text:
MelaniePhillips.com
Going wherever the evidence leads
The unthinkable prospect
February 7, 2017 February 7, 2017 Melanie
Join me below as I ask why the most passionate opponents of both Brexit and Trump are so adamant that they will both fail. The answer? The consequences of their success are simply unthinkable for these opponents themselves. The transcript follows under the video.
A great deal has been written about the hysterical reaction to President Donald Trump. But what would these over-the-top protesters do if Trump proved to be a success? Would they admit they had been wrong?
A few days ago, I put this to someone in London. He looked at me in absolute horror. The question had simply never occurred to him. "He can't possibly be a success," he said in astonishment. "I agree he may become popular, which would be a nightmare for me. But no way is he not going to fail."
You get a similar reaction amongst many deeply opposed to Brexit. Asked what they'll do if it turns out to be a success they flatly reply that it's simply impossible.
Well, these are truly remarkable powers of prophecy. All the more so since all predictions over Brexit and Trump have so far been proved wrong.
Now of course it's possible that both Brexit and Trump will fail. But why are opponents so categorical they just can't work? It's because for the most hysterical of these opponents, their fundamental political assumptions about universal values, group rights, multiculturalism, the evils of western national identity and so on can brook no deviation whatsoever. No opposition at all.
So for them it's just not possible to think, as I do, that Trump has certain very alarming features and what he says is sometimes indefensible but that he also represents something basically legitimate and even admirable: the deep desire of the people who voted for him to live in a country which they can call home, and that those attacking or undermining their country will be held to account.
No no, say his opponents, Mr Trump's suspension of immigration from certain Muslim-majority countries – deemed by the Obama administration to pose a particular threat to America – was not (as is perfectly obvious to me) to defend national security but an eruption of racism.
Among the most passionate opponents of Britain's exit from the EU, it's just not possible to think there were legitimate and even desirable reasons for voting for Brexit. Such as the people's deep desire for Britain to control its own policies and decisions and for the promotion and defence of Britain's historic national identity.
No no, say its opponents, all those those who voted Brexit were motivated entirely by a racist desire to keep out immigrants. And so on. Trump and his voters and Brexit and its supporters aren't to be allowed one single redeeming virtue.
Of course, it's perfectly legitimate to oppose both Trump and Brexit. But this reaction I'm talking about is clearly unbalanced and disproportionate. For these opponents, reason itself assumes to have been suspended. They are driven entirely by emotion. And there seems to be no evidence at all that can persuade them to think again.
The reason for this, it seems to me, is that their general perspective rests on the world being remade according to their idea of virtue. Hence all who oppose that perspective are innately bad and anything they do or say is therefore bad.
So if those opponents win, as they have now done in both Britain and America, that just can't be allowed to happen and the millions who voted that way must be delegitimised. Otherwise the political and moral personality of those against Brexit and Trump will itself be destroyed. So it's unthinkable that Brexit and Trump won't crash and burn.
But here's the thing. In both Britain and America, something is crashing and burning right now. It's called the democratic left. Both Britain's Labour party and America's Democratic party are in disarray. Caught flat-footed by Brexit and Trump, they have absolutely no idea what do do to regroup. The reason is they have turned people off in droves. And they still don't understand why.
In Britain, thousands of Labour party members are deserting the party. More than 7000 left in a week after its leader, Jeremy Corbyn, ordered his MPs to back the measure to trigger Brexit. Those leaving the party over this are Remainers who are furious that MPs are being ordered to vote for Brexit against Labour's position during the referendum and against the wishes of the majority in many Labour constituencies.
Mr Corbyn did this because he knows that, in the party's traditional working class heartlands, there's been a haemorrhage of Labour voters who were mostly passionately for Brexit. So if the party in Westminster is seen to be defying the will of the people, that haemorrhage will become uncontrollable.
But it's not just the widely criticised leadership of the far-left Jeremy Corbyn. The party is split between metropolitan universalists and lower-class traditionalists wedded to Britain's national identity. The metropolitan universalists run the party. Brexit gave the non-metropolitans the opportunity to vote against a consensus that has disenfranchised them for decades. This is a profound split and Labour will never govern again unless it reconnects with that traditional constituency.
Something similar happened in the US. There people rose up against a political and intellectual elite in favour of someone who spoke directly to their interests and promised to keep his word to them. He has now indicated that he will act against this elite in many ways, including withdrawing presidential patronage and funding. This threatens to cut them off at the knees.
In their desperation, opponents of Brexit and Trump have ramped up the rhetoric of demonisation along with street protests as an alternative form of legitimacy. But the more they resort to these deeply questionable tactics, the more they will reinforce the Brexiteers and Trump voters in their certainty that they got their decision right. And the more they will also persuade more undecided voters that, much as they may dislike Trump and worry about Brexit, the other lot are far worse.
The more hysterical these protesters become, the more they dig their own political graves. And if Britain departs the EU into a confident and optimistic future, and if Trump succeeds in defending America against its enemies outside and in, the democratic left on both sides of the pond will be finished for many years to come.
On the other hand – if Britain's Prime Minister Theresa May screws up Brexit, which is certainly possible, and if President Trump screws up America, which is also perfectly possible, then the rage of those who made this tremendous leap of faith in voting Brexit and Trump will turn very ugly indeed. Because then they really will have nowhere else to go. Democracy will then be in peril and disorder will loom. And that is the great danger of the revolution which has taken place on both sides of the pond.
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text:
Шарлотта «Карли» Джир (; род. , , Коннектикут, США) — американская гребчиха, серебряный призёр летних Олимпийских игр 1984 года в Лос-Анджелесе в одиночке.

Биография
Шарлотта Джир — потомственная спортсменка. Её родная тетка Джулия Джир вместе с мужем Ричардом Дрейссигекером также занимались академической греблей и участвовали в Олимпийских играх. Племянница Джир Ханна Дрейссигекер — биатлонистка, член сборной США по биатлону, участница Зимних Олимпийских игр в Сочи.

Пик карьеры спортсменки пришёлся на домашнюю для неё Олимпиаду-1984, на которой ей удалось стать серебряным призёром. В дальнейшем Шарлотта Джир не смогла бороться за высокие результаты на крупных турнирах.

Ссылки

Гребцы (академическая гребля) США
Гребцы (академическая гребля) на летних Олимпийских играх 1984 года
Серебряные призёры летних Олимпийских игр 1984 года

redpajama_set_name: RedPajamaWikipedia


text:
Q: 550 Error when connecting to FTP server. Only occurs with C# I'm trying to write a program in C# that will FTP into a machine, download some logs, and then delete the logs off of the machine. This process works with a dev FTP server I have to test on my machine but when I try to connect to the production server I want this program to be used on I get a "550 No files found or invalid directory or permission problem" error on the server.
The server will list the directory file for FileZilla, even when using the exact same URI. I have captured the packets with wireshark and the server just cuts off after sending the text "total" to the data port when trying it with C#
Uri uri = new Uri("ftp://username:password@10.205.205.200:21/");
FtpWebRequest ftpWebRequest =  FtpWebRequest)WebRequest.Create(uri.ToString());

ftpWebRequest.Method = WebRequestMethods.Ftp.ListDirectoryDetails;

// Get the response
FtpWebResponse response = (FtpWebResponse)ftpWebRequest.GetResponse();

// Get the stream and reader
Stream responseStream = response.GetResponseStream();
StreamReader reader = new StreamReader(responseStream);

// Close the response
response.Close();

// Get all the results into a list
List<string> results = new List<string>();
results.AddRange(reader.ReadToEnd().Split('\n')); //<---- Web Exception Here

A: Please try it this way:
Uri uri = new Uri("ftp://username:password@10.205.205.200:21/");
FtpWebRequest ftpWebRequest = (FtpWebRequest)WebRequest.Create(uri.ToString());
ftpWebRequest.Method = WebRequestMethods.Ftp.ListDirectoryDetails;

using (FtpWebResponse response = (FtpWebResponse)ftpWebRequest.GetResponse())
using (Stream responseStream = response.GetResponseStream())
using (StreamReader reader = new StreamReader(responseStream))
{
    List<string> results = new List<string>();
    results.AddRange(reader.ReadToEnd().Split('\n'));
}

In general it is safest to use using when dealing with streams or other disposable resources.

