HHS Announces Overhaul of Kickback and Stark Rules

Wilson Sonsini Goodrich & Rosati

Wilson Sonsini Goodrich & Rosati

On October 9, 2019, the U.S. Department of Health and Human Services' (HHS') Centers for Medicare and Medicaid Services (CMS) and Office of Inspector General (OIG) announced plans for sweeping changes to rules policing health care fraud and abuse. The proposals extend to rules implementing the federal Anti-Kickback Statute (AKS), the Physician Self-Referral Law (the Stark Law), and the Civil Monetary Penalty (CMP) Law prohibiting beneficiary inducements.1 Although CMS and the OIG coordinated the release of these proposed rules, OIG also acknowledged that its proposed safe harbors for value-based arrangements are more restrictive than CMS' proposals in order to serve as a backstop to fraud and abuse issues that may arise with arrangements protected by an exception.

HHS's announcement promises to modernize how these laws apply to rapidly evolving aspects of care delivery, organization and reimbursement, including: value-based care; coordinated care; alternative payment systems; telehealth; electronic health records (EHR); personal services and management contracts; and patient engagement. The proposed rules include significant new safe harbors from the AKS and exceptions from the CMP Law and the Stark Law. In the respective announcements, OIG and CMS emphasize the joint purposes of more broadly accommodating value-based payment and care and better coordinating the two agencies' oversight of such matters. The proposals extend far beyond, however, to changes with broad potential consequences for AKS and the Stark Law enforcement. We highlight a few key elements below.

The proposals are expected to publish in the Federal Register on October 17, 2019. Interested parties will then have 75 days for submitting comments.

OIG's Value-Based Purchasing Proposals

To promote coordinated patient care and health outcomes-based payments, OIG proposes three new safe harbors that cover certain money and in-kind remuneration exchanged between or among parties of value-based arrangements, with greater flexibilities provided to parties that assume more downside financial risk for the cost and quality of care: (1) care coordination arrangements that improve quality, health outcomes, and efficiency (§ 1001.952(ee)), including certain in-kind remuneration, including services and infrastructure; (2) value-based arrangements with substantial downside financial risk (§ 1001.952(ff)), which covers certain in-kind and monetary arrangements where a value-based enterprise (VBE) is at substantial downside financial risk from a payor; and (3) value-based arrangements with full financial risk (§ 1001.952(gg)), which covers certain in-kind and monetary arrangements where the VBE is at full downside financial risk from a payor.

The OIG proposes to exclude "device manufacturers" from the definition of "VBE participant" and from protection under the various proposed safe harbors, including the exclusion from participation in outcomes-based payment arrangements. The OIG's proposed definition of "VBE participant" is "an individual or entity that engages in at least one value-based activity as part of a value-based enterprise." The OIG states that the definition "expressly excludes pharmaceutical manufacturers; manufacturers, distributors, or suppliers of durable medical equipment, prosthetics, orthotics or supplies (DMEPOS); and laboratories." The OIG believes that not all device manufacturers play a role in the coordination of care but they note that it may not be possible to distinguish a traditional medical device manufacturer from a health technology company that does assume such role.

The OIG has several proposals for the definition of "medical device manufacturers."

  • CMS's definition of "applicable manufacturer" in 42 CFR 403.902, which relates to the "Sunshine" provisions of the ACA.
  • The definition will include an entity that manufacturers any item that requires premarket approval by, or premarket notification to, the FDA or that is classified by the FDA as a medical device.
  • Whether the item the manufacturer manufactures is eligible for separate or bundled payment from a Federal health care program or other payor or is used in a test that is eligible for separate or bundled payment from a Federal health care program or other payor.
  • The definition will include distributors or wholesalers when they are distributing or selling devices manufactured by a device manufacturer.

OIG's Proposed New Safe Harbors to the AKS

42 CFR § 1001.952(hh) Patient Engagement and Support Arrangements. This proposed safe harbor would allow providers to offer patients beneficial tools and supports to improve quality, health outcomes, and efficiency, by promoting patient engagement with their care and adherence to care protocols, without violating beneficiary inducement prohibitions.

