Liles Parker PLLC
(202) 298-8750 (800) 475-1906
Washington, DC | Houston, TX
San Antonio, TX | Baton Rouge, LA

We Defend Healthcare Providers Nationwide in Audits & Investigations

Duties of Referring and Ordering Physicians

(May 30, 2012): AdvanceMed Corporation (AdvanceMed), a Zone Program Integrity Contractor (ZPIC) for Medicare Parts A and B, recently released a letter discussing the responsibilities of referring and ordering physicians when asked to supply home health agencies, DMEPOS suppliers, therapists, labs and similar services with records associated with the referral. Specifically, AdvanceMed cited Section 1833(q) of the Social Security Act, which requires that, “if [the government] requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.”

From a practical standpoint, when dealing with Medicare post-payment audits, this doesn’t make much sense, since the statute requires that referring and ordering physicians provide records when the service is ordered or referred. Nevertheless, the intent of the law is clear: if Medicare contractors are auditing a home health agency, DME supplier or the like, the physician who ordered those services in the first place has to turn over the relevant records when requested.

I.     What are the Penalties Associated With Referring and Ordering Physicians?

AdvanceMed continues by citing 42 C.F.R. § 424.535, which provides that the failure of referring and ordering physicians to provide records as required may lead to revocation of a provider’s Medicare enrollment and billing privileges. As you can imagine, such an event would effectively put a provider out of business.

In recent years, our attorneys have worked on a variety of revocation actions instituted by the Centers for Medicare & Medicaid Services (CMS) and its contractors, and they can be difficult matters to overcome. The law lists a number of reasons CMS may revoke a provider’s privileges, with one being the Failure to document or provide CMS access to documentation.” Based on the cases we have seen, this provision typically is cited when contractors have been denied access to a provider’s records during an unannounced visit.  Should you be subjected to an unannounced visit by a ZPIC or other contractor, take care.  We strongly recommend that you immediately call your attorney for guidance.

If you are a physician who regularly refers patients for these types of services, take seriously any requests from subsequent providers or suppliers when they ask for records. Conversely, if you are a DME supplier, home health agency, or other provider or supplier who receives referrals, when you are audited by Medicare, you should know that referring and ordering physicians are required to provide you the information described above for review by Medicare contractors. Note that 42 C.F.R. § 424.516 requires that both referring and ordering physicians and entities actually furnishing the service or supply must maintain documentation related to the service for 7 years.

II.      Conclusion:

The responsibilities of referring and ordering physicians can be complex, and you should know – before you ever start referring services – what your duties in that regard are. Likewise, as a referring or ordering physician, you should not sign prescriptions or write orders for any patient you do not know and have not treated – many Medicare fraud schemes begin this way. For home health agencies, DMEPOS suppliers, labs, and imaging facilities, be sure to request document from referring and ordering physicians should any Medicare contractor ever question your billing or audit your claims. Providers and suppliers must continue to work together in order to provide high quality healthcare to beneficiaries and remain compliant with applicable Federal and state laws. Click here to read AdvanceMed’s letter.

Robert W. LilesHealthcare Lawyer is the Managing Member of Liles Parker and is based in the firm’s Washington D.C. office. Mr. Liles represents clients around the country in Medicare administrative appeals, compliance issues, fraud and abuse concerns, and other health law matters. For a complimentary consultation, please call Mr. Liles today.  He can reached at 1 (800) 475-1906.

  • Advertisement

Speak Your Mind

Tell us what you're thinking...
and oh, if you want a pic to show with your comment, go get a gravatar!

You must be logged in to post a comment.