redpajama_set_name: RedPajamaStackExchange


text:
Indian Scientists Who Obtained Nobel Prize in Physics
April 23, 2020 In Uncategorized
Recently Indian Boffins who obtained the Nobel prize in Physics were presented together with all the award at the White House . There has been still a lot of press coverage about the scientists. Discussions many content and debates took place.
The local journal presented an article about the scientists. The report said that the former president of the Nobel prize committee Prof Professor Arno reference Hochmuth presented the award to the scientists. He also talked about how many Indian scientists have received the Nobel prize in physics. Most of the names in the list were of Indian origin.
In this essay Prof. Hochmuth cites that he was amazed to understand one of those distinguished physicists in India was among the current laureates. It had been a name. Prof Hochmuth says"a exact prominent scientist at India has won the Nobel prize. It's really a great moment for the country to secure a Nobel prize".
He gives Charge to Also a member of This Academy of Sciences a Famed scientist and Prof G C Gupta for Pulling out this brilliant scientist. The person isn't aware of Prof Gupta's do the job.
Gupta received the honour for his exploration on magnetic monopoles. The exact same had been proposed by him and worked for nearly ten years.
Nevertheless https://music.uchicago.edu/ he was the first scientist to be named, the Nobel prize was not won by him. The Committee didn't award him that the award. He did undergo an appointment among the committee's two mature scientific advisers. He was appointed in 1969.
Guptas also did a while in United States in Physics. So he could not function as an Indian scientist, even in this specific sense. We must ask that's.
Profession is really a field by the cooperation of physicists along with the others from some other areas is important. A powerful tie up together using folks of math, chemistry and computer science, to list several, is critical. This is not likely in the event of physicists from root.
Indian physicists have played with a major part in the specialty of quantum physics. Indian physics has contributed greatly to our understanding of subject and of course quantum procedures. However, it stays a actuality that physics can not be known without the collaboration of people who're very well versed in these disciplines.
But even the boffins that obtained the Nobel prize in Physics through the century came from India. The primary reason for that can be that Indian experts are still represented in leading establishments.
One way outside of the dilemma is always to move forwards and invite physicists to pursue their livelihood in American Academy of Arts and Sciences, American Physical Society, Institute of Physics, leading institutions like the American Institute of Physics and also others. This is a slow procedure which takes a while and energy for you to become acknowledged by academe.
You can find a number of scientists that got the Nobel prize in math. But there were also fewer them and the ones who were recognized had been working in the context for quite some moment; point. Indian physicists who got the Nobel prize in physics also have made lots of donations to society and physics and deserve honor and recognition.
Warning: ./cache is not writable. Make sure you've set the correct relative or absolute path, and that the location is server-writable. in /home/adbuddyi/vanillamoonlagos.com/wp-includes/class-simplepie.php on line 1510

redpajama_set_name: RedPajamaCommonCrawl


A service that runs Internet servers, allowing organizations and individuals to serve content to the Internet.
Google has given me 15GB of storage. Can I host my own website having my own domain?
How can I publish a word document on the same URL but changing content from time to time?
I am a newbie to all this. And am currently planning as well as learning to make a dynamic site.. Can I host site on the free space offered in Google Drive?
How to add several domain names?
How to use a GitHub as a hosting for a small static website?
How does Trello store my information?
May I use Dropbox as hosting for website's static files?
How do I set credit card limits for Amazon EC2?
I just signed-up for Amazon EC2, for a micro instance server. Does anyone know how I can set-up limits on data usage and/or the monthly amount that can be charged to my Credit Card?
imageshack / quick host for webpages?
Is there a chat program where I can own my chat?
We just switched email hosts to GMail Apps, but we already have few GMail accounts. Is there any way to transfer these into the Gmail hosting?
I am trying to find the country of web hosting of a website. Is there any web application online which I can use, or any method to find it?
Is there some online service that gives all the hosts that are served by a given IP address (or eventually the sugared version hostname -> ip -> other names)?


Take on the camo print trend in my flatting and ultra soft seamed peplum top.
Camo print. Seamed detail through the body. Short sleeves. Peplum hem. Stretch. Soft and smooth to the touch fabrication all over.


A Central Valley Congressman may be worrying that the fallout from Donald Trump's policies could land on himself.
Blue State/Red District: What Do the Suburbs Want?
Seven Republican congressional districts in California went for Hillary Clinton in 2016. CA-4 was not one of them but Democrats are hoping to unseat Tom McClintock in November.
This week, in a run-up to the June 5 primary, we are re-highlighting our profiles of seven Republic congressional districts whose flipping would signal a fundamental groundswell against the Trump administration.
In February we rolled out our "Blue State/Red District" series, which found significant voter discontent expressed against Congresspeople representing previously "safe" Republican districts. This week we present updated summaries of our reports.


During the past, Adam Jones said he has been yelled at the entire game while playing at Fenway Park in Boston. However, things changed on Monday said Jones as his treatment by fans at Fenway Park took a disturbing turn.
After the Orioles 5-2 victory, the five-time MLB All-Star claimed he had been called the n-word a few times by fans who also tossed peanuts at him.
He called it different and very unfortunate. He said he heard a number of fans are ejected each night at games and unfortunate that fans need to degrade another person.
He added that he was out playing trying to earn a living for he and his family and will just try to move on and play the game hard.
According to reports, officials from the Red Sox confirmed that a fan had thrown a bag full of peanuts at Jones. Security ejected the fans following that incident.
Officials with the team said they were investigating the number of ejections during Monday's game.
Jones called the fan who threw peanuts at him a coward and disrespectful and expressed hope authorities would hand out a more severe punishment.
Jones said the person should be fined as much as $30,000. Something he said that hurts the person so they will think twice before they say it again.
Jones said that players do not have any idea what objects are being thrown onto the playing field. He wondered out loud what could happen if he had been hit in the eye and had lost ability to play pro baseball.
Earlier in the season, tensions increased between the Red Sox and Orioles after Manny Machado of the Orioles injured Boston second baseman Dustin Pedroia through a hard slide at second forcing the Red Sox player to leave the game.
Later during the same series, Matt Barnes a pitcher for Boston threw at Machado's head, although Barnes claimed that his pitch had accidently got away from him.
Monday night Dylan Bundy the starting pitcher for Baltimore hit Mookie Betts one of Boston's best hitters which led to speculation it could be retaliation.
Jones has talked about race related to baseball in the past. As the protest by Colin Kaepernick of the national anthem were making headlines in the NFL last fall, the Orioles outfielder said a few black players in MLB were apt to emulate the quarterback's protests because baseball remains a white man's sport.


text:
Q: Kendo UI Grid Showing json objects as [object Object] I get json objects as [object Object] in Kendo UI Grid, How can i visualize it or is there any way to show a detail view of a cell in a Kendo grid ?

A: The reason you see [object Object] is because address is of type object and you pass it into your cell which will convert it to a string. And thus the cell is filled with the string representation of object which in this case is [object Object].

Example 1:
function formatAddress(address){
    return address.street + ' ' + address.phone;
}

var grid = $("#grid").kendoGrid({
    dataSource: {
        pageSize: 20,
        data: createRandomData(50)
    },
    pageable: true,
    height: 430,
    columns: [
        { field: "FirstName", title: "First Name", width: "140px" },
        { field: "LastName", title: "Last Name", width: "140px" },
        // `formatAddress` will be called from the global variable scope like eval() usually does
        { field: "Address", template: "#= formatAddress(data) #" }
    ]
}).data("kendoGrid");

Example 2: (MVVM)

<div id="grid" data-role="grid" data-bind="source: gridSource"
     data-columns='[{field:"FirstName",title:"First Name"}, {field:"LastName",title:"Last Name"}, {field:"Address",template:"#= formatAddress(data) #"}]'>
</div>


MATWIJIW, William T., age 90. Beloved husband of Alice (nee Dziat). Dearest father of Bill (Chris), Gary (Kim, deceased) and Karen. Loving grandfather of Kim, Heather Ball (Rory), Stacey Coxon (Dan), Candace and Ashley, and Big Papa of 6. Dear brother of the late Robert L. Retired member of Teamsters Local 407 as a truck driver.
VISITATION TUESDAY, AUGUST 7TH FROM 4-8 AT THE ZABOR FUNERAL HOME, 5680 PEARL RD., PARMA (between Ridge and Snow), Mass of Christian Burial Wednesday at 10am at St. Bridget of Kildare Parish. Entombment, Holy Cross Cemetery.
Offer Condolence for the family of MATWIJIW, William T.
Posted by obits on August 3, 2018 3 Comments on MATWIJIW, William T.
So very sad to hear about your dear father. Through the years at Pleasant Lakes Villa, visiting my mother Irene, he was always so kind and pleasant. His passing breaks my heart. May God comfort your family.


text:
Großschweidnitz () je obec v Horní Lužici v německé spolkové zemi Sasko. Nachází se v zemském okrese Zhořelec poblíž města Löbau a má  obyvatel. Mezi významné památky patří kamenný železniční viadukt dlouhý 150 metrů a vysoký dvacet metrů, který byl postaven mezi lety 1846 až 1848.

