13.1 The Stark Law (Physician Self-Referral)

AHIP Medicare Certification Exam

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1 Introduction

1.1 About the AHIP Medicare Certification Exam 1.2 How to Use This Study Guide

2 Chapter 2: Medicare Program Fundamentals

2.1 What Medicare Is: Program Structure & How Parts A–D Fit Together 2.2 Medicare Part A — Hospital Insurance 2.3 Medicare Part B — Medical Insurance 2.4 Medicare Eligibility Rules (Age 65, Disability, ESRD, ALS)

3 Chapter 3: Medicare Enrollment Periods

3.1 Initial Enrollment Period (IEP) 3.2 Annual Enrollment Period (AEP): October 15 – December 7 3.3 Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31 3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events 3.5 Late Enrollment Penalties (Part A, Part B, Part D)

4 Chapter 4: Medigap & Coordination of Coverage

4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights 4.2 Dual Eligibility & Medicare Savings Programs 4.3 How Original Medicare, MA, Part D & Medigap Interact

5 Chapter 5: Medicare Advantage Plan Types

5.1 Medicare Advantage (Part C) Overview: How MA Differs from Original Medicare 5.2 HMO & HMO-POS Plans 5.3 PPO Plans 5.4 PFFS Plans (Private Fee-for-Service) 5.5 MSA Plans (Medicare Medical Savings Accounts) 5.6 Cost Plans & Employer Group Waiver Plans (EGWPs)

6 Chapter 6: Special Needs Plans & MA Plan Design

6.1 Special Needs Plans (SNPs) Overview 6.2 D-SNP — Dual-Eligible Special Needs Plans 6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans 6.4 MA Benefits, MOOP & Supplemental Benefits 6.5 MA Star Ratings & Plan Quality

7 Chapter 7: Part D Structure & the 2026 Redesign

7.1 Part D Overview & Eligibility 7.2 Formularies & Drug Tiers 7.3 The 2026 Part D Benefit Redesign ($2,100 OOP Cap, $615 Max Deductible, Catastrophic Phase) 7.4 Medicare Prescription Payment Plan (Drug-Cost Smoothing)

8 Chapter 8: Part D Costs, Assistance & Appeals

8.1 Low-Income Subsidy (LIS) / Extra Help 8.2 Part D Late Enrollment Penalty & Creditable Coverage 8.3 Coverage Determinations, Exceptions & Appeals

9 Chapter 9: CMS Marketing Rules & Scope of Appointment

9.1 CMS Medicare Communications & Marketing Guidelines (MCMG) Overview 9.2 Scope of Appointment (SOA): the 48-Hour Rule & Exceptions 9.3 Permitted vs. Prohibited Marketing & Sales Activities 9.4 Marketing Events vs. Educational Events

10 Chapter 10: Enrollment & Disclosure Requirements

10.1 The Pre-Enrollment Checklist (PEC) 10.2 Enrollment Procedures & Application Requirements 10.3 Call Recording & Third-Party Marketing Organization (TPMO) Disclaimers 10.4 Agent & Broker Compensation Rules

11 Chapter 11: Marketing Conduct & Oversight

11.1 Cross-Selling Restrictions & Nominal Gift Value Rules 11.2 Marketing to Vulnerable Populations & Non-Discrimination in Sales 11.3 Website, Social Media & Advertising Compliance 11.4 Complaint Tracking Module (CTM) & Agent Oversight

12 Chapter 12: Understanding Fraud, Waste & Abuse

12.1 Defining Fraud, Waste & Abuse (and the Difference Between Them) 12.2 The False Claims Act 12.3 The Anti-Kickback Statute

13 Chapter 13: Compliance Laws & Screening

13.1 The Stark Law (Physician Self-Referral) 13.2 HIPAA Privacy & Security Basics 13.3 The OIG Exclusion List & Sanctioned-Provider Screening

14 Chapter 14: Reporting, Compliance Programs & Consequences

14.1 Detecting & Reporting FWA 14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training 14.3 Consequences & Corrective Action Plans

13.1 The Stark Law (Physician Self-Referral)

Key Takeaways Explain This Topic AI

The Stark Law prohibits a physician from referring Medicare patients for Designated Health Services (DHS) to an entity with which the physician or an immediate family member has a financial relationship, unless an exception applies.

Stark is a strict-liability civil statute — no intent to defraud must be proven, which is the key difference from the Anti-Kickback Statute.

Base civil penalties run about $15,000 per prohibited service (inflation-adjusted to roughly $31,670) and about $100,000 per circumvention scheme (inflation-adjusted to roughly $211,146).

Common exceptions include in-office ancillary services, bona fide employment, personal service arrangements, and fair-market-value space or equipment rentals.

Stark applies only to physician self-referrals for DHS billed to Medicare — not to referrals by non-physicians or referrals unrelated to the DHS list.

Last updated: July 2026

The Stark Law (Physician Self-Referral)
Why This Topic Matters

Module 5 (Fraud, Waste & Abuse + General Compliance) carries 20% of the AHIP final, and the Stark Law is one of the three federal fraud statutes the exam expects you to distinguish cold — alongside the False Claims Act (FCA) and the Anti-Kickback Statute (AKS) , both covered in Chapter 12. AHIP loves to build a single question stem describing a physician-ownership scenario and then offer four answer choices that swap in the wrong statute. If you cannot instantly separate Stark from AKS, you will burn time (or points) even in an open-book exam, because the rules sound similar on the surface but differ in one legally critical way: intent .