42 CFR § 1001.952(ii) CMS-Sponsored Model Arrangements and CMS-Sponsored Model Patient Incentives. The OIG has proposed this new safe harbor to "standardize and simplify anti-kickback statute compliance for CMS-sponsored model participants." This proposal acknowledged CMS's "ability to oversee and monitor CMS sponsored models and initiatives and to embed program integrity protections in such models and initiatives in ways that do not necessarily apply to arrangements outside the models." If finalized, this proposal would eliminate the need for the OIG to provide fraud and abuse waivers to participants on a case-by-case basis.

Other OIG Proposals

  • Patient Engagement – a new safe harbor (§ 1001.952(hh)) for certain tools and supports furnished to patients to improve quality, health outcomes, and efficiency.
  • CMS-Sponsored Models – a new safe harbor (§ 1001.952(ii)) for certain remuneration provided in connection with a CMS-sponsored model.
  • Cybersecurity Technology and Services – a new safe harbor (§ 1001.952(jj)) for donations of cybersecurity technology and services.
  • Electronic Health Records Items and Services – modifications to the existing safe harbor for electronic health records items and services (§ 1001.952(y)) to add protections for certain related cybersecurity technology, to update provisions regarding interoperability, and to remove the sunset date.
  • Outcomes-Based Payments and Part-Time Arrangements – modifications to the existing safe harbor for personal services and management contracts (§ 1001.952(d)) to add more flexibility with respect to outcomes-based payments and part-time arrangements.
  • Warranties – modifications to the existing safe harbor for warranties (§ 1001.952(g)) to revise the definition of "warranty" and to provide protection for bundled warranties for one or more items and related services.
  • Local Transportation – modifications to the existing safe harbor for local transportation (§ 1001.952(bb)) to expand and modify mileage limits for rural areas and for transportation for patients discharged from inpatient facilities.
  • Accountable Care Organization (ACO) Beneficiary Incentive Programs – codification of the statutory exception for ACO Beneficiary Incentive Programs for the Medicare Shared Savings Program (§ 1001.952(kk)).
  • Telehealth for In-Home Dialysis – provides a new statutory exception to the prohibition on beneficiary inducements for "telehealth technologies" furnished to certain in-home dialysis patients.

CMS Value-Based Purchasing Proposals

In its proposed rule, CMS proposes several exceptions to the Stark Law for: (1) value-based compensation arrangements between or among physicians, providers, and suppliers; (2) arrangements under which a physician receives limited remuneration for items or services that the physician actually provides; and (3) a new exception for donations of cybersecurity technology and related services. To support the new exceptions, CMS is proposing definitions of key terms in those exceptions. CMS also proposes to amend the existing exception for EHR items and services.

CMS' Proposed Changes to Existing Stark Law Exceptions

Commercially Reasonable: CMS is proposing two alternative definitions for the term "commercially reasonable." CMS is proposing that commercially reasonable means either: (a) the particular arrangement furthers a legitimate business purpose of the parties and is on similar terms and conditions as like arrangement or (b) arrangement makes commercial sense and is entered into by a reasonable entity of similar type and size and a reasonable physician of similar scope and specialty. Notably, CMS stated in the proposed rule that an arrangement may be commercially reasonable even if the arrangement does not result in a profit for one or both parties. CMS noted that the Stark statute itself does not include a definition of commercially reasonable.

Designated Health Services: CMS is proposing to amend the definition of designated health services "to clarify that a service provided by a hospital to an inpatient does not constitute a designated health service payable, in whole or in part, by Medicare, if the furnishing of the service does not affect the amount of Medicare's payment to the hospital under the Acute Care Hospital Inpatient Prospective Payment System (IPPS)." This proposal is in response to disclosures CMS has received under Self-Referral Disclosure Protocol.

Writing and Signature Requirement: CMS is proposing that the writing requirement or the signature requirements of certain compensation arrangements would be deemed to be satisfied if: (1) the compensation arrangement satisfies all requirements of an applicable exception other than the writing or signature requirement(s); and (2) the parties obtain the required writing or signature(s) within 90 consecutive calendar days immediately after the date on which the arrangement failed to satisfy the requirement(s) of the applicable exception.

