The treatment of family members falls under General Exclusions from Coverage under Medicare. No payment will be made for items or services for a family member when the charge is from an immediately related provider, any of their associates or their professional corporations.

As part of Stark I in 1989, self-referrals for clinical laboratory services were the first to be barred.   The ban for other designated health services was expanded in 1993 and final modifications to the Stark Law published in 2007 as part of the Social Security Act.

The physician self-referral law also referred to as Stark Law:

  1. Prohibits a physician from making referrals for certain designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies.
  1. Prohibits the entity from presenting or causing to be presented claims to Medicare (or billing another individual, entity, or third party payer) for those referred services.
  1. Establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that do not pose a risk of program or patient abuse.

 

The definition of a family member as related to Stark Law is broad and extends to spouses, parents, children, siblings, step- parents, step- children, step- siblings, children-in-law, siblings-in-law, grandparents, grandchildren, and spouses of grandparents and spouses of grandchildren.

Designated Health Services included in the Stark Law are:

  • Clinical laboratory services
  • Physical therapy services
  • Occupational therapy services
  • Outpatient speech-language pathology services
  • Radiology and certain other imaging services
  • Radiation therapy services and supplies
  • Durable medical equipment and supplies
  • Parenteral and enteral nutrients, equipment, and supplies
  • Prosthetics, orthotics, and prosthetic devices and supplies
  • Home health services.
  • Outpatient prescription drugs.
  • Inpatient and outpatient hospital services

The American Medical Association (AMA) discusses the ethical issues behind self treatment or treatment of a family member. The AMA Code of Medical Ethics states that physicians should not treat themselves or members of their immediate family unless in an emergency setting or for short- term minor problems. According to the AMA Opinion, a family member’s illness may obscure physician judgment and lead to provision of services that are not considered reasonable and necessary or standard of care. Patient autonomy and informed consent may also be at risk. Minors may not feel comfortable refusing care from their parents.

Federal law does not prohibit physicians from self-prescribing or prescribing for friends and family. However, writing prescriptions for controlled substances for family members or themselves is considered inappropriate by the AMA, unless in an emergency situation.