Core Terms and Rules

The Stark Law (formally the Physician Self-Referral Law , codified at 42 U.S.C. § 1395nn) prohibits a physician from referring Medicare patients for certain Designated Health Services (DHS) to an entity with which the physician — or an immediate family member — has a financial relationship , unless the arrangement fits a specific exception. A "financial relationship" under Stark means either:

An ownership or investment interest (stock, partnership share, or similar equity), or

A compensation arrangement (any arrangement involving remuneration between the physician and the entity, direct or indirect).

Designated Health Services is a defined, closed list. The exam does not expect you to memorize every line, but recognize the category names:

DHS Category Example
Clinical laboratory services Bloodwork sent to a lab the physician co-owns
Physical therapy, occupational therapy, speech-language pathology In-house PT suite
Radiology and imaging (including MRI, CT, ultrasound) Physician-owned imaging center
Radiation therapy services Oncology radiation equipment
Durable medical equipment (DME) and supplies Wheelchairs, oxygen equipment
Parenteral and enteral nutrients, equipment, and supplies Home nutrition therapy
Prosthetics, orthotics, and prosthetic devices Braces, artificial limbs
Home health services Home health agency the physician owns
Outpatient prescription drugs Physician-dispensed medications
Inpatient and outpatient hospital services Hospital admissions and procedures
The Critical Distinguishing Feature: Strict Liability

This is the single most tested contrast on the exam: Stark Law is a strict-liability statute. A violation exists the moment a prohibited financial relationship and a prohibited referral both exist — CMS does not need to prove the physician intended to profit improperly or knew the arrangement was illegal. This is the opposite of the Anti-Kickback Statute, which is a criminal statute requiring proof of intent to induce referrals.

Feature Stark Law Anti-Kickback Statute
Who it restricts Physicians only (self-referral) Anyone (physicians, agents, suppliers, plans)
Intent required? No — strict liability Yes — knowing and willful intent
Penalty type Civil only Criminal AND civil

What triggers it Referral for DHS + financial relationship Payment/receipt of anything of value tied to referrals

Exceptions Agents Should Recognize

Because Stark is strict liability, the exceptions do the real legal work — an arrangement that fits an exception is not a violation at all. The most frequently tested exceptions include:

In-office ancillary services exception — allows a physician group practice to provide DHS (like basic imaging or lab work) within the same building, under specific supervision and billing conditions.

Bona fide employment relationship — a hospital may employ a physician and pay a salary, provided compensation is fair market value and not tied to referral volume.

Personal service arrangements — a written, signed agreement covering at least a year, with fair-market-value compensation set in advance.

Space and equipment rental — rent must be fair market value, set in advance, and not based on referral volume.

Physician recruitment — hospitals may offer limited recruitment incentives to bring physicians into underserved areas.

Ownership in publicly traded securities or mutual funds — owning shares of a large, publicly traded health system through a mutual fund does not create a prohibited financial relationship.

Enforcement and Penalties

Stark violations carry only civil penalties — never criminal charges, which is another common exam trap (test-takers sometimes assume any "fraud law" carries jail time). Penalty exposure (base statutory amounts, adjusted annually for inflation) includes:

Denial of payment for the improperly referred DHS claims, plus a refund obligation for amounts already collected.

Civil monetary penalties of roughly $15,000 per service (inflation-adjusted to roughly $31,670 per service as of 2025) for knowingly submitting a claim the person knows or should know is for a service furnished under a prohibited referral.

Penalties of roughly $100,000 per scheme (inflation-adjusted to roughly $211,146) for arrangements or schemes intended to circumvent the law.

Possible exclusion from federal health care programs for a pattern of violations (see Section 13.3).

A provider that discovers a Stark violation can self-report through CMS's Self-Referral Disclosure Protocol (SRDP) to negotiate a reduced settlement rather than face full enforcement — a fact occasionally tested as "what should a provider do upon discovering a violation."

Exam Scenario

A cardiologist owns 40% of a freestanding imaging center and refers her Medicare patients there for echocardiograms, billing Medicare for the studies. No exception applies. This is a textbook Stark violation: DHS (radiology/imaging) + a financial relationship (ownership interest) + a referral from that physician, with no exception in play. Because Stark is strict liability, it does not matter whether she believed the arrangement was legal or that the imaging was medically necessary — the referral itself is prohibited, and claims submitted for it can also trigger False Claims Act liability once billed to Medicare.

Key Takeaways

The Stark Law bans physician referrals for Designated Health Services to an entity where the physician (or immediate family) has a financial relationship, absent an exception.

Stark is strict liability — no intent to defraud is required, unlike the Anti-Kickback Statute.

Penalties are civil only : refund obligations, per-service penalties ( $15,000 base/ $31,670 inflation-adjusted), and per-scheme penalties ( $100,000 base/ $211,146 inflation-adjusted).

Key exceptions include in-office ancillary services, bona fide employment, personal service arrangements, and fair-market-value space/equipment rentals.

Stark-violating claims submitted to Medicare can also create separate False Claims Act exposure.