AOA Code of Ethics and ACOS Ethical Interpretations

The American Osteopathic Association has formulated this Code to guide its member physicians in their professional lives. The standards presented are designed to address the osteopathic physician’s ethical and professional responsibilities to patients, to society, to the AOA, to others involved in healthcare, and to self.

Further, the American Osteopathic Association has adopted the position that physicians should play a major role in the development and instruction of medical ethics.

The American College of Osteopathic Surgeons subscribes to and adopts the Code of Ethics of the American Osteopathic Association; requires of its Members in all categories that they be familiar with the AOA Code of Ethics; and requires that they adhere to its provisions as so set forth and as revised, amended and/or interpreted from time to time.

Members of this organization shall not practice the division of fees (fee splitting) and shall oppose such practice in every possible manner.

AOA Code of Ethics; AOA Interpretations of Sections of its Code of Ethics; and AOA Position Papers/Ethical Content

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ACOS Ethical Interpretations

ACOS provides the following guidelines to assist Members and Candidates in determining whether particular practice arrangements are ethical. The College’s objective is to encourage ethical practice arrangements and avoid fee splitting or other potential compliance issues. Professional referrals should always be based on the patient’s need for quality care.

Group Practices: All Surgeon

Surgeons in group practice who receive referrals from outside the group should charge their patients only for the services actually rendered. Each physician participating in the patient’s care should bill and be compensated for services rendered.

With respect to acceptable group members’ salaries and methods of compensation, they can vary.  These compensation arrangements must be compliant with federal and state laws and regulations.  Group members draw salaries  based on a number of acceptable factors, which may include individual fees collected and/or overall member contribution to the group. Patients are charged according to services rendered. Groups may also guarantee a minimum salary for individual surgeons.

A fixed salary (not based on production) for a new surgeon in the group is acceptable.  Some surgeons may be compensated as employees with no intention of becoming full partners in the group.  Other surgeons may begin as employees but later become partners at the group’s discretion.

Group Practices: Surgeons and Physicians Who Are Non-Surgeons

When a group of physicians includes both surgeons and non-surgeons, members of the group are often compensated based on tracking contributions to the group based on the relative value units (RVUs) of the services provided.  Other contributions to the group may also be used to determine compensation, as long as the method used is compliant with federal and state laws and regulations.

In some instances a surgeon may rent office space from non-surgeon(s). Regardless of whether or not the non-surgeon(s) refers patients to the surgeon, the surgeon should rent the office space only under terms and conditions available in the open market and documented as such. The rental of such space at an above or below market rate would represent a form of fee splitting and would not be in the interest of quality care.

Group Practices: Surgeons and Non-Physician Practitioners

A group practice may include both surgeons and non-physician practitioners such as nurse practitioners, physician assistants, surgical assistants, or physical therapists. Compensation should be based on the medically necessary services that each individual provides and should avoid fee splitting.

For office-based procedures, services should be billed in the name of the practitioner performing the service unless the services meet the definition of “incident to” services. For services in a hospital setting, the service is only a shared service that may be billed by the surgeon if both the surgeon and the non-physician practitioner actually see the patient.

If non-physician practitioners are renting office space from surgeons, the rent and terms should be at fair market value and documented as such.

Group Practices: Alternative Delivery Systems (ADS)

With the explosive growth of alternative delivery systems (ADS) in the healthcare market, surgical practice groups are likely to encounter clauses in ADS contracts in which surgeons agree to provide care to a defined population for fees that represent a discount from a surgeon’s usual rate of compensation through managed care networks or an agreement to bundle fees with hospitals and sub-acute providers.  A surgeon also may enter into arrangements with a hospital in which the hospital provides the surgeon with a percentage share of any reduction in patient care costs that are attributable to the surgeon’s efforts while ensuring that quality of care is maintained or improved. Such arrangements are not considered to be fee splitting and may be fully compliant with applicable federal and state laws and regulations if structured appropriately to ensure continued quality of patient care.

Surgeons who work for an HMO, government agency, or other provider under a “staff model” and receive salaries based on the value of services should not encounter problems of fee splitting. In this situation, the surgeon is dealing with a defined group of patients and a closed panel of physicians who refer patients for surgery and receive no compensation for the referral. It is also acceptable for a surgeon who works for a provider under the “staff model” to receive a salary plus a bonus that is contingent on the provider’s cost performance and/or profits. However, the “staff model” should be structured so that such cost containment incentives do not reduce the quality of care or penalize the physician when, in his or her professional judgment, medical care is deemed necessary for the patient.

In situations where an osteopathic surgeon joins a group practice consisting of non-surgeons who have a contractual agreement with a provider in which the non-surgeon’s salary is on a capitation basis, the surgeon may share along with the other physicians in the “capitation risks.” These “capitation risk” clauses are usually included in contracts as an incentive for cost containment. Again, these clauses should be structured to eliminate waste and stimulate efficiency without interfering with a surgeon’s professional judgment and consequently reducing the quality of medical care to the patient.

Group Practices: Allowance of Training in the Operating Room By Industry Representatives

Health care industry representatives may provide valuable technical assistance to a surgical team in the operating room (OR) to ensure the delivery of safe and effective patient care. Written policies in compliance with applicable federal and state laws should be established in all settings of care, acute care hospital, ambulatory surgery center, office-based OR, governing the presence of industry representaties in the OR. These policies would include a designation of the approval pathway, provision of appropriate identification to the industry representative, confirmation of sterile technique, among others. The surgeon should provide notice to the patient of the presense of the industry representative in the OR through written and signed informed consent, and this presence should be documented in the medical record.

 The surgeon should not compensate the industry representative for this assistance and the representative should not scrub, or engage in the practice of medicine or nursing, or take part in the medical decision making.


The College has concluded that certain methods of allocating salaries or other compensation among physicians in group practices should not be construed as violative of Section 12 of the AOA Code of Ethics provided that these methods are compliant with federal and state laws and regulations.  These federal and state requirements are subject to change from year to year, and group practices must remain in compliance at all times.  Specifically, groups must maintain separate accounts for surgeons and non-surgeons practicing on a fee for service basis, and patients must be charged only for professional services rendered that are medically necessary.

Further, it is acceptable for individuals in a group practice to share a “capitation risk” within the group practice or with outside facilities as a method of cost containment, if this incentive does not interfere with professional judgment and the delivery of quality care to the patient.

Performing Surgery Away from the Surgeon’s ‘Home’ Hospital(s)

If a surgeon performs surgery at a distance from his usual practice or “home” hospital(s), the surgeon will be upholding the standards of the AOA Code and will not be abandoning his patients if: 1) the surgeon assures himself that the hospital at which he performs the surgery has adequate and appropriate staff and facilities to render necessary care to the patient; 2) the surgeon either makes or confirms the diagnosis and reviews the adequacy of the preoperative preparation prior to surgery; and 3) the surgeon personally renders the postoperative care or, with the consent of the patient, delegates it to another qualified physician.

The surgeon should assure that the patient will be cared for as well as if the operation had been performed in the surgeon’s home hospital(s). Emergency surgery may, however, pose exigent circumstances which should be taken into consideration when determining whether the AOA Code has been maintained. If these standards cannot be met, the physician should take the steps necessary to assure the standard of care needed.

Revised 3/27/12