Fair Market Value: CMS is proposing three definitions of fair market value for (1) equipment rentals, (2) office space, and (3) FMV in general. All three definitions would reference "general market value," which has its own proposed changes. This proposal is to eliminate the connection to the volume or value standard and "to give parties with ready access to the definition of "fair market value," with the attendant modifiers, that is applicable to the specific type of compensation arrangement at issue."

The Volume or Value Standard and the Other Business Generated Standard: CMS is proposing that compensation would take into account the volume or value or referrals only when the formula used to calculate the compensation includes a referrals or other business generated as a variable. CMS states that there must be a direct correlation between referrals or other business generated and the prospective rate of compensation to be paid.

Other CMS Proposals

CMS is also proposing revisions to the Stark law generally to modernize and clarify the existing regulations and changes that would affect the deeming provision pertaining to interoperability at and provisions related to interoperability and data lock-in. Specifically, the proposal would clarify that donations of certain cybersecurity software and services are permitted under the EHR exception, the sunset provision would be removed, among other changes.

42 CFR § 411.357(z) Limited Compensation to a Physician. CMS is proposing a new exception for limited compensation to a physician of up to $3,500. CMS states that this proposal is in response to arrangements they have reviewed under their Stark Self-Referral Disclosure Protocol. CMS expected that once compensation exceeds the $3,500 threshold, other applicable exceptions would control.

42 CFR § 411.357(bb) Cybersecurity Technology and Related Services. This proposal would protect certain types of donated cybersecurity technology and related services.

Melissa Hudzik, Jeff Weinstein, and Eva Yin contributed to the preparation of this WSGR alert.

1 OIG, Proposed Rule, “Medicare and State Healthcare Programs: Fraud and Abuse; Revisions To Safe Harbors Under the Anti-Kickback Statute, And Civil Monetary Penalty Rules Regarding Beneficiary Inducements”, available at https://www.hhs.gov/sites/default/files/oig-nprm.pdf.

CMS, Proposed Rule, “Medicare Program; Modernizing and Clarifying the Physician Self-Referral Regulations”, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-22028.pdf.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Wilson Sonsini Goodrich & Rosati | Attorney Advertising

Written by:

Wilson Sonsini Goodrich & Rosati

Wilson Sonsini Goodrich & Rosati on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
- hide

JD Supra Privacy Policy

Updated: May 25, 2018:

JD Supra is a legal publishing service that connects experts and their content with broader audiences of professionals, journalists and associations.

This Privacy Policy describes how JD Supra, LLC ("JD Supra" or "we," "us," or "our") collects, uses and shares personal data collected from visitors to our website (located at www.jdsupra.com) (our "Website") who view only publicly-available content as well as subscribers to our services (such as our email digests or author tools)(our "Services"). By using our Website and registering for one of our Services, you are agreeing to the terms of this Privacy Policy.

Please note that if you subscribe to one of our Services, you can make choices about how we collect, use and share your information through our Privacy Center under the "My Account" dashboard (available if you are logged into your JD Supra account).

Collection of Information

Registration Information. When you register with JD Supra for our Website and Services, either as an author or as a subscriber, you will be asked to provide identifying information to create your JD Supra account ("Registration Data"), such as your:

  • Email
  • First Name
  • Last Name
  • Company Name
  • Company Industry
  • Title
  • Country

Other Information: We also collect other information you may voluntarily provide. This may include content you provide for publication. We may also receive your communications with others through our Website and Services (such as contacting an author through our Website) or communications directly with us (such as through email, feedback or other forms or social media). If you are a subscribed user, we will also collect your user preferences, such as the types of articles you would like to read.

Information from third parties (such as, from your employer or LinkedIn): We may also receive information about you from third party sources. For example, your employer may provide your information to us, such as in connection with an article submitted by your employer for publication. If you choose to use LinkedIn to subscribe to our Website and Services, we also collect information related to your LinkedIn account and profile.

