Medicare

March 17, 2016

Posted on by hortyspringer

QUESTION:        Occasionally, a physician on our medical staff will want to treat a family member.   Medical staff leadership does not think this is a good idea, but we have not expressly addressed this in any of our documents.  If we allow it, can the physician bill for the services he provides to a family member?

ANSWER:           The American Medical Association (“AMA”) has taken a strong stance against the treatment of family members by a physician.  The AMA’s Opinions on Practice Matters, E-8.19 Self?Treatment or Treatment of Immediate Family Members, includes the following statement:

Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member … is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered. Physicians may fail to probe sensitive areas when taking the medical history or may fail to perform intimate parts of the physical examination. Similarly, patients may feel uncomfortable disclosing sensitive information or undergoing an intimate examination when the physician is an immediate family member…. If tensions develop in a physician’s professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician….

Since this issue has come up, or even if it hasn’t, we recommend that you add language to your rules and regulations to address it.

With respect to your second question, it is important for physicians to know that they cannot bill Medicare for services provided to family members. Medicare policy clearly states that the treatment of certain family members is not to be reimbursed by Medicare or any Medicare Advantage program.  The following relationships are included in the definition of family members:

  • Husband and wife;
  • Natural or adoptive parent, child, and sibling;
  • Stepparent, stepchild, stepbrother, and stepsister;
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
  • Grandparent and grandchild; and
  • Spouse of grandparent and grandchild.

While this is a Medicare policy, many other insurance companies have adopted this as part of their contractual policies with providers.

July 2, 2015

Posted on by hortyspringer

QUESTION:        We are in the process of buying a Medicare provider. Can you provide any guidance on Medicare’s Change of Ownership (“CHOW”) process?

ANSWER:             Yes. Medicare has made it practically impossible to acquire any provider without assuming that provider’s Medicare Provider Number. As a result, you will have to follow Medicare’s CHOW process.

The CHOW process requires both the Seller and the Buyer to complete a CMS Form 855-A for each Medicare Provider Number. (It is not unusual for one provider to have several Medicare Provider Numbers.) You will also need to obtain a new NPI number that will correspond to each Medicare Provider Number.

The Buyer and the Seller’s completed Forms, 855-A, with all attachments, must be sent to the Medicare Contractor. Please be sure to provide all information requested in the required format. When they ask for a zip code +4 or the date in an mm/dd/year format, they mean it! If you have to provide any supplemental information, then you also have to have a new certification statement (Section 15 of Form 855-A) signed and dated by an “Authorized Official.” An “Authorized Official” is defined in the 855-A as an individual who has the authority to make the changes in that submission and to commit the Buyer to fully abide by the statutes, regulations and program construction of the Medicare Program.

Once the Medicare carrier approves the application, it will be sent to CMS’s Regional Office for their review and comment. Once approved, the Regional Office will issue an approval to the provider, the Medicare Contractor and the State.

This process takes time, so plan accordingly. Also since the Buyer will be assuming the Seller’s provider number, the acquisition agreement should address the rights of the Buyer in the event of an overpayment that was caused by the Seller’s pre-closing operation of the provider but is not discovered until after the Closing Date.

Did you notice how many of this week’s cases involved employed physicians? We did!

Please join Henry, Charlie and Rachel in Las Vegas on October 15-17 for the Institute on Employed Physicians and Their Impact on the Medical Staff.