Tuesday, January 3, 2017

Ordering/Referring Physician Documentation Responsibility

Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program. (f) Maintaining and providing access to documentation.

(1) A provider or a supplier who furnishes covered ordered DMEPOS or referred home health, laboratory, imaging, or specialist services is required to maintain documentation for 7 years from the date of service and, upon the request of CMS or a Medicare contractor, to provide access to that documentation. The documentation includes written and electronic documents (including the NPI of the physician who ordered the home health  services and the NPI of the physician or the eligible professional who ordered or referred the DMEPOS, laboratory, imaging, or specialist services) relating to written orders and requests for payments for items of DMEPOS and home health, laboratory, imaging, and specialist services.

(2) A physician who ordered home health services and a physician and an eligible professional who ordered or referred items of DMEPOS or laboratory, imaging, and specialist services is required to maintain documentation for 7 years from the date of the order, certification, or referral and, upon request of CMS or a Medicare contractor, to provide access to that documentation. The documentation includes written and electronic documents (including the NPI of the physician who ordered the home health services and the NPI of the physician or the eligible professional who ordered or referred the DMEPOS, laboratory, imaging, or specialist services) relating to written orders or requests for payments for items of DMEPOS and home health, laboratory, imaging, and specialist services.

The Office of the Inspector General (OIG) U.S. Department of Health and Human Services provides physician educational resources on physician relationships with payers and vendors. These resources are found here: http://oig.hhs.gov/compliance/physician-education/index.asp. The educational information discusses maintaining and providing documentation as well as the importance of legitimate prescriptions for patients.

As a billing provider/supplier, if you are asked and/or required to pay for or refused documentation by a referring/ordering physician, please report the incident as potential fraud and/or abuse. As a referring/ordering physician, if you are asked to sign or write prescriptions for Medicare beneficiaries by a provider/supplier for unnecessary services/items or for patients you do not know, please report the incident.

Executive Summary

When physicians believe their patients may require the expertise of another physician, effective, timely and informative communication between all physicians is essential to ensure appropriate use of specialty care services. The results of physician surveys indicate a lack of informative referral communication exists in Canada. Significant variation exists in referral request processes*. This is contributing to the poor access to specialty care that many patients are experiencing.

Some of this variation is necessary, however, which means that a single, standardized solution to improve the entire referral and consultation process is not feasible. Nonetheless, while communication processes and information requirements for referral requests vary considerably, the communication and information needs in consultant responses is essentially the same for all referring physicians. Unfortunately, provision of this information is often lacking. This problem can be addressed through standard communication protocols because all referring physicians benefit from receiving the same types of information in response to referral requests; for example, acknowledgement of referral receipt or patient consult reports.

Furthermore, when referrals are initiated, specific types of requests can benefit from standardization of communication methods and information requirements. Such activities are already underway in Canada in select areas. These successful initiatives, used together as complementary approaches to address the varying needs of referral requests, should be adopted throughout the country.

RECOMMENDATIONS

** All stakeholders, especially physicians, but also, where appropriate, office assistants, nurses, other health care providers as well as patients, must be engaged in an early and meaningful way regarding any initiative that has a goal to improve referral or consultation processes.

** There is no single best way to access specialist expertise; as a result, a combination of complementary initiatives (e.g., formal consultation systems, standardized referral processes with central intake systems and/or physician directories) should be implemented to reduce variation in the approaches that are used and to facilitate more timely access to specialty care for patients.

** While acknowledging the referring physician’s ability to interpret certain test results, the referral must be accompanied by appropriate information to allow the consulting specialist to fully assess the request, and the referring physician must be informed of what is “appropriate”.

** The referring physician (and family physician if different), as well as the patient, should be kept informed, in a timely fashion, of the status of the referral request, using standardized procedures, minimum information requirements and timelines.

** Physician and/or physician practices should receive compensation and support in recognition of the time and effort undertaken to communicate appropriate information regarding referral requests as well as to conduct electronic or real-time consultations.

The most appropriate method of communication differs depending on the degree of specialist involvement that is required. There are no standards about which method of communication is the most appropriate or effective, or what information is required, for each situation. Referral request processes† vary significantly; not only across specialties but among specialists within a particular specialty and even within a geographic region.

Examples of this variation include: some consulting specialists will accept referrals only if the referring physician has used their specific referral form; others accept referrals using only one particular communication method (e.g., by fax); and others accept referrals on just one day each month. Such variation creates inefficiencies because referring physicians must familiarize themselves with each request process that is required by each consulting specialist.

The range and quality of information provided in a referral request also varies considerably; for example, too little information (i.e. no reason for referral provided), insufficient information (i.e. out-of-date or a lack of lab or imaging tests), or to too much information (i.e. noncontributory family history).

This lack of standardization is problematic. In this context, standardization means simplification rather than obligation. Standardized processes facilitate communications for referrals by removing ambiguities about which method is most appropriate for each situation.

Communication methods and the types of information that are transferred between referring physicians and consulting specialists vary based on numerous factors, ranging from those beyond the control of physicians such as regulations and available technology, to those completely within their control such as their own individual preferences.

An effective way to facilitate appropriate and timely access to specialty care that is within the control of the health care profession is to explore the rationale behind these varying communication and information preferences and address these variations by developing, with meaningful participation and approval from physicians and their administrative staff, standard processes for requesting a specialist referral and for communicating back to the referring physician.

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