Galerie

Odkazy

Reference

Externí odkazy

  Oficiální stránky obce
  Digitales Historisches Ortsverzeichnis von Sachsen

Obce v zemském okrese Zhořelec
Obce v Horní Lužici
Obce v Euroregionu Nisa


We have really enjoyed our visit to the island of Antigua. The weather has been great (a little more wind to cool us off would be nice), the beach in Falmouth is one of the best we've been to and the locals have been absolutely amazing. They are some of the friendliest in the Caribbean. More than the Grenadians? That's pretty hard to beat so I'd have to say that they are tied for now and that's really saying something because the people of Grenada are legendary. Every day we encounter friendly helping people. Sure, most of these people are in service industries and since tourism counts for more than 60% of the country's GDP they really know how to make sure foreigners have a great time. But today, we met a large, local family that tops them all.
Today, being Good Friday, is the beginning of a four day holiday in Antigua. We start the day celebrating the 10th birthday of one of our cruising friends. A small party on the beach under the warm morning sun, surrounded by lots of kids and families, very nice. The day moves on but we don't. While some of the families have to leave, a small group of us remain at the beach into the late afternoon. The kids are having a blast in the water, the grown ups are getting quality socializing time, the sun is warm, the trees are shady. It's a perfect day.
The afternoon passes and the beach is filling up. As I think I mentioned, it's Good Friday and it seems every other family on Antigua decided to spend the day on the beach with us. It's getting crowded but so far everyone's just having a great time. The kids are having so much fun they play right through lunch!
Dinner time arrives and we manage to squeeze a few morsels into them. Then, a local woman from the very large family next to us comes over with a paper plate heaped with pieces of a dark, rich cake dripping white icing.
"Here, have some cake for da kids," she says and leaves the plate at our table. We're stunned. Not only was it very thoughtful of her but the cake is delicious! Not too sweet, not too heavy, not too moist and not too dry. It's perfect. We later learn that the guy who baked it is a well known island chef. As the kids (and adults) are still licking their fingers another woman from the other family comes over and asks if we want some food. She takes our stunned silence as an affirmative and leads us, kids first, over to their table to serve us up some of their local grub. We each get a heaping plate full of food. I'm not sure of everything we got but there was "chop-chop" (a steamed spinach dish), fish, yam, and fungie (pronounced "foon-jee"). Fantastic! The boys even found things that they would eat.
After the meal we sat around and visited with the family who had been so generous. The group was an extended family from all over the island. Some of them were visiting from their homes in the US. Apparently they usually spend Good Friday eating local cuisine with family at someone's home but decided to go to the beach instead this year. Lucky us!
Austin said that the experience was one of the tops for the whole trip. I'd certainly have to agree. Go Antigua!
When you're on the move all the time, it must feel great to be so welcomed and comfortable with the local people. We could sure learn from these congenial folk how to be more welcoming here in Canada.
Any sign of Easter Bunnies?? or their droppings ==== the chocolate kind, that is.
Easter this year was a little fishy. Stay tuned for the blog now that we're back in civilization.


