

Yes No


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2005 (n=105)

2006 (n=99)

2007 (n=97)

2008* (n=83)

2009 (n=242)

2010 (n=189)

2011 (n=181)

2012 (n=195)

2013 (n=176)

2014 (n=158)

$-

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

$67,901

$190,626

$325,276

$193,316

Trends in Net Loss per FTE PhysicianHospital-Owned Multispecialty Practices

1998 Loss per Physician = $83,000

Source: MGMA Cost Survey, 2006 – 2015.Note: For 2008, Net income, practices without financial support were used to provide a more accurate data point.


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Affiliation Considerations

▪Physician/hospital coordinated care leads to lower costs, higher quality

▪Physicians concentrating on service can improve quality

▪Better information sharing among providers and patients

▪Reduced contracting costs▪ Increased visibility with

insurers▪Economies of scale▪Eliminate duplicative

services

▪ Degree of Desired Autonomy

▪ Degree of Business Risk ▪ Volatility of

Compensation/Revenues▪ Demographics▪ Market Factors

Potential Efficiencies Factors Impacting Model


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Alignment Changing: Over Time

Hospital/Physician Employment

Trending

Private Practice/ Hospital Employed

Physicians

Influx of Acquisitions of Private Practices

Focus Begins Shifting from Volume to Quality

Quality-Based Reimbursement Initiatives Begin

Hospitals Implement Metrics to Align with Physicians on

Quality Goals

TIME


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Affiliation Options

Independent Practice

Office Sharing

Partnerships (PS)

Limited Liability Company (LLC)

Professional Corporation

Independent Practice

Association

Group Practice Without Walls

Hospital Services

Agreement

Hospital-Owned Physician Practice

Hospital Employment

Less More


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Affiliation Models1 Service Line Co-Management Arrangement

▪ Hospital and physician group enter into a service line co-management arrangement for physician group (alone or in conjunction with other physician practices and/or the hospital) to manage a hospital-based service line

▪ Physician group continues to exist and provides services consistent with historical practice

2 Acquisition PSA ("Synthetic Affiliation") ▪ Hospital acquires assets/certain employees of physician group ▪ Can convert practice locations to provider-based status▪ Physician group maintains itself as a separate legal entity and

contracts with the hospital under a PSA to provide professional medical services (and potentially management, billing, and medical director services when needed)

3 Acquisition Employment▪ Hospital acquires assets of physician group and employs physicians


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Affiliation Models4 Clinically Integrated Network (CIN)

▪ Health network utilizing proven protocols and measures to improve patient care

▪ Decrease cost and demonstrate value to the market

5 Independent Physician Associations (IPA)▪ Group of independent physicians to execute single contract to provide

services to managed care or healthcare delivery organizations▪ Leveraging the scale and collective strength of member physicians

6 Physician-Hospital Organization (PHO)▪ Overseeing affiliation of physicians and hospitals into health delivery

networks▪ Collecting, analyzing, and disseminating information▪ Contracting with managed care organizations with joint risk sharing


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New Bundled Payment – Incoming Models

Who?(Mandatory)

788 Hospitals in the chosen 67 Metropolitan Statistical Areas

What? Perform on 3 quality measures Perform lower extremity joint replacement DRGs at set

target price or less Gainsharing. Alternative Payment Models.

When? CJR takes place April 1, 2016 – December 31, 2020

Why? Increase quality while decreasing cost

Comprehensive Care for Joint Replacement (CJR)


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Applicable Healthcare Laws

▪ Federal Physician Self-Referral Law, aka “Stark” & Federal Anti-Kickback Statute

▪ Establish requirements for healthcare transactions which include:

▪ Fair market value

▪ Not based on volume or value of referrals or other business generated between the parties

▪ Commercial reasonableness

www.aicpa.org/fvs


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Regulatory Requirements

TIME

1863False Claims Act

1972Anti-Kickback Statute

1992Stark Law Phase I

2015 $712M

Largest Fraudulent Billing Case to Date

2007Stark Law Phase III

2015OIG Litigation Team Formed

1993Stark Law Phase II

1977Origins of Exclusion

Statute

Changes Over Time


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2016 Medicare Physician Fee Schedule Final Rule:

Over 100 pages of the rule are dedicated to Stark Law changes – including an acknowledgement that Stark Law may actually impede hospital-physician collaboration.