Your interactions with our Website and Services: As is true of most websites, we gather certain information automatically. This information includes IP addresses, browser type, Internet service provider (ISP), referring/exit pages, operating system, date/time stamp and clickstream data. We use this information to analyze trends, to administer the Website and our Services, to improve the content and performance of our Website and Services, and to track users' movements around the site. We may also link this automatically-collected data to personal information, for example, to inform authors about who has read their articles. Some of this data is collected through information sent by your web browser. We also use cookies and other tracking technologies to collect this information. To learn more about cookies and other tracking technologies that JD Supra may use on our Website and Services please see our "Cookies Guide" page.

How do we use this information?

We use the information and data we collect principally in order to provide our Website and Services. More specifically, we may use your personal information to:

  • Operate our Website and Services and publish content;
  • Distribute content to you in accordance with your preferences as well as to provide other notifications to you (for example, updates about our policies and terms);
  • Measure readership and usage of the Website and Services;
  • Communicate with you regarding your questions and requests;
  • Authenticate users and to provide for the safety and security of our Website and Services;
  • Conduct research and similar activities to improve our Website and Services; and
  • Comply with our legal and regulatory responsibilities and to enforce our rights.

How is your information shared?

  • Content and other public information (such as an author profile) is shared on our Website and Services, including via email digests and social media feeds, and is accessible to the general public.
  • If you choose to use our Website and Services to communicate directly with a company or individual, such communication may be shared accordingly.
  • Readership information is provided to publishing law firms and authors of content to give them insight into their readership and to help them to improve their content.
  • Our Website may offer you the opportunity to share information through our Website, such as through Facebook's "Like" or Twitter's "Tweet" button. We offer this functionality to help generate interest in our Website and content and to permit you to recommend content to your contacts. You should be aware that sharing through such functionality may result in information being collected by the applicable social media network and possibly being made publicly available (for example, through a search engine). Any such information collection would be subject to such third party social media network's privacy policy.
  • Your information may also be shared to parties who support our business, such as professional advisors as well as web-hosting providers, analytics providers and other information technology providers.
  • Any court, governmental authority, law enforcement agency or other third party where we believe disclosure is necessary to comply with a legal or regulatory obligation, or otherwise to protect our rights, the rights of any third party or individuals' personal safety, or to detect, prevent, or otherwise address fraud, security or safety issues.
  • To our affiliated entities and in connection with the sale, assignment or other transfer of our company or our business.

How We Protect Your Information

JD Supra takes reasonable and appropriate precautions to insure that user information is protected from loss, misuse and unauthorized access, disclosure, alteration and destruction. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. You should keep in mind that no Internet transmission is ever 100% secure or error-free. Where you use log-in credentials (usernames, passwords) on our Website, please remember that it is your responsibility to safeguard them. If you believe that your log-in credentials have been compromised, please contact us at privacy@jdsupra.com.

Children's Information

Our Website and Services are not directed at children under the age of 16 and we do not knowingly collect personal information from children under the age of 16 through our Website and/or Services. If you have reason to believe that a child under the age of 16 has provided personal information to us, please contact us, and we will endeavor to delete that information from our databases.

Links to Other Websites

Our Website and Services may contain links to other websites. The operators of such other websites may collect information about you, including through cookies or other technologies. If you are using our Website or Services and click a link to another site, you will leave our Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We are not responsible for the data collection and use practices of such other sites. This Policy applies solely to the information collected in connection with your use of our Website and Services and does not apply to any practices conducted offline or in connection with any other websites.

Information for EU and Swiss Residents

JD Supra's principal place of business is in the United States. By subscribing to our website, you expressly consent to your information being processed in the United States.

  • Our Legal Basis for Processing: Generally, we rely on our legitimate interests in order to process your personal information. For example, we rely on this legal ground if we use your personal information to manage your Registration Data and administer our relationship with you; to deliver our Website and Services; understand and improve our Website and Services; report reader analytics to our authors; to personalize your experience on our Website and Services; and where necessary to protect or defend our or another's rights or property, or to detect, prevent, or otherwise address fraud, security, safety or privacy issues. Please see Article 6(1)(f) of the E.U. General Data Protection Regulation ("GDPR") In addition, there may be other situations where other grounds for processing may exist, such as where processing is a result of legal requirements (GDPR Article 6(1)(c)) or for reasons of public interest (GDPR Article 6(1)(e)). Please see the "Your Rights" section of this Privacy Policy immediately below for more information about how you may request that we limit or refrain from processing your personal information.
  • Your Rights
    • Right of Access/Portability: You can ask to review details about the information we hold about you and how that information has been used and disclosed. Note that we may request to verify your identification before fulfilling your request. You can also request that your personal information is provided to you in a commonly used electronic format so that you can share it with other organizations.
    • Right to Correct Information: You may ask that we make corrections to any information we hold, if you believe such correction to be necessary.
    • Right to Restrict Our Processing or Erasure of Information: You also have the right in certain circumstances to ask us to restrict processing of your personal information or to erase your personal information. Where you have consented to our use of your personal information, you can withdraw your consent at any time.