text:
CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B - MEDICARE PROGRAM
PART 411 - EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT
Subpart J - Financial Relationships Between Physicians and Entities Furnishing Designated Health Services
§ 411.357 Exceptions to the referral prohibition related to compensation arrangements.
42 CFR § 411.357 - Exceptions to the referral prohibition related to compensation arrangements.
Link to an amendment published at 85 FR 77656, Dec. 2, 2020.
For purposes of § 411.353, the following compensation arrangements do not constitute a financial relationship:
(a) Rental of office space. Payments for the use of office space made by a lessee to a lessor if the arrangement meets the following requirements:
(1) The lease arrangement is set out in writing, is signed by the parties, and specifies the premises it covers.
(2) The duration of the lease arrangement is at least 1 year. To meet this requirement, if the lease arrangement is terminated with or without cause, the parties may not enter into a new lease arrangement for the same space during the first year of the original lease arrangement.
(3) The space rented or leased does not exceed that which is reasonable and necessary for the legitimate business purposes of the lease arrangement and is used exclusively by the lessee when being used by the lessee (and is not shared with or used by the lessor or any person or entity related to the lessor), except that the lessee may make payments for the use of space consisting of common areas if the payments do not exceed the lessee's pro rata share of expenses for the space based upon the ratio of the space used exclusively by the lessee to the total amount of space (other than common areas) occupied by all persons using the common areas.
(4) The rental charges over the term of the lease arrangement are set in advance and are consistent with fair market value.
(5) The rental charges over the term of the lease arrangement are not determined -
(i) In a manner that takes into account the volume or value of any referrals or other business generated between the parties; or
(ii) Using a formula based on -
(A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed or business generated in the office space; or
(B) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
(6) The lease arrangement would be commercially reasonable even if no referrals were made between the lessee and the lessor.
(7) If the lease arrangement expires after a term of at least 1 year, a holdover lease arrangement immediately following the expiration of the lease arrangement satisfies the requirements of paragraph (a) of this section if the following conditions are met:
(i) The lease arrangement met the conditions of paragraphs (a)(1) through (6) of this section when the arrangement expired;
(ii) The holdover lease arrangement is on the same terms and conditions as the immediately preceding arrangement; and
(iii) The holdover lease arrangement continues to satisfy the conditions of paragraphs (a)(1) through (6) of this section.
(b) Rental of equipment. Payments made by a lessee to a lessor for the use of equipment under the following conditions:
(1) The lease arrangement is set out in writing, is signed by the parties, and specifies the equipment it covers.
(2) The equipment leased does not exceed that which is reasonable and necessary for the legitimate business purposes of the lease arrangement and is used exclusively by the lessee when being used by the lessee (and is not shared with or used by the lessor or any person or entity related to the lessor).
(3) The duration of the lease arrangement is at least 1 year. To meet this requirement, if the lease arrangement is terminated with or without cause, the parties may not enter into a new lease arrangement for the same equipment during the first year of the original lease arrangement.
(4) The rental charges over the term of the lease arrangement are set in advance, are consistent with fair market value, and are not determined -
(A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed on or business generated through the use of the equipment; or
(5) The lease arrangement would be commercially reasonable even if no referrals were made between the parties.
(6) If the lease arrangement expires after a term of at least 1 year, a holdover lease arrangement immediately following the expiration of the lease arrangement satisfies the requirements of paragraph (b) of this section if the following conditions are met:
(i) The lease arrangement met the conditions of paragraphs (b)(1) through (5) of this section when the arrangement expired;
(ii) The holdover lease arrangement is on the same terms and conditions as the immediately preceding lease arrangement; and
(iii) The holdover lease arrangement continues to satisfy the conditions of paragraphs (b)(1) through (5) of this section.
(c) Bona fide employment relationships. Any amount paid by an employer to a physician (or immediate family member) who has a bona fide employment relationship with the employer for the provision of services if the following conditions are met:
(1) The employment is for identifiable services.
(2) The amount of the remuneration under the employment is -
(i) Consistent with the fair market value of the services; and
(ii) Except as provided in paragraph (c)(4) of this section, is not determined in a manner that takes into account (directly or indirectly) the volume or value of any referrals by the referring physician.
(3) The remuneration is provided under an arrangement that would be commercially reasonable even if no referrals were made to the employer.
(4) Paragraph (c)(2)(ii) of this section does not prohibit payment of remuneration in the form of a productivity bonus based on services performed personally by the physician (or immediate family member of the physician).
(d) Personal service arrangements.
(1) General - Remuneration from an entity under an arrangement or multiple arrangements to a physician or his or her immediate family member, or to a group practice, including remuneration for specific physician services furnished to a nonprofit blood center, if the following conditions are met:
(i) Each arrangement is set out in writing, is signed by the parties, and specifies the services covered by the arrangement.
(ii) The arrangement(s) covers all of the services to be furnished by the physician (or an immediate family member of the physician) to the entity. This requirement is met if all separate arrangements between the entity and the physician and the entity and any family members incorporate each other by reference or if they cross-reference a master list of contracts that is maintained and updated centrally and is available for review by the Secretary upon request. The master list must be maintained in a manner that preserves the historical record of contracts. A physician or family member can "furnish" services through employees whom they have hired for the purpose of performing the services; through a wholly-owned entity; or through locum tenens physicians (as defined at § 411.351, except that the regular physician need not be a member of a group practice).
(iii) The aggregate services covered by the arrangement do not exceed those that are reasonable and necessary for the legitimate business purposes of the arrangement(s).
(iv) The duration of each arrangement is at least 1 year. To meet this requirement, if an arrangement is terminated with or without cause, the parties may not enter into the same or substantially the same arrangement during the first year of the original arrangement.
(v) The compensation to be paid over the term of each arrangement is set in advance, does not exceed fair market value, and, except in the case of a physician incentive plan (as defined at § 411.351 of this subpart), is not determined in a manner that takes into account the volume or value of any referrals or other business generated between the parties.
(vi) The services to be furnished under each arrangement do not involve the counseling or promotion of a business arrangement or other activity that violates any Federal or State law.
(vii) If the arrangement expires after a term of at least 1 year, a holdover arrangement immediately following the expiration of the arrangement satisfies the requirements of paragraph (d) of this section if the following conditions are met:
(A) The arrangement met the conditions of paragraphs (d)(1)(i) through (vi) of this section when the arrangement expired;
(B) The holdover arrangement is on the same terms and conditions as the immediately preceding arrangement; and
(C) The holdover arrangement continues to satisfy the conditions of paragraphs (d)(1)(i) through (vi) of this section.
(2) Physician incentive plan exception. In the case of a physician incentive plan (as defined at § 411.351) between a physician and an entity (or downstream contractor), the compensation may be determined in a manner (through a withhold, capitation, bonus, or otherwise) that takes into account directly or indirectly the volume or value of any referrals or other business generated between the parties, if the plan meets the following requirements:
(i) No specific payment is made directly or indirectly under the plan to a physician or a physician group as an inducement to reduce or limit medically necessary services furnished with respect to a specific individual enrolled with the entity.
(ii) Upon request of the Secretary, the entity provides the Secretary with access to information regarding the plan (including any downstream contractor plans), in order to permit the Secretary to determine whether the plan is in compliance with paragraph (d)(2) of this section.
(iii) In the case of a plan that places a physician or a physician group at substantial financial risk as defined at § 422.208, the entity or any downstream contractor (or both) complies with the requirements concerning physician incentive plans set forth in § 422.208 and § 422.210 of this chapter.
(e) Physician recruitment.
(1) Remuneration provided by a hospital to recruit a physician that is paid directly to the physician and that is intended to induce the physician to relocate his or her medical practice to the geographic area served by the hospital in order to become a member of the hospital's medical staff, if all of the following conditions are met:
(i) The arrangement is set out in writing and signed by both parties;
(ii) The arrangement is not conditioned on the physician's referral of patients to the hospital;
(iii) The amount of remuneration under the arrangement is not determined in a manner that takes into account (directly or indirectly) the volume or value of any actual or anticipated referrals by the physician or other business generated between the parties; and
(iv) The physician is allowed to establish staff privileges at any other hospital(s) and to refer business to any other entities (except as referrals may be restricted under an employment or services arrangement that complies with § 411.354(d)(4)).
(i) The "geographic area served by the hospital" is the area composed of the lowest number of contiguous zip codes from which the hospital draws at least 75 percent of its inpatients. The geographic area served by the hospital may include one or more zip codes from which the hospital draws no inpatients, provided that such zip codes are entirely surrounded by zip codes in the geographic area described above from which the hospital draws at least 75 percent of its inpatients.
(ii) With respect to a hospital that draws fewer than 75 percent of its inpatients from all of the contiguous zip codes from which it draws inpatients, the "geographic area served by the hospital" will be deemed to be the area composed of all of the contiguous zip codes from which the hospital draws its inpatients.
(iii) Special optional rule for rural hospitals. In the case of a hospital located in a rural area (as defined at § 411.351), the "geographic area served by the hospital" may also be the area composed of the lowest number of contiguous zip codes from which the hospital draws at least 90 percent of its inpatients. If the hospital draws fewer than 90 percent of its inpatients from all of the contiguous zip codes from which it draws inpatients, the "geographic area served by the hospital" may include noncontiguous zip codes, beginning with the noncontiguous zip code in which the highest percentage of the hospital's inpatients resides, and continuing to add noncontiguous zip codes in decreasing order of percentage of inpatients.
(iv) A physician will be considered to have relocated his or her medical practice if the medical practice was located outside the geographic area served by the hospital and -
(A) The physician moves his or her medical practice at least 25 miles and into the geographic area served by the hospital; or
(B) The physician moves his medical practice into the geographic area served by the hospital, and the physician's new medical practice derives at least 75 percent of its revenues from professional services furnished to patients (including hospital inpatients) not seen or treated by the physician at his or her prior medical practice site during the preceding 3 years, measured on an annual basis (fiscal or calendar year). For the initial "start up" year of the recruited physician's practice, the 75 percent test in the preceding sentence will be satisfied if there is a reasonable expectation that the recruited physician's medical practice for the year will derive at least 75 percent of its revenues from professional services furnished to patients not seen or treated by the physician at his or her prior medical practice site during the preceding 3 years.
(3) The recruited physician will not be subject to the relocation requirement of this paragraph, provided that he or she establishes his or her medical practice in the geographic area served by the recruiting hospital, if -
(i) He or she is a resident or physician who has been in practice 1 year or less;
(ii) He or she was employed on a full-time basis for at least 2 years immediately prior to the recruitment arrangement by one of the following (and did not maintain a private practice in addition to such full-time employment):
(A) A Federal or State bureau of prisons (or similar entity operating one or more correctional facilities) to serve a prison population;
(B) The Department of Defense or Department of Veterans Affairs to serve active or veteran military personnel and their families; or
(C) A facility of the Indian Health Service to serve patients who receive medical care exclusively through the Indian Health Service; or
(iii) The Secretary has deemed in an advisory opinion issued under section 1877(g) of the Act that the physician does not have an established medical practice that serves or could serve a significant number of patients who are or could become patients of the recruiting hospital.
(4) In the case of remuneration provided by a hospital to a physician either indirectly through payments made to another physician practice, or directly to a physician who joins a physician practice, the following additional conditions must be met:
(i) The writing in paragraph (e)(1) of this section is also signed by the physician practice.
(ii) Except for actual costs incurred by the physician practice in recruiting the new physician, the remuneration is passed directly through to or remains with the recruited physician.
(iii) In the case of an income guarantee of any type made by the hospital to a recruited physician who joins a physician practice, the costs allocated by the physician practice to the recruited physician do not exceed the actual additional incremental costs attributable to the recruited physician. With respect to a physician recruited to join a physician practice located in a rural area or HPSA, if the physician is recruited to replace a physician who, within the previous 12-month period, retired, relocated outside of the geographic area served by the hospital, or died, the costs allocated by the physician practice to the recruited physician do not exceed either -
(A) The actual additional incremental costs attributable to the recruited physician; or
(B) The lower of a per capita allocation or 20 percent of the practice's aggregate costs.
(iv) Records of the actual costs and the passed-through amounts are maintained for a period of at least 6 years and made available to the Secretary upon request.
(v) The remuneration from the hospital under the arrangement is not determined in a manner that takes into account (directly or indirectly) the volume or value of any actual or anticipated referrals by the recruited physician or the physician practice (or any physician affiliated with the physician practice) receiving the direct payments from the hospital.
(vi) The physician practice may not impose on the recruited physician practice restrictions that unreasonably restrict the recruited physician's ability to practice medicine in the geographic area served by the hospital.
(vii) The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(5) Recruitment of a physician by a hospital located in a rural area (as defined at § 411.351) to an area outside the geographic area served by the hospital is permitted under this exception if the Secretary determines in an advisory opinion issued under section 1877(g) of the Act that the area has a demonstrated need for the recruited physician and all other requirements of this paragraph (e) are met.
(i) This paragraph (e) applies to remuneration provided by a federally qualified health center or a rural health clinic in the same manner as it applies to remuneration provided by a hospital, provided that the arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(ii) The "geographic area served" by a federally qualified health center or a rural health clinic is the area composed of the lowest number of contiguous or noncontiguous zip codes from which the federally qualified health center or rural health clinic draws at least 90 percent of its patients, as determined on an encounter basis. The geographic area served by the federally qualified health center or rural health clinic may include one or more zip codes from which the federally qualified health center or rural health clinic draws no patients, provided that such zip codes are entirely surrounded by zip codes in the geographic area described above from which the federally qualified health center or rural health clinic draws at least 90 percent of its patients.
(f) Isolated transactions. Isolated financial transactions, such as a one-time sale of property or a practice, if all of the following conditions are met:
(1) The amount of remuneration under the isolated transaction is -
(i) Consistent with the fair market value of the transaction; and
(ii) Not determined in a manner that takes into account (directly or indirectly) the volume or value of any referrals by the referring physician or other business generated between the parties.
(2) The remuneration is provided under an arrangement that would be commercially reasonable even if the physician made no referrals to the entity.
(3) There are no additional transactions between the parties for 6 months after the isolated transaction, except for transactions that are specifically excepted under the other provisions in § 411.355 through § 411.357 and except for commercially reasonable post-closing adjustments that do not take into account (directly or indirectly) the volume or value of referrals or other business generated by the referring physician.
(g) Certain arrangements with hospitals. Remuneration provided by a hospital to a physician if the remuneration does not relate, directly or indirectly, to the furnishing of DHS. To qualify as "unrelated," remuneration must be wholly unrelated to the furnishing of DHS and must not in any way take into account the volume or value of a physician's referrals. Remuneration relates to the furnishing of DHS if it -
(1) Is an item, service, or cost that could be allocated in whole or in part to Medicare or Medicaid under cost reporting principles;
(2) Is furnished, directly or indirectly, explicitly or implicitly, in a selective, targeted, preferential, or conditioned manner to medical staff or other persons in a position to make or influence referrals; or
(3) Otherwise takes into account the volume or value of referrals or other business generated by the referring physician.
(h) Group practice arrangements with a hospital. An arrangement between a hospital and a group practice under which DHS are furnished by the group but are billed by the hospital if the following conditions are met:
(1) With respect to services furnished to an inpatient of the hospital, the arrangement is pursuant to the provision of inpatient hospital services under section 1861(b)(3) of the Act.
(2) The arrangement began before, and has continued in effect without interruption since, December 19, 1989.
(3) With respect to the DHS covered under the arrangement, at least 75 percent of these services furnished to patients of the hospital are furnished by the group under the arrangement.
(4) The arrangement is in accordance with a written agreement that specifies the services to be furnished by the parties and the compensation for services furnished under the agreement.
(5) The compensation paid over the term of the agreement is consistent with fair market value, and the compensation per unit of service is fixed in advance and is not determined in a manner that takes into account the volume or value of any referrals or other business generated between the parties.
(6) The compensation is provided in accordance with an agreement that would be commercially reasonable even if no referrals were made to the entity.
(i) Payments by a physician. Payments made by a physician (or his or her immediate family member) -
(1) To a laboratory in exchange for the provision of clinical laboratory services; or
(2) To an entity as compensation for any other items or services that are furnished at a price that is consistent with fair market value, and that are not specifically excepted by another provision in §§ 411.355 through 411.357 (including, but not limited to, § 411.357(l)). "Services" in this context means services of any kind (not merely those defined as "services" for purposes of the Medicare program in § 400.202 of this chapter).
(j) Charitable donations by a physician. Bona fide charitable donations made by a physician (or immediate family member) to an entity if all of the following conditions are satisfied:
(1) The charitable donation is made to an organization exempt from taxation under the Internal Revenue Code (or to a supporting organization);
(2) The donation is neither solicited, nor offered, in any manner that takes into account the volume or value of referrals or other business generated between the physician and the entity; and
(3) The donation arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(k) Nonmonetary compensation.
(1) Compensation from an entity in the form of items or services (not including cash or cash equivalents) that does not exceed an aggregate of $300 per calendar year, as adjusted for inflation in accordance with paragraph (k)(2) of this section, if all of the following conditions are satisfied:
(i) The compensation is not determined in any manner that takes into account the volume or value of referrals or other business generated by the referring physician.
(ii) The compensation may not be solicited by the physician or the physician's practice (including employees and staff members).
(iii) The compensation arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act) or any Federal or State law or regulation governing billing or claims submission.
(2) The annual aggregate nonmonetary compensation limit in this paragraph (k) is adjusted each calendar year to the nearest whole dollar by the increase in the Consumer Price Index - Urban All Items (CPI-U) for the 12-month period ending the preceding September 30. CMS displays after September 30 each year both the increase in the CPI-U for the 12-month period and the new nonmonetary compensation limit on the physician self-referral Web site at http://www.cms.hhs.gov/PhysicianSelfReferral/10_CPI-U_Updates.asp.
(3) Where an entity has inadvertently provided nonmonetary compensation to a physician in excess of the limit (as set forth in paragraph (k)(1) of this section), such compensation is deemed to be within the limit if -
(i) The value of the excess nonmonetary compensation is no more than 50 percent of the limit; and
(ii) The physician returns to the entity the excess nonmonetary compensation (or an amount equal to the value of the excess nonmonetary compensation) by the end of the calendar year in which the excess nonmonetary compensation was received or within 180 consecutive calendar days following the date the excess nonmonetary compensation was received by the physician, whichever is earlier.
(iii) Paragraph (k)(3) may be used by an entity only once every 3 years with respect to the same referring physician.
(4) In addition to nonmonetary compensation up to the limit described in paragraph (k)(1) of this section, an entity that has a formal medical staff may provide one local medical staff appreciation event per year for the entire medical staff. Any gifts or gratuities provided in connection with the medical staff appreciation event are subject to the limit in paragraph (k)(1).
(l) Fair market value compensation. Compensation resulting from an arrangement between an entity and a physician (or an immediate family member) or any group of physicians (regardless of whether the group meets the definition of a group practice set forth in § 411.352) for the provision of items or services (other than the rental of office space) by the physician (or an immediate family member) or group of physicians to the entity, or by the entity to the physician (or an immediate family member) or a group of physicians, if the arrangement meets the following conditions:
(1) The arrangement is in writing, signed by the parties, and covers only identifiable items or services, all of which are specified in writing.
(2) The writing specifies the timeframe for the arrangement, which can be for any period of time and contain a termination clause, provided that the parties enter into only one arrangement for the same items or services during the course of a year. An arrangement may be renewed any number of times if the terms of the arrangement and the compensation for the same items or services do not change.
(3) The writing specifies the compensation that will be provided under the arrangement. The compensation must be set in advance, consistent with fair market value, and not determined in a manner that takes into account the volume or value of referrals or other business generated by the referring physician. Compensation for the rental of equipment may not be determined using a formula based on -
(i) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed or business generated through the use of the equipment; or
(ii) Per-unit of service rental charges, to the extent that such charges reflect services provided to patients referred by the lessor to the lessee.
(4) The arrangement is commercially reasonable (taking into account the nature and scope of the transaction) and furthers the legitimate business purposes of the parties.
(5) The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(6) The services to be performed under the arrangement do not involve the counseling or promotion of a business arrangement or other activity that violates a Federal or State law.
(m) Medical staff incidental benefits. Compensation in the form of items or services (not including cash or cash equivalents) from a hospital to a member of its medical staff when the item or service is used on the hospital's campus, if all of the following conditions are met:
(1) The compensation is offered to all members of the medical staff practicing in the same specialty (but not necessarily accepted by every member to whom it is offered) and is not offered in a manner that takes into account the volume or value of referrals or other business generated between the parties.
(2) Except with respect to identification of medical staff on a hospital Web site or in hospital advertising, the compensation is provided only during periods when the medical staff members are making rounds or are engaged in other services or activities that benefit the hospital or its patients.
(3) The compensation is provided by the hospital and used by the medical staff members only on the hospital's campus. Compensation, including, but not limited to, internet access, pagers, or two-way radios, used away from the campus only to access hospital medical records or information or to access patients or personnel who are on the hospital campus, as well as the identification of the medical staff on a hospital Web site or in hospital advertising, meets the "on campus" requirement of this paragraph (m).
(4) The compensation is reasonably related to the provision of, or designed to facilitate directly or indirectly the delivery of, medical services at the hospital.
(5) The compensation is of low value (that is, less than $25) with respect to each occurrence of the benefit (for example, each meal given to a physician while he or she is serving patients who are hospitalized must be of low value). The $25 limit in this paragraph (m)(5) is adjusted each calendar year to the nearest whole dollar by the increase in the Consumer Price Index - Urban All Items (CPI-I) for the 12 month period ending the preceding September 30. CMS displays after September 30 each year both the increase in the CPI-I for the 12 month period and the new limits on the physician self-referral Web site at http://www.cms.hhs.gov/PhysicianSelfReferral/10_CPI-U_Updates.asp.
(6) The compensation is not determined in any manner that takes into account the volume or value of referrals or other business generated between the parties.
(7) The compensation arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(8) Other facilities and health care clinics (including, but not limited to, federally qualified health centers) that have bona fide medical staffs may provide compensation under this paragraph (m) on the same terms and conditions applied to hospitals under this paragraph (m).
(n) Risk-sharing arrangements. Compensation pursuant to a risk-sharing arrangement (including, but not limited to, withholds, bonuses, and risk pools) between a MCO or an IPA and a physician (either directly or indirectly through a subcontractor) for services provided to enrollees of a health plan, provided that the arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission. For purposes of this paragraph (n), "health plan" and "enrollees" have the meanings set forth in § 1001.952(l) of this title.