Regulatory RequirementsStark Law Changes


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Stark Law Moving ForwardRegulatory Requirements

▪Exceptions for “remuneration” for recruitment of “non-physician practitioners”

▪ Implementation of “take into account” terminology ▪Favorable changes in required documentation for

agreements▪Clarification of term requirements▪Extension of “holdover periods”▪Exceptions for “timeshare leasing”▪Physician-owned hospital clarification regarding ownership

levels and availability of ownership information to patients


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▪ June 30, 2015, OIG announced a new “litigation team.”

▪ The litigation team will focus on pursuing civil -based monetary penalties and applying the exclusionary principle.

▪ The goal of the OIG in forming this new team is not only to pursue penalties from those in violation, but also to create publicity surrounding the cases.

▪ It is anticipated that this generation of public interest will lead to voluntary reporting for those avoiding the wrath of the DOJ.

New Litigation TeamRegulatory Requirements


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Regulatory Requirements

▪ Regulators are “cracking down” and it will continue…

▪ Recent Headlines:▪ “New Jersey Doctor Sentenced for

Taking Bribes in Test-Referrals Scheme with New Jersey Clinical Lab”

▪ “Former President of Houston Hospital, Son and Co-Conspirator Sentenced in $158 Million Medicare Fraud Scheme”

▪ “New York Pharmacist Sentenced for Multimillion-Dollar Medicare/Medicaid Fraud Scheme”

Source: IRS

More to Come


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▪Fair market value considerations for compensation agreements:▪ Impact of value-based payments?▪ Bonuses for population health – care-coordination efforts

▪Ensure that provider coordination is well structured, particularly for arrangements like clinically integrated networks▪ Vast regulatory requirements▪ Significant amount of due diligence is required on the front end of such

arrangements

Future ConsiderationsRegulatory Requirements

• Major Affiliation Cases• Recent Settlements and

Noteworthy Decisions• HIPAA Privacy and Security

Examination of Recent Cases

Section 2


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Major Affiliation Cases

▪ Successor Liability for Overpayments▪ United States v. Vernon Home Health, Inc., 21 F.3d 693, 5th Cir.

1994 Antitrust

▪ Federal Trade Commission v. St. Luke's Health System, Ltd. Case No. 1:12-CV-00560-BLW and 1:13-CV-00116-BLW (D. Idaho 2014)

Fraud and Abuse/Physician Compensation▪ U.S. ex rel. Baklid-Kunz v. Halifax Hospital Medical Center, Case

No. 6:09-cv-1002-Orl-31TBS (M.D. Fla. 2014)


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Major Affiliation Cases

Fraud and Abuse/Physician Compensation and Leasing Issues

▪ Intermountain Health Care, Inc., Settlement Agreement (2013) ▪ U.S. ex rel. Osheroff v. Tenet Healthcare, Case No. 09-22253-CIV-

HUCK/O'SULLIVAN (S.D. Fla 2013)

▪ U.S. ex rel. Schubert v. All Children's Health System, Inc., Case No. 8:11-cv-1687-T-27-EAJ (M.D. Fla 2013)


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Settlement Trends

▪Kickback cases still yielding big settlements▪ Novartis AG $390M (kickbacks to specialty pharmacies

for pushing Novartis drugs)▪ Millennium Health $256M (free specimen testing cups)▪ Warner Chilcott $125M (cash payments and expensive

dinners for referring physicians) ▪ Health Diagnostics Laboratories $48.5M (S&H for lab

specimens, waiver of co-pays)▪ Daiichi Sanko $39M (honoraria and meals for referring

physicians)▪ Westchester Medical Center $18.8M (advancing money to

physician practice and forgiving debt)


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Settlement Trends

▪Physician employment and compensation cases▪ Citizens Medical Center paid $21.7M

▪Non-FMV payments to cardiologists ▪Bonus payments to ED MDs based on cardiology

referrals ▪ North Broward Hospital District paid $69.5M

▪Non-FMV comp for nine employed physicians in violation of Stark

▪Complaint alleged that losses on hospital-owned practice was evidence of non-FMV compensation


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Settlement Trends

▪Resolution of DOJ’s ICD investigation ($250M settlement with 457 hospitals)

▪Sandoz Inc., $12.6M (CMP for misrepresenting drugs pricing data)

▪Piedmont Pathology Associates Inc., $500,000 (providing free EMR licenses allegedly for referrals)

▪Regent Management Services $3.2M (alleged swapping arrangement for ambulance transport)

▪Shelby Regional Med. Center's former CFO pled guilty and sentenced to 23 months for falsely certifying compliance with meaningful use


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Settlement Trends▪ 2 Louisiana physicians sentenced for roles in $50M Medicare

fraud scheme ▪ Two physicians and a registered nurse were sentenced for their roles in

a $50 million Medicare fraud scheme, which federal prosecutors said involved multiple companies over the course of more than 10 years.