You can make a request to exercise any of these rights by emailing us at privacy@jdsupra.com or by writing to us at:

Privacy Officer
JD Supra, LLC
10 Liberty Ship Way, Suite 300
Sausalito, California 94965

You can also manage your profile and subscriptions through our Privacy Center under the "My Account" dashboard.

We will make all practical efforts to respect your wishes. There may be times, however, where we are not able to fulfill your request, for example, if applicable law prohibits our compliance. Please note that JD Supra does not use "automatic decision making" or "profiling" as those terms are defined in the GDPR.

  • Timeframe for retaining your personal information: We will retain your personal information in a form that identifies you only for as long as it serves the purpose(s) for which it was initially collected as stated in this Privacy Policy, or subsequently authorized. We may continue processing your personal information for longer periods, but only for the time and to the extent such processing reasonably serves the purposes of archiving in the public interest, journalism, literature and art, scientific or historical research and statistical analysis, and subject to the protection of this Privacy Policy. For example, if you are an author, your personal information may continue to be published in connection with your article indefinitely. When we have no ongoing legitimate business need to process your personal information, we will either delete or anonymize it, or, if this is not possible (for example, because your personal information has been stored in backup archives), then we will securely store your personal information and isolate it from any further processing until deletion is possible.
  • Onward Transfer to Third Parties: As noted in the "How We Share Your Data" Section above, JD Supra may share your information with third parties. When JD Supra discloses your personal information to third parties, we have ensured that such third parties have either certified under the EU-U.S. or Swiss Privacy Shield Framework and will process all personal data received from EU member states/Switzerland in reliance on the applicable Privacy Shield Framework or that they have been subjected to strict contractual provisions in their contract with us to guarantee an adequate level of data protection for your data.

California Privacy Rights

Pursuant to Section 1798.83 of the California Civil Code, our customers who are California residents have the right to request certain information regarding our disclosure of personal information to third parties for their direct marketing purposes.

You can make a request for this information by emailing us at privacy@jdsupra.com or by writing to us at:

Privacy Officer
JD Supra, LLC
10 Liberty Ship Way, Suite 300
Sausalito, California 94965

Some browsers have incorporated a Do Not Track (DNT) feature. These features, when turned on, send a signal that you prefer that the website you are visiting not collect and use data regarding your online searching and browsing activities. As there is not yet a common understanding on how to interpret the DNT signal, we currently do not respond to DNT signals on our site.

Access/Correct/Update/Delete Personal Information

For non-EU/Swiss residents, if you would like to know what personal information we have about you, you can send an e-mail to privacy@jdsupra.com. We will be in contact with you (by mail or otherwise) to verify your identity and provide you the information you request. We will respond within 30 days to your request for access to your personal information. In some cases, we may not be able to remove your personal information, in which case we will let you know if we are unable to do so and why. If you would like to correct or update your personal information, you can manage your profile and subscriptions through our Privacy Center under the "My Account" dashboard. If you would like to delete your account or remove your information from our Website and Services, send an e-mail to privacy@jdsupra.com.

Changes in Our Privacy Policy

We reserve the right to change this Privacy Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our Privacy Policy will become effective upon posting of the revised policy on the Website. By continuing to use our Website and Services following such changes, you will be deemed to have agreed to such changes.

Contacting JD Supra

If you have any questions about this Privacy Policy, the practices of this site, your dealings with our Website or Services, or if you would like to change any of the information you have provided to us, please contact us at: privacy@jdsupra.com.