(o) Compliance training. Compliance training provided by an entity to a physician (or to the physician's immediate family member or office staff) who practices in the entity's local community or service area, provided that the training is held in the local community or service area. For purposes of this paragraph (o), "compliance training" means training regarding the basic elements of a compliance program (for example, establishing policies and procedures, training of staff, internal monitoring, or reporting); specific training regarding the requirements of Federal and State health care programs (for example, billing, coding, reasonable and necessary services, documentation, or unlawful referral arrangements); or training regarding other Federal, State, or local laws, regulations, or rules governing the conduct of the party for whom the training is provided. For purposes of this paragraph, "compliance training" includes programs that offer continuing medical education credit, provided that compliance training is the primary purpose of the program.
(p) Indirect compensation arrangements. Indirect compensation arrangements, as defined at § 411.354(c)(2), if all of the following conditions are satisfied:
(i) The compensation received by the referring physician (or immediate family member) described in § 411.354(c)(2)(ii) is fair market value for services and items actually provided and not determined in any manner that takes into account the volume or value of referrals or other business generated by the referring physician for the entity furnishing DHS.
(ii) Compensation for the rental of office space or equipment may not be determined using a formula based on -
(A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services performed or business generated in the office space or to the services performed on or business generated through the use of the equipment; or
(2) The compensation arrangement described in § 411.354(c)(2)(ii) is set out in writing, signed by the parties, and specifies the services covered by the arrangement, except in the case of a bona fide employment relationship between an employer and an employee, in which case the arrangement need not be set out in writing, but must be for identifiable services and be commercially reasonable even if no referrals are made to the employer.
(q) Referral services. Remuneration that meets all of the conditions set forth in § 1001.952(f) of this title.
(r) Obstetrical malpractice insurance subsidies. Remuneration that meets all of the conditions of paragraph (r)(1) or (2) of this section.
(1) Remuneration that meets all of the conditions set forth in § 1001.952(o) of this title.
(2) A payment from a hospital, federally qualified health center, or rural health clinic that is used to pay for some or all of the costs of malpractice insurance premiums for a physician who engages in obstetrical practice as a routine part of his or her medical practice, if all of the following conditions are met:
(A) The physician's medical practice is located in a rural area, a primary care HPSA, or an area with demonstrated need for the physician's obstetrical services as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
(B) At least 75 percent of the physician's obstetrical patients reside in a medically underserved area or are members of a medically underserved population.
(ii) The arrangement is set out in writing, is signed by the physician and the hospital, federally qualified health center, or rural health clinic providing the payment, and specifies the payment to be made by the hospital, federally qualified health center, or rural health clinic and the terms under which the payment is to be provided.
(iii) The arrangement is not conditioned on the physician's referral of patients to the hospital, federally qualified health center, or rural health clinic providing the payment.
(iv) The hospital, federally qualified health center, or rural health clinic does not determine the amount of the payment in a manner that takes into account (directly or indirectly) the volume or value of any actual or anticipated referrals by the physician or any other business generated between the parties.
(v) The physician is allowed to establish staff privileges at any hospital(s), federally qualified health center(s), or rural health clinic(s) and to refer business to any other entities (except as referrals may be restricted under an employment arrangement or services arrangement that complies with § 411.354(d)(4)).
(vi) The payment is made to a person or organization (other than the physician) that is providing malpractice insurance (including a self-funded organization).
(vii) The physician treats obstetrical patients who receive medical benefits or assistance under any Federal health care program in a nondiscriminatory manner.
(viii) The insurance is a bona fide malpractice insurance policy or program, and the premium, if any, is calculated based on a bona fide assessment of the liability risk covered under the insurance.
(ix)
(A) For each coverage period (not to exceed 1 year), at least 75 percent of the physician's obstetrical patients treated under the coverage of the obstetrical malpractice insurance during the prior period (not to exceed 1 year) -
(1) Resided in a rural area, HPSA, medically underserved area, or an area with a demonstrated need for the physician's obstetrical services as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
(2) Were part of a medically underserved population.
(B) For the initial coverage period (not to exceed 1 year), the requirements of paragraph (r)(2)(ix)(A) of this section will be satisfied if the physician certifies that he or she has a reasonable expectation that at least 75 percent of the physician's obstetrical patients treated under the coverage of the malpractice insurance will -
(1) Reside in a rural area, HPSA, medically underserved area, or an area with a demonstrated need for the physician's obstetrical services as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
(2) Be part of a medically underserved population.
(x) The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(3) For purposes of paragraph (r)(2) of this section, costs of malpractice insurance premiums means:
(i) For physicians who engage in obstetrical practice on a full-time basis, any costs attributable to malpractice insurance; or
(ii) For physicians who engage in obstetrical practice on a part-time or sporadic basis, the costs attributable exclusively to the obstetrical portion of the physician's malpractice insurance, and related exclusively to obstetrical services provided -
(A) In a rural area, primary care HPSA, or an area with demonstrated need for the physician's obstetrical services, as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
(B) In any area, provided that at least 75 percent of the physician's obstetrical patients treated in the coverage period (not to exceed 1 year) resided in a medically underserved area or were part of a medically underserved population.
(s) Professional courtesy. Professional courtesy (as defined at § 411.351) offered by an entity with a formal medical staff to a physician or a physician's immediate family member or office staff if all of the following conditions are met:
(1) The professional courtesy is offered to all physicians on the entity's bona fide medical staff or in such entity's local community or service area, and the offer does not take into account the volume or value of referrals or other business generated between the parties;
(2) The health care items and services provided are of a type routinely provided by the entity;
(3) The entity has a professional courtesy policy that is set out in writing and approved in advance by the entity's governing body;
(4) The professional courtesy is not offered to a physician (or immediate family member) who is a Federal health care program beneficiary, unless there has been a good faith showing of financial need; and
(t) Retention payments in underserved areas -
(1) Bona fide written offer. Remuneration provided by a hospital directly to a physician on the hospital's medical staff to retain the physician's medical practice in the geographic area served by the hospital (as defined in paragraph (e)(2) of this section), if all of the following conditions are met:
(i) The physician has a bona fide firm, written recruitment offer or offer of employment from a hospital, academic medical center (as defined at § 411.355(e)), or physician organization (as defined at § 411.351) that is not related to the hospital making the payment, and the offer specifies the remuneration being offered and requires the physician to move the location of his or her medical practice at least 25 miles and outside of the geographic area served by the hospital making the retention payment.
(ii) The requirements of § 411.357(e)(1)(i) through § 411.357(e)(1)(iv) are satisfied.
(iii) Any retention payment is subject to the same obligations and restrictions, if any, on repayment or forgiveness of indebtedness as the written recruitment offer or offer of employment.
(iv) The retention payment does not exceed the lower of -
(A) The amount obtained by subtracting the physician's current income from physician and related services from the income the physician would receive from comparable physician and related services in the written recruitment or employment offer, provided that the respective incomes are determined using a reasonable and consistent methodology, and that they are calculated uniformly over no more than a 24-month period; or
(B) The reasonable costs the hospital would otherwise have to expend to recruit a new physician to the geographic area served by the hospital to join the medical staff of the hospital to replace the retained physician.
(v) The requirements of paragraph (t)(3) are satisfied.
(2) Written certification from physician. Remuneration provided by a hospital directly to a physician on the hospital's medical staff to retain the physician's medical practice in the geographic area served by the hospital (as defined in paragraph (e)(2) of this section), if all of the following conditions are met:
(i) The physician furnishes to the hospital before the retention payment is made a written certification that the physician has a bona fide opportunity for future employment by a hospital, academic medical center (as defined at § 411.355(e)), or physician organization (as defined at § 411.351) that requires the physician to move the location of his or her medical practice at least 25 miles and outside the geographic area served by the hospital. The certification contains at least the following -
(A) Details regarding the steps taken by the physician to effectuate the employment opportunity;
(B) Details of the physician's employment opportunity, including the identity and location of the physician's future employer or employment location or both, and the anticipated income and benefits (or a range for income and benefits);
(C) A statement that the future employer is not related to the hospital making the payment;
(D) The date on which the physician anticipates relocating his or her medical practice outside of the geographic area served by the hospital; and
(E) Information sufficient for the hospital to verify the information included in the written certification.
(ii) The hospital takes reasonable steps to verify that the physician has a bona fide opportunity for future employment that requires the physician to relocate outside the geographic area served by the hospital.
(iii) The requirements of § 411.357(e)(1)(i) through § 411.357(e)(1)(iv) are satisfied.
(A) An amount equal to 25 percent of the physician's current annual income (averaged over the previous 24 months), using a reasonable and consistent methodology that is calculated uniformly; or
(3) Remuneration provided under paragraph (t)(1) or (t)(2) must meet the following additional requirements:
(A) The physician's current medical practice is located in a rural area or HPSA (regardless of the physician's specialty) or is located in an area with demonstrated need for the physician as determined by the Secretary in an advisory opinion issued in accordance with section 1877(g)(6) of the Act; or
(B) At least 75 percent of the physician's patients reside in a medically underserved area or are members of a medically underserved population.
(ii) The hospital does not enter into a retention arrangement with a particular referring physician more frequently than once every 5 years.
(iii) The amount and terms of the retention payment are not altered during the term of the arrangement in any manner that takes into account the volume or value of referrals or other business generated by the physician.
(iv) The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(4) The Secretary may waive the relocation requirement of paragraphs (t)(1) and (t)(2) of this section for payments made to physicians practicing in a HPSA or an area with demonstrated need for the physician through an advisory opinion issued in accordance with section 1877(g)(6) of the Act, if the retention payment arrangement otherwise complies with all of the conditions of this paragraph.
(5) This paragraph (t) applies to remuneration provided by a federally qualified health center or a rural health clinic in the same manner as it applies to remuneration provided by a hospital.
(u) Community-wide health information systems. Items or services of information technology provided by an entity to a physician that allow access to, and sharing of, electronic health care records and any complementary drug information systems, general health information, medical alerts, and related information for patients served by community providers and practitioners, in order to enhance the community's overall health, provided that -
(1) The items or services are available as necessary to enable the physician to participate in a community-wide health information system, are principally used by the physician as part of the community-wide health information system, and are not provided to the physician in any manner that takes into account the volume or value of referrals or other business generated by the physician;
(2) The community-wide health information systems are available to all providers, practitioners, and residents of the community who desire to participate; and
(v) Electronic prescribing items and services. Nonmonetary remuneration (consisting of items and services in the form of hardware, software, or information technology and training services) necessary and used solely to receive and transmit electronic prescription information, if all of the following conditions are met:
(1) The items and services are provided by a -
(i) Hospital to a physician who is a member of its medical staff;
(ii) Group practice (as defined at § 411.352) to a physician who is a member of the group (as defined at § 411.351); or
(iii) PDP sponsor or MA organization to a prescribing physician.
(2) The items and services are provided as part of, or are used to access, an electronic prescription drug program that meets the applicable standards under Medicare Part D at the time the items and services are provided.
(3) The donor (or any person on the donor's behalf) does not take any action to limit or restrict the use or compatibility of the items or services with other electronic prescribing or electronic health records systems.
(4) For items or services that are of the type that can be used for any patient without regard to payer status, the donor does not restrict, or take any action to limit, the physician's right or ability to use the items or services for any patient.
(5) Neither the physician nor the physician's practice (including employees and staff members) makes the receipt of items or services, or the amount or nature of the items or services, a condition of doing business with the donor.
(6) Neither the eligibility of a physician for the items or services, nor the amount or nature of the items or services, is determined in a manner that takes into account the volume or value of referrals or other business generated between the parties.
(7) The arrangement is set forth in a written agreement that -
(i) Is signed by the parties;
(ii) Specifies the items and services being provided and the donor's cost of the items and services; and
(iii) Covers all of the electronic prescribing items and services to be provided by the donor. This requirement is met if all separate agreements between the donor and the physician (and the donor and any family members of the physician) incorporate each other by reference or if they cross-reference a master list of agreements that is maintained and updated centrally and is available for review by the Secretary upon request. The master list must be maintained in a manner that preserves the historical record of agreements.
(8) The donor does not have actual knowledge of, and does not act in reckless disregard or deliberate ignorance of, the fact that the physician possesses or has obtained items or services equivalent to those provided by the donor.
(w) Electronic health records items and services. Nonmonetary remuneration (consisting of items and services in the form of software or information technology and training services) necessary and used predominantly to create, maintain, transmit, or receive electronic health records, if all of the following conditions are met:
(1) The items and services are provided to a physician by an entity (as defined at § 411.351) that is not a laboratory company.
(2) The software is interoperable (as defined in § 411.351) at the time it is provided to the physician. For purposes of this paragraph, software is deemed to be interoperable if, on the date it is provided to the physician, it has been certified by a certifying body authorized by the National Coordinator for Health Information Technology to an edition of the electronic health record certification criteria identified in the then-applicable version of 45 CFR part 170.
(3) The donor (or any person on the donor's behalf) does not take any action to limit or restrict the use, compatibility, or interoperability of the items or services with other electronic prescribing or electronic health records systems (including, but not limited to, health information technology applications, products, or services).
(4) Before receipt of the items and services, the physician pays 15 percent of the donor's cost for the items and services. The donor (or any party related to the donor) does not finance the physician's payment or loan funds to be used by the physician to pay for the items and services.
(6) Neither the eligibility of a physician for the items or services, nor the amount or nature of the items or services, is determined in a manner that directly takes into account the volume or value of referrals or other business generated between the parties. For purposes of this paragraph, the determination is deemed not to directly take into account the volume or value of referrals or other business generated between the parties if any one of the following conditions is met:
(i) The determination is based on the total number of prescriptions written by the physician (but not the volume or value of prescriptions dispensed or paid by the donor or billed to the program);
(ii) The determination is based on the size of the physician's medical practice (for example, total patients, total patient encounters, or total relative value units);
(iii) The determination is based on the total number of hours that the physician practices medicine;
(iv) The determination is based on the physician's overall use of automated technology in his or her medical practice (without specific reference to the use of technology in connection with referrals made to the donor);
(v) The determination is based on whether the physician is a member of the donor's medical staff, if the donor has a formal medical staff;
(vi) The determination is based on the level of uncompensated care provided by the physician; or
(vii) The determination is made in any reasonable and verifiable manner that does not directly take into account the volume or value of referrals or other business generated between the parties.
(ii) Specifies the items and services being provided, the donor's cost of the items and services, and the amount of the physician's contribution; and
(iii) Covers all of the electronic health records items and services to be provided by the donor. This requirement is met if all separate agreements between the donor and the physician (and the donor and any family members of the physician) incorporate each other by reference or if they cross-reference a master list of agreements that is maintained and updated centrally and is available for review by the Secretary upon request. The master list must be maintained in a manner that preserves the historical record of agreements.
(10) The items and services do not include staffing of physician offices and are not used primarily to conduct personal business or business unrelated to the physician's medical practice.
(11) [Reserved]
(12) The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(13) The transfer of the items or services occurs and all conditions in this paragraph (w) are satisfied on or before December 31, 2021.
(x) Assistance to compensate a nonphysician practitioner.
(1) Remuneration provided by a hospital to a physician to compensate a nonphysician practitioner to provide patient care services, if all of the following conditions are met:
(i) The arrangement is set out in writing and signed by the hospital, the physician, and the nonphysician practitioner.
(ii) The arrangement is not conditioned on -
(A) The physician's referrals to the hospital; or
(B) The nonphysician practitioner's referrals to the hospital.
(iii) The remuneration from the hospital -
(A) Does not exceed 50 percent of the actual compensation, signing bonus, and benefits paid by the physician to the nonphysician practitioner during a period not to exceed the first 2 consecutive years of the compensation arrangement between the nonphysician practitioner and the physician (or the physician organization in whose shoes the physician stands); and
(B) Is not determined in a manner that takes into account (directly or indirectly) the volume or value of any actual or anticipated referrals by -
(1) The physician (or any physician in the physician's practice) or other business generated between the parties; or
(2) The nonphysician practitioner (or any nonphysician practitioner in the physician's practice) or other business generated between the parties.
(iv) The compensation, signing bonus, and benefits paid to the nonphysician practitioner by the physician does not exceed fair market value for the patient care services furnished by the nonphysician practitioner to patients of the physician's practice.
(v) The nonphysician practitioner has not, within 1 year of the commencement of his or her compensation arrangement with the physician (or the physician organization in whose shoes the physician stands under § 411.354(c)) -
(A) Practiced in the geographic area served by the hospital; or
(B) Been employed or otherwise engaged to provide patient care services by a physician or a physician organization that has a medical practice site located in the geographic area served by the hospital, regardless of whether the nonphysician practitioner furnished services at the medical practice site located in the geographic area served by the hospital.
(A) The nonphysician practitioner has a compensation arrangement directly with the physician or the physician organization in whose shoes the physician stands under § 411.354(c); and
(B) Substantially all of the services that the nonphysician practitioner furnishes to patients of the physician's practice are primary care services or mental health care services.
(vii) The physician does not impose practice restrictions on the nonphysician practitioner that unreasonably restrict the nonphysician practitioner's ability to provide patient care services in the geographic area served by the hospital.
(viii) The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act), or any Federal or State law or regulation governing billing or claims submission.
(2) Records of the actual amount of remuneration provided under paragraph (x)(1) of this section by the hospital to the physician, and by the physician to the nonphysician practitioner, must be maintained for a period of at least 6 years and made available to the Secretary upon request.
(3) For purposes of this paragraph (x), "nonphysician practitioner" means a physician assistant as defined in section 1861(aa)(5) of the Act, a nurse practitioner or clinical nurse specialist as defined in section 1861(aa)(5) of the Act, a certified nurse-midwife as defined in section 1861(gg) of the Act, a clinical social worker as defined in section 1861(hh) of the Act, or a clinical psychologist as defined in § 410.71(d) of this subchapter.
(4) For purposes of paragraphs (x)(1)(ii)(B) and (x)(1)(iii)(B)(2) of this section, "referral" means a request by a nonphysician practitioner that includes the provision of any designated health service for which payment may be made under Medicare, the establishment of any plan of care by a nonphysician practitioner that includes the provision of such a designated health service, or the certifying or recertifying of the need for such a designated health service, but not including any designated health service personally performed or provided by the nonphysician practitioner.
(5) For purposes of paragraph (x)(1) of this section, "geographic area served by the hospital" has the meaning set forth in paragraph (e)(2) of this section.
(6) For purposes of paragraph (x)(1) of this section, a "compensation arrangement" between a physician (or the physician organization in whose shoes the physician stands under § 411.354(c) and a nonphysician practitioner -
(i) Means an employment, contractual, or other arrangement under which remuneration passes between the parties; and
(ii) Does not include a nonphysician practitioner's ownership or investment interest in a physician organization.
(i) This paragraph (x) may be used by a hospital, federally qualified health center, or rural health clinic only once every 3 years with respect to the same referring physician.
(ii) Paragraph (x)(7)(i) of this section does not apply to remuneration provided by a hospital, federally qualified health center, or rural health clinic to a physician to compensate a nonphysician practitioner to provide patient care services if -
(A) The nonphysician practitioner is replacing a nonphysician practitioner who terminated his or her employment or contractual arrangement to provide patient care services with the physician (or the physician organization in whose shoes the physician stands) within 1 year of the commencement of the employment or contractual arrangement; and
(B) The remuneration provided to the physician is provided during a period that does not exceed 2 consecutive years as measured from the commencement of the compensation arrangement between the nonphysician practitioner who is being replaced and the physician (or the physician organization in whose shoes the physician stands).
(i) This paragraph (x) applies to remuneration provided by a federally qualified health center or a rural health clinic in the same manner as it applies to remuneration provided by a hospital.
(ii) The "geographic area served" by a federally qualified health center or a rural health clinic has the meaning set forth in paragraph (e)(6)(ii) of this section.
(y) Timeshare arrangements. Remuneration provided under an arrangement for the use of premises, equipment, personnel, items, supplies, or services if the following conditions are met:
(1) The arrangement is set out in writing, signed by the parties, and specifies the premises, equipment, personnel, items, supplies, and services covered by the arrangement.
(2) The arrangement is between a physician (or the physician organization in whose shoes the physician stands under § 411.354(c) and -
(i) A hospital; or
(ii) Physician organization of which the physician is not an owner, employee, or contractor.
(3) The premises, equipment, personnel, items, supplies, and services covered by the arrangement are used -
(i) Predominantly for the provision of evaluation and management services to patients; and
(ii) On the same schedule.
(4) The equipment covered by the arrangement is -
(i) Located in the same building where the evaluation and management services are furnished;
(ii) Not used to furnish designated health services other than those incidental to the evaluation and management services furnished at the time of the patient's evaluation and management visit; and
(iii) Not advanced imaging equipment, radiation therapy equipment, or clinical or pathology laboratory equipment (other than equipment used to perform CLIA-waived laboratory tests).
(5) The arrangement is not conditioned on the referral of patients by the physician who is a party to the arrangement to the hospital or physician organization of which the physician is not an owner, employee, or contractor.
(6) The compensation over the term of the arrangement is set in advance, consistent with fair market value, and not determined -
(i) In a manner that takes into account (directly or indirectly) the volume or value of referrals or other business generated between the parties; or
(A) A percentage of the revenue raised, earned, billed, collected, or otherwise attributable to the services provided while using the premises, equipment, personnel, items, supplies, or services covered by the arrangement; or
(B) Per-unit of service fees that are not time-based, to the extent that such fees reflect services provided to patients referred by the party granting permission to use the premises, equipment, personnel, items, supplies, or services covered by the arrangement to the party to which the permission is granted.
(7) The arrangement would be commercially reasonable even if no referrals were made between the parties.
(8) The arrangement does not violate the anti-kickback statute (section 1128B(b) of the Act) or any Federal or State law or regulation governing billing or claims submission.
(9) The arrangement does not convey a possessory leasehold interest in the office space that is the subject of the arrangement.
[72 FR 51091, Sept. 5, 2007; 72 FR 68076, Dec. 4, 2007, as amended at 73 FR 48752, Aug. 19, 2008; 73 FR 57543, Oct. 3, 2008; 78 FR 78768, Dec. 27, 2013; 80 FR 71374, Nov. 16, 2015; 81 FR 12030, Mar. 8, 2016; 81 FR 80553, Nov. 15, 2016]
Internal Revenue Code