▪ Ex-hospital CFO, physicians guilty in $580M kickback scheme▪ The ex-CFO of the now-defunct Pacific Hospital in Long Beach, Calif.,

was among those who reached a plea agreement with prosecutors for his involvement in a fraud scheme that generated $580 million in false billings.

▪ Millennium Health inks $256M deal to settle kickback, false claims allegations▪ San Diego-based Millennium Health, formerly Millennium Laboratories,

agreed to pay the federal government $256 million to resolve claims the company violated the False Claims Act and the Anti-Kickback Statute.

Source: Articles from Becker’s Hospital Review, 2015


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Noteworthy Court Decisions

▪First decision addressing ACA’s 60-day rule▪ U.S. ex rel. Kane v. Continuum Health Partners (S.D.N.Y.)

▪ Medicaid HMO has IT glitch that causes large NY hospitals to bill Medicaid FFS (resulting in Medicaid overpayments)

▪ All overpayments were refunded before DOJ intervened (but after DOJ investigation)

▪ Relator ran report identifying 900 claims, of which only 50% were actual overpayments; relator terminated 4 days after emailing report, and files complaint 61 days after email

▪ DOJ investigates for 3.25 years, then intervenes ▪ Court denies motion to dismiss



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Noteworthy Court Decisions

▪U.S. v. Patel - 7th Circuit upholds physician’s AKS conviction, expands definition of “referral” to include home healthcare recertification

▪U.S. ex rel. Boise v. Cephalon Inc. – Breach of corporate integrity agreement actionable under the FCA

▪Amarin Pharma Inc., v. FDA – Truthful non-misleading off-label promotion of drug held not to violate FDCA’s prohibition on misbranding



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HIPAA Privacy and Security

▪Triple – S Management Corp. - $3.5M settlement ▪ Widespread non-compliance including disclosing PHI to third-parties

without permission and using or disclosing more than the min. necessary for mailings

▪Lahey Hospital and Medical Center - $815,000 settlement ▪ Stolen laptop exposed PHI for 599 individuals

▪The University of Washington Medicine - $750,000 settlement▪ PHI of 90,000 individuals exposed after employee downloaded

an email attachment that contained malicious malware▪Cancer Care Group PC - $750,000 settlement

▪ Stolen laptop from car exposed PHI for 55,000 current/former patients

▪St. Elizabeth Medical Center - $218,000 settlement ▪ Use of unsecure internet-based document sharing system,

unsecured PHI on employee’s laptop and USB drive


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HIPAA Privacy and Security

▪Large volume of individuals’ PHI exposed during breaches based on hackers▪ Anthem, Inc. (IN) – cyber attack on unencrypted PHI,

37.5M records impacted▪ Premera Blue Cross (WA) – cyber attack exposed medical,

financial, and claims data for 11M customers ▪ Excellus Health Plan Inc., (NY) – cyber attack allowed

unauthorized access to 10M beneficiaries information ▪ UCLA (CA) – cyber attack on unencrypted data allowed

access to information for 4.5M patients▪ Medical Informatics Engineering (IN) – cyber attack on

EHR provider compromised PHI for 3.9M individuals

• The Yates Memo• OIG Fraud Alerts Related to Affiliation

Discussion of Recent OIG Fraud Alerts

Section 3


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The Yates Memo

▪September 2015 memorandum from Deputy Attorney General Sally Quillian Yates▪ Outlined six steps to strengthen pursuit of individual

corporate wrongdoing▪ Some areas of focus new, while others were affirmation of

prior policy▪ Revision to USAM, particularly in regard to “cooperation

credit”▪True impact is unclear at best

▪ New articulation of old policy?▪ Practical impact of pursuing individuals and ability to

reach civil settlements with entities substantially implicated if DOJ strictly interprets this policy


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OIG Also Focusing on Individuals