JD Supra Cookie Guide

As with many websites, JD Supra's website (located at www.jdsupra.com) (our "Website") and our services (such as our email article digests)(our "Services") use a standard technology called a "cookie" and other similar technologies (such as, pixels and web beacons), which are small data files that are transferred to your computer when you use our Website and Services. These technologies automatically identify your browser whenever you interact with our Website and Services.

How We Use Cookies and Other Tracking Technologies

We use cookies and other tracking technologies to:

  1. Improve the user experience on our Website and Services;
  2. Store the authorization token that users receive when they login to the private areas of our Website. This token is specific to a user's login session and requires a valid username and password to obtain. It is required to access the user's profile information, subscriptions, and analytics;
  3. Track anonymous site usage; and
  4. Permit connectivity with social media networks to permit content sharing.

There are different types of cookies and other technologies used our Website, notably:

  • "Session cookies" - These cookies only last as long as your online session, and disappear from your computer or device when you close your browser (like Internet Explorer, Google Chrome or Safari).
  • "Persistent cookies" - These cookies stay on your computer or device after your browser has been closed and last for a time specified in the cookie. We use persistent cookies when we need to know who you are for more than one browsing session. For example, we use them to remember your preferences for the next time you visit.
  • "Web Beacons/Pixels" - Some of our web pages and emails may also contain small electronic images known as web beacons, clear GIFs or single-pixel GIFs. These images are placed on a web page or email and typically work in conjunction with cookies to collect data. We use these images to identify our users and user behavior, such as counting the number of users who have visited a web page or acted upon one of our email digests.

JD Supra Cookies. We place our own cookies on your computer to track certain information about you while you are using our Website and Services. For example, we place a session cookie on your computer each time you visit our Website. We use these cookies to allow you to log-in to your subscriber account. In addition, through these cookies we are able to collect information about how you use the Website, including what browser you may be using, your IP address, and the URL address you came from upon visiting our Website and the URL you next visit (even if those URLs are not on our Website). We also utilize email web beacons to monitor whether our emails are being delivered and read. We also use these tools to help deliver reader analytics to our authors to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

Analytics/Performance Cookies. JD Supra also uses the following analytic tools to help us analyze the performance of our Website and Services as well as how visitors use our Website and Services:

  • HubSpot - For more information about HubSpot cookies, please visit legal.hubspot.com/privacy-policy.
  • New Relic - For more information on New Relic cookies, please visit www.newrelic.com/privacy.
  • Google Analytics - For more information on Google Analytics cookies, visit www.google.com/policies. To opt-out of being tracked by Google Analytics across all websites visit http://tools.google.com/dlpage/gaoptout. This will allow you to download and install a Google Analytics cookie-free web browser.

Facebook, Twitter and other Social Network Cookies. Our content pages allow you to share content appearing on our Website and Services to your social media accounts through the "Like," "Tweet," or similar buttons displayed on such pages. To accomplish this Service, we embed code that such third party social networks provide and that we do not control. These buttons know that you are logged in to your social network account and therefore such social networks could also know that you are viewing the JD Supra Website.

Controlling and Deleting Cookies

If you would like to change how a browser uses cookies, including blocking or deleting cookies from the JD Supra Website and Services you can do so by changing the settings in your web browser. To control cookies, most browsers allow you to either accept or reject all cookies, only accept certain types of cookies, or prompt you every time a site wishes to save a cookie. It's also easy to delete cookies that are already saved on your device by a browser.

The processes for controlling and deleting cookies vary depending on which browser you use. To find out how to do so with a particular browser, you can use your browser's "Help" function or alternatively, you can visit http://www.aboutcookies.org which explains, step-by-step, how to control and delete cookies in most browsers.

Updates to This Policy

We may update this cookie policy and our Privacy Policy from time-to-time, particularly as technology changes. You can always check this page for the latest version. We may also notify you of changes to our privacy policy by email.

Contacting JD Supra

If you have any questions about how we use cookies and other tracking technologies, please contact us at: privacy@jdsupra.com.

- hide

This website uses cookies to improve user experience, track anonymous site usage, store authorization tokens and permit sharing on social media networks. By continuing to browse this website you accept the use of cookies. Click here to read more about how we use cookies.