Do online charter schools measure up?
New research offers evidence that online charter schools post weaker academic performance and struggle more to maintain student engagement than their conventional brick-and-mortar peers.
The National Study of Online Charter Schools, released Oct. 27, analyzed online charter school operations, policy environments, and their impacts on student achievements.
The three-volume study, conducted by Mathematica Policy Research, the Center on Reinventing Public Education at the University of Washington, and the Center for Research on Education Outcomes at Stanford University, describes the achievement effects of online charter schools.
Volume 1 analyzed the 200 online charter schools in operation in the U.S. and the 200,000 K-12 students in attendance. It examines the instructional programs of online charter schools; methods used to engage students and parents, along with expectations of parental involvement; the teachers and principals of online charter schools; and the schools' management and governance.
"Challenges in maintaining student engagement are inherent in online instruction, and they are exacerbated by high student-teacher ratios and minimal student-teacher contact time, which the data reveal are typical of online charter schools nationwide. These findings suggest reason for concern about whether the sector is likely to be effective in promoting student achievement," said Brian Gill, a Mathematica senior fellow and lead author of the report.
In Volume II, the Center on Reinventing Public Education examined how state policy impacts the online charter school landscape. Researchers found that online charter schools exist in a number of different policy environments due to variation in state charter law and administrative regulation.
Most of the existing regulation is reactive to controversy (restrictions on growth and autonomy), rather than proactive policies to guide the unique opportunities and challenges of online charters.
likely to be successful in an online school.
Volume III, from the CREDO at Stanford University, examines impacts of online charter enrollment on the academic progress of students.
While findings vary for each student, the results in CREDO's report show that the majority of online charter students had far weaker academic growth in both math and reading compared to their traditional public school peers.
To conceptualize this shortfall, it would equate to a student losing 72 days of learning in reading and 180 days of learning in math, based on a 180-day school year. This pattern of weaker growth remained consistent across racial-ethnic subpopulations and students in poverty.
students and to connect with and learn from operators who are doing well," said Dr. James Woodworth, Senior Quantitative Research Analyst for CREDO at Stanford University.
Columbia. The data set for online school students is restricted to those students attending public, full-time online charter schools.


