JR - Health Care Compliance Association

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PHYSICIAN PRACTICE AND BILLING ISSUES...continued from page 11 Beware that a number of state sites may still be under construction or may not have any “search” capabilities. Further, some states do not provide explicit written guidance concerning physician supervision, while others default to the requirements established by Medicare or their contracted managed care payers. When you may be faced with a lengthy, and oftentimes unsuccessful, review of years of Medicaid program bulletins, it is generally easier to solicit information directly from their provider relations group. Remember to always get answers in writing. Send a letter or fax to confirm answers provided over the phone. Finally, a number of state programs do not enroll all types of NPPs. For example, MediCal enrolls advance practice nurses, but only pediatric nurse practitioners and primary care nurse practitioners. In these states, you may end up having to petition the state program to recognize a new type of NPP. Be prepared to submit extensive information regarding qualifications and types of services provided (e.g., CPT codes). Another important step in effectively dealing with the issues presented by NPPs requires careful reading and interpretation of the AMA’s CPT (Common Procedure Terminology) manual. Many of the services provided by physician practices in both the inpatient and outpatient settings entail evaluation and management (E&M) services which, with the exception of 99211, are described as requiring the presence of a physician. However, in a state where the supervision requirement is “available by telephone,” E&M services may be reported under an enrolled, mid-level provider’s name and PIN. Conversely, other E&M services performed by an enrolled mid-level provider should be reported under the supervising physician’s name and PIN even if the supervision requirements have been met. For example, the 2002 CPT manual defines the neonatal critical care codes as “services provided by a physician directing the care of a critically ill newborn [or managing the continuing intensive care of the very low birth weight (VLBW) infant].” The reported service is the physician’s direction of the critically ill newborn’s care, not the individual services that may have been rendered by the mid-level provider. State laws and practice acts also need to be researched to confirm that services fall within the NPP’s scope of practice; e.g., licensure. For example, Arizona permits delivery services to be provided by a licensed midwife without direct physician supervision, but only to Medicaid beneficiaries for whom an uncomplicated prenatal course and a low-risk labor and delivery can be anticipated. Also, make certain that any mid-level providers working in an inpatient setting have been granted appropriate privileges by the hospitals. Once the regulatory research is complete, the next step is to ensure that the practice’s operations supports both the billing and record keeping requirements; i.e., are all NPPs properly enrolled (including those cross-over states), would existing documentation evidence that supervision requirements had been met, etc. All appropriate practice personnel need to be educated regarding pertinent requirements. Lastly, don’t leave your fate to chance. Conduct a follow-up review a short while after implementing any changes to ensure compliance. A few unintentional errors may be acceptable, but a pattern of errors may have serious consequences. ■ August 2002 WEB RESOURCES...continued from page 10 ■ OIG ISSUES Draft Compliance Program Guidance for Ambulance Suppliers http://oig.hhs.gov/fraud/docs/ complianceguidance/draftambulance compliance060602.pdf ■ IG Testimony: Medicare pays above 12 market prices for medical supplies http://oig.hhs.gov/testimony/docs/2002/ 020611fin.pdf ■ Federal Register Notice RE: Revision of OIG Compliance Guidance for the Hospital Industry http://oig.hhs.gov/authorities/docs/ cpg%20hospital%20solicitation %20notice.pdf ■ OIG Advisory Opinion No. 9–concerning whether a proposed singlespecialty ambulatory surgical center that would be wholly-owned by a physician would violate the administrative authorities related to the antikickback statute http://oig.hhs.gov/fraud/docs/advisory opinions/2002/ao0209.pdf ■
feature article Editor’s note: This interview with James Roosevelt, Senior Vice President and General Counsel for Tufts Health Plan in Boston and recently named President of the American Health Lawyers Association was conducted by F. Lisa Murtha, HCCA Board member and Chief Audit and Compliance Officer for Children’s Hospital of Philadelphia. Mr. Roosevelt may be reached at 781/466-8564 and Ms. Murtha may be reached at 215/590- 9156. LM: Thank you so much Jim for joining us. We really appreciate your time this morning. I wanted to chat with you a bit about your new role as the President of American Health Lawyers Association (AHLA). When does your term begin or has it already begun and what is your single biggest mission for the AHLA for your term as President? JR: My term with AHLA begins at our annual meeting in San Francisco on July 1st. The fundamental mission of AHLA is education of lawyers and others who work with health law and regulations. So my single biggest mission is to maintain and continue to improve the high standard of education both in in-person conferences and teleconferences as well as publications. My secondary mission is to expand the audience and membership of AHLA. LM: Do you see any obstacles over the course of the next year with AHLA Meet James Roosevelt Senior Vice President and General Counsel for Tufts Health Plan in achieving your mission. I mean, in light of world events such as September 11th. JR: Well, we have increased teleconferences, some of them on issues that come up quickly, and we’ve put together a quick mini-seminar or discussion. We’ve initiated a series of conversations with major policymakers by teleconference. However, our in-person conferences have returned to the sort of attendance that we were getting before 9-11. After 9-11, we had a little dip, maybe 20 percent or so, but within about two months, we came back to the pre-9-11 level. LM: Well, as you know, the Health Care Compliance Association is partnering with the American Health Lawyers Association on the Fraud and Compliance Forum. And I was just curious as to your perspective on partnerships with associations like the HCCA or others, as the case may be. Do you think that that is the wave of the future? JR: I participated in the Fraud and Compliance Forum last fall actually and I was also a participant in another joint conference that Health Lawyers put on this year with the American Association of Health Plans. And I do think that joint events are valuable to both organizations. Health Lawyers bring a particularly high standard in legal education and great resources in terms of our speakers and writers. The organizations of people who work in the field bring both an important perspective on planning the conferences so that the conferences are relevant to very current issues, not just what might have come to a lawyer in a law firm six months, a year, two years after the fact when some litigation matter has arisen or something like that. So, I think that the collaboration between Health Lawyers and some of the health care industry organizations is valuable both for the content and the attendance at the events. LM: Have you been involved in the Continued on Page 14 13 August 2002
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Page 5 and 6: FOCUS ON ETHICS & COMPLIANCE Compli
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JR - Health Care Compliance Association

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