▪OIG creates new litigation team to pursue CMP and exclusion cases:▪ Jump in CMP cases from 36 in FY13 to 60 in FY14▪ Stated goal of holding individuals accountable▪ Meant to complement DOJ’s enforcement activities (filling

enforcement gaps) ▪ Potential to spin-off from FCA cases and pursuit of

executives or physicians ▪OIG issues Special Fraud Alert: “Physician

Compensation Arrangements May Result in Significant Liability” ▪ Focus on FMV and bona fide services and MD exposure ▪ Came before North Broward settlements


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OIG Fraud Alert

▪February 8, 2012 – Exercise Caution When Reassigning Their Medicare Payments

▪ Physicians should use caution when selecting entities to reassign their Medicare payments

▪ OIG settlements with eight physicians who submitted false claims from physical medicine companies


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OIG Fraud Alert

▪ June 26, 2014 – Laboratory Payments to Referring Physicians

▪ Addressed blood specimen collection, processing, and packaging.

▪ OIG aware of remuneration to physicians for these activities, directly or indirectly


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OIG Fraud Alert

▪ June 9, 2015 – Physician Compensation Arrangements

▪ Focused on Medical Directorships▪ Ensure that such arrangements reflect fair market value

for bona fide services▪ Recently reached settlements with 12 individual

physicians who entered into questionable arrangements

• OIG FY 2016 Work Plan• Best Practices

Best Practices for Providers and Provider Organizations

Section 4


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HHS OIG Work Plan – FY 2016

1 Medicare oversight of provider-based status.▪ Monitoring the extent to which these facilities meet requirements▪ MedPAC has expressed significant concerns about the financial

incentives of this status

2 Comparison of provider-based and freestanding clinics.▪ Linked to first work plan item.


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▪ Identifying parties open to buying, selling, integrating, etc.▪ Confidentiality and non-solicitation agreements▪ Getting the transaction team together

▪ BOD, Administrators (C-levels), Legal, Compliance, Finance, HR▪ Outside counsel and advisors

▪ Valuations and fair market valuation (FMV) analysis▪ Execution of letter of intent (LOI) or term sheet

▪ Sets forth the structure of the deal (asset or stock), price and payment terms, expected closing date, and other material terms.

▪ Used as the basis of the main transaction agreement (such as the asset purchase agreement).

Planning and Negotiation


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Due Diligence

▪Purpose: obtain information about what is material to the seller’s business and identify items that may need additional attention and analysis.

▪Evaluate the risks of the transaction (search for “red flags”)▪Typical requests include information regarding: Corporate Documents Legal Issues and Govt. Investigations

Accounting and Financial Statements Licensure and Certifications

Assets and Liens Compliance Program and Training

Material Contracts and Payor Agreements Privacy and Security

Real Property – Owned/Leased Employees / Independent Contractors

Intellectual Property Medical Staff

Insurance Environmental


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Transaction Closing

▪Signing and delivery of closing documents▪ Transaction Documents (e.g., Asset Purchase

Agreement)▪ Officer Certificates/Secretary’s Certificates▪ Bond Counsel Opinions▪ Required Consents

▪Payment / Consideration▪Escrows for indemnification


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CHOW/CHOI Notifications

▪Change of Ownership (CHOW) or Change of Information (CHOI) Notifications▪ Medicare/Medicaid▪ Certificate of Need (CON)▪ State Facility Licenses▪ Accreditations▪ CLIA / Laboratory Permits▪ DEA Permits / State-Controlled Substances Permits▪ Pharmacy Licenses▪ Boiler Permits / Air Quality Permits▪ Business Licenses▪ Insurance Coverage


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Licenses/Permits/Certifications

▪ Different licensing agencies have varying definitions of “change of ownership” and notification requirements / timelines (pre- and post-closing). Plan ahead!

▪ Potential Issues: ▪ Verify with the agency regulators that the buyer can operate

under old license until new license is issued. ▪ Verify that the new license will be retroactive to the date of

closing. ▪ Agencies may require surveys or inspections, which can delay

issuance of a new license. Failure to provide proper notices and address provider enrollment

issues can have substantial financial consequences and result in unnecessary risk and liability


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Medicare and Medicaid Enrollment

▪ Is this a Medicare/Medicaid CHOW?▪ Whether to accept assignment:

▪ Under Medicare you can: ▪ (1) file a “change of ownership” and accept assignment of

the provider number/agreement; or ▪ (2) file a new enrollment application and not accept

assignment of the provider number/agreement ▪ Medicaid varies by state. Some states require the buyer to

accept assignment of the selling provider’s Medicaid number.▪ Be cautious of successor liability! Accepting assignment usually

means accepting prior liabilities. Due diligence should assist in uncovering any potential liabilities.