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We're the refractory products that stand the test of time. The people who respond like no one else. And the ideas that will change tomorrow. We're nearly 2,000 people with one goal: to keep your business moving forward.
Every day around the world, HarbisonWalker International's people and products stand up to the challenges and pressures of every job. And for more than 150 years, companies have relied on our world-class products that continue to set the gold standard for the refractory industry.
Ready to put our intensity to work for you?
What sets the people of HWI apart? We have a burning desire for answers, excellence, and accuracy. We're thorough and meticulous. And absolute accountability is baked into our DNA.
Products That Pass the Test. Every Day.
With the right mix of products and technology, HarbisonWalker International has one of the best operations in the world to deliver what you need, when you need it. No one produces more tonnage in the United States, and our manufacturing footprint spans the globe. HWI operates 17 manufacturing facilities in North America, as well as one in the United Kingdom and one in Indonesia. And we have supply partners in China and Europe to support the full range of customer needs.
*Emisshield® coatings are manufactured by Emisshield, Inc. Emisshield® is a registered trademark of Emisshield, Inc.
We're not just in the refractory business, we're in the relationship business. After all, the more we understand you and your business, the more we are able to customize our solutions.
The competitive edge you're looking for starts with us—and with your dedicated HWI application specialist. They're experts who will understand every inch of your process and who will work intensely to optimize your refractory performance.
Want to save time and money? Want to improve your productivity? Talk to your HWI sales representative today.
The products you need. When you need them. HarbisonWalker International delivers like a world-class pro. Of course our 30 global sourcing centers across North America are strategically placed. Of course we ship around the world at a moment's notice. Of course we stock our most popular products so that you can have them the same day or the next day. How can we work with you to reduce your potential for downtime?
At HarbisonWalker International, the bottom line is this: We live the refractory business. We rise to every challenge and do whatever it takes to get the job done.


