Healthcare Event: Review the Provider Based Rule


Provider based rule was founded 4-13-65 in the code of Federal Regulations. It's difficult to interpret.  Now, it's almost a stealth rule because it's easy to overlook it because nobody may be there looking over your shoulder to make sure you're doing things correctly. And it would suddenly come up that somebody would come in and claim that you were overpaid because you didn’t meet a certain criterion, et cetera. Read this advice provided by our expert in a health system conference.

And we have questions about NPIs, the CMS 855 billing privileges, all of the forms, we have to fill out, the A, the B, the I, the R, et cetera especially if you're employing physicians. And we still need interpretation for a number of the provisions in the provider based rule.

Now, one of the key issues particularly today although we've recognized it is that when you look at provider based clinics, you need to separate them into three different geographical buckets. Put these into three different geographical classes keeping in line with the CMS rules. Those that are off campus, those that are on campus but outside of the hospital and then those that are in the hospital. So those are the three buckets, three classifications we will consider today.

And it turns out that just recently, we're right in the middle of changing the healthcare rules relative to these on campus out of hospital physician supervisory requirements. And in order to do that, we have to have a definition of what's in the hospital. And we're going to make all of these stuff crystal clear relative to who's doing what, when, where and how.

Now, physician supervision, that's what we're talking about. Medicare and CMS divides this into two categories, one for diagnostic, diagnostic physician supervision which for hospitals is typically not a major issue. But for freestanding independent diagnostic testing facilities, et cetera, this is a major issue.

And there are three levels as per CMS rules. There is general which basically means the doctors, you know, can be telephoned or within fax range or something. Direct is where the doctor is physically available may not be right there when the service is provided. And then there is personal where the doctor has to be right there.

Now, if you want to look up these three levels and know which diagnostic tests fall under these three levels, you'll have to go to RBRVS the resource based relative value system more specifically the Medicare physician fee schedule.

And if you download that, it'll be in a Microsoft Excel file. And it's very big. But it has a lot of really good information. And one of the columns in this fee schedule, one of the columns indicates the supervisory level. Now, usually, they only have the supervisory indicator with certain radiology test. But that's where it is. That's where it is.

The other category is therapeutic according to healthcare guidelines. And that's mainly what hospitals or hospice hospitals are interested in. And with therapeutic, we have direct physician supervision. And we have indirect physician supervision where the doctor is contactable but not necessarily physically a close by.

Now, another question that has risen is who can provide supervision. In other words, if CMS is going to require direct physician supervision, who can qualify to give that supervision? And it turns out that just recently, Medicare has gone through the logical process of analyzing this issue. They have determined that midlevels, the practitioners do not qualify. It has to be a doctor, MD or DO.

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