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Medicare and Medicaid Enrollment

▪Transition Issues:▪ Can buyer use seller’s provider number prior to tie-in

issuance? ▪ How will the parties handle reimbursement from payors

during the transition? Usually the transaction documents will provide for a “true-up” process.

▪Potential Enrollment Issues: ▪ Reimbursement gap▪ Survey requirement in some cases▪ Medicare/Medicaid processing times can be lengthy


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▪Determine whether locations will qualify for on-campus or off-campus provider-based status

▪Review CMS provider-based regulations to ensure documents and relationships comply with requirements [42 CFR §413.65]

▪Pay particular attention to management relationships – specific regulations

▪Advertising/publicity is often significant issue▪Provider-based facilities are gaining greater attention from

regulators▪Navigators can help with patient issues

Provider-Based Facilities


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▪Review HIPAA privacy and security policies and procedures with acquired entity and obtain documentation attesting to compliance with such policies and procedures

▪Conduct HIPAA/HITECH training for employees and independent contractors of the acquired entity

▪Obtain Business Associate Agreements, as necessary

▪There may be significant penalties for data breaches or violations of HIPAA/HITECH (not to mention the bad publicity)

Privacy and Security


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▪Determine whether the electronic health records (EHR) systems are compatible and, if not, which system will be used

▪Work with IT team to plan and execute IT system transitions▪Educate acquired entity and its professionals on proper

technology security measures: ▪ Access Controls (e.g., password, encryption)▪ Workstation use (e.g., shielding screens when PHI is

being viewed)▪ Data backups ▪ Use of portable devices with sensitive information (e.g.,

smart phones, tablet computers, laptops, flash drives)

IT Affiliation


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▪ Compliance with Legal Requirements▪ Stark, 42 C.F.R. §411.357(e) ▪ Anti-kickback Statute, 42 CFR 1001.952

▪ “Recent” Guidance – Adv. Opinion 2007-01; Advisory Opinion 2011-01

Hospital/Physician Recruitment


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When to Recruit• Established Community Need

• Medical Staff Shortages as Indicated in a Physician Needs Assessment or Medical Staff Development Plan

When Not To Recruit• Physicians Asking for Incentives

/ Payments

• Surplus of Specific Services

• Fear of Losing Referrals or Looking for Additional Referrals


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▪ Key Practical Aspects:▪ Applies to recruitment of physicians (note: new legislation

impacts non-physician providers)▪ Requires that physician “relocate” (exceptions for physicians

employed full-time by correctional agency, U.S. Departments of Defense or Veterans Affairs, or facilities of the Indian Health Service)

▪ Available to hospitals and rural health clinics▪ Typically 12- 24 months▪ Agreement with physician practice; typically guaranteed by

practice ▪ Only include “incremental costs” ▪ Can include non-compete clause that does not “unreasonably”

restrict ability to practice medicine▪ One Size Does NOT Fit All▪ Document everything with the expectation that it will be reviewed



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Need and FMV

▪Basic elements in all the regulatory safe harbors and exceptions:▪ Be in writing, signed by both parties▪ Not conditioned on physician’s referrals▪ Remuneration is not based on volume or value of actual

or anticipated referrals▪ Physician allowed to establish privileges at other facilities


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Need and FMV

Advisory Opinion No. 01-4▪ Is there documented evidence of objective need for the

physician?▪Does physician have existing stream of referrals within the

service area?▪Are benefits narrowly constructed not to exceed what is

reasonably necessary?▪Do the benefits directly/indirectly benefit other referral

sources?


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Contact Information

CHRISTOPHER T. BECKHAM, MSHASENIOR [email protected]

R. ROSS BURRIS III, [email protected]

PERSHING YOAKLEY & ASSOCIATESMonarch Tower, Suite 700 | 3424 Peachtree Road NE | Atlanta, GA 30326

800.270.9629 | www.pyapc.com

Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny

Healthcare

Transcript of Modern Physician-Hospital Affiliations in an Era of Increased Fraud and Abuse Scrutiny