text:
About Megan Walrod, Founder, Live Your Yes
Megan Walrod, M.A., C.F.M.W., is an Award-Winning Author, Copywriter, Business and Book Coach. Over the past decade she's supported hundreds of women entrepreneurs build profitable and purposeful businesses. She has supported clients in having $6- and $7-figure launches and written copy for million-dollar global business owners and non-profits.
Megan encourages her clients to "Live Your Yes," knowing that when we live an inspired life, we are more magnetic and create greater success for everyone.
Before starting Live Your Yes, Megan was one of the lead coaches, trainers and copywriters for a premier $7-figure company in the marketing industry. Before that, she was a consultant for a Global Fortune 500 Company, writing and delivering training for an international audience.
Megan received a Master's degree in Organization Development (from Bowling Green State University) and one in Transpersonal Counseling Psychology (from Naropa University). Her love of learning is surpassed only by her love of words, and using them to inspire and empower.
In Megan's world, being turned on by life is essential. And dancing, dark chocolate and skinny-dipping are always fabulous ideas. She shows her clients how to bring the fun and magic into marketing, business and life.
Writing is Megan's passion, super power and profession.
In 2017-2018, she "lived her Yes" for 6 months volunteering in Uganda with a non-profit. They co-wrote a book entitled, "We Have Something To Say: True Stories From Adolescent Girls Growing Up In The Slums Of Kampala."
Megan's latest writing project? A novel!
Her novel delivers important messages for women that often can't be received by the rational mind. Which is why they're being shared through a fun, deep, engaging, sexy romance and heroine's journey.
These messages include insight into how to:
Be in relationship without giving ourselves away
Value ourselves and the journey that we've been on and are on
Lean into and trust our unique creative expression
Trust – and follow – our desires
Access our depths – our emotional nature – and excavate the gems and wisdom as medicine for our own healing and transformation and as contributions to others
Megan is thrilled to be participating in a Writing Retreat in September (in Montana!) with a NY Times Bestselling Author. Stay tuned for more updates about her novel, and the adventure of getting it written and published and shared with the world.