2022 Medicare Rules for Facility-Based Split/Shared Visits

There has been much discussion and controversy over the new CMS position on billing for split/shared services in facility settings.

As originally proposed, and starting in January 2022, if the service was shared among providers (such as physicians and physician assistants), the provider who performed the substantive portion of the visit would be the provider in whose name the service should be billed.

This has been a particular hot point in groups, such as hospital employed groups, where a significant portion of the services have traditionally been performed by physician assistants but billed in the name of the physician because the physician was still present for some portion of those services.  Note this type of situation is not amenable to incident to billing because incident to billing is not available for facility visits.

As a result of significant comment and controversy, there is a transition exception available for calendar year 2022 only.  That exception allows the service to be billed in the name of the provider who performs a key component of the visit (history, exam or medical decision making), but the billing provider must fully document that service.

In addition, the facility that is doing the billing must agree to follow that protocol, because there are still two other key components and there could be a dispute about that as well.

For physicians compensated on a productivity basis, these WRVUs may be important and this 2022 transitional role should be carefully understood.

2022 Federal Compliance Enforcement Outlook

There is almost universal agreement regarding predictions for 2022 federal enforcement in the following areas:

  1. The use of fraudulently obtained COVID relief funds in both healthcare and in general, but specifically as a foundation for False Claims Act enforcement.
  1. Furthermore, the reinstatement of the Yates memo of 2015 by the Deputy Attorney General Lisa Monaco’s Memo in October 2021 returns to the policy of individual liability for corporate misconduct.

There is general consensus regarding the resurgence of target, probe and educate (TPE) audits.  I have attached a link from the CMS website which provides an outline of the process and a humorous but misleading YouTube video regarding the alleged simplicity and intended fairness of the process.

We also expect significant audit activity around the new shared service billing rules for Evaluation and Management (E&M) visits which provide, the visit should be billed by the physician or physician assistant who provided the substantive portion of the visit, i.e. which is defined as more than half of the total time spent, and that both practitioners must be in the same group.  This may not be problematic if the visits are conducted separately and it’s accepted that the PA will be doing the billing.  However, when the visits are conducted jointly, so that the physician and the PA are both present, the physician should have an understanding of how the billing will be done, especially in a large group or system arrangement when the physician is relaying upon WRVU productivity.

“Stark” Rules: Navigating Physician Leases and Subleases

Under the Federal Ethics in Patient Referrals Act (more commonly known as “Stark”), if a physician[1] has a financial relationship with an entity, the physician may not refer patients to the entity for medical services payable by Medicare unless the financial relationship complies with the Stark safe harbors.  Thus, entities that lease or sublease space or equipment to or from physicians must ensure the terms of those agreements comply with Stark if they are planning to bill Medicare for services rendered or referred by the physicians.

For these agreements to comply with Stark, all the following must be satisfied:

1.  The agreement must be in writing, signed by the parties, and specify the premises or equipment involved.  Beware of situations in which the lease generalizes the space or equipment utilized or the parties continue to use the space or equipment after the written lease has terminated.[2]

2.  The term of the agreement must be at least one year[3], and compensation terms may not be amended during the first year. The parties may terminate the agreement within the first year of the arrangement, but if they do, the parties may not enter into a new agreement until after the first year expires.

3.  The space or equipment must not exceed that which is reasonable for legitimate business purposes.

4.  The space or equipment must be used exclusively by the lessee during the time the space or equipment is leased, except that the lessee may make payments, representing lessee’s pro rata share of expenses, for the use of common areas.

5.  The rental charges over the term of the agreement must be set in advance and consistent with fair market value and they must not be determined in a manner that considers the volume or value of any referrals or other business generated between the parties.

6.  The agreement must be commercially reasonable for each party, even if no referrals were made between them.

Stark is a strict liability statute, meaning that a person is held liable if they violate it, even if that person did not intentionally violate it.  Entities which bill Medicare for services improperly referred must repay amounts improperly received.  Failure to do so within 60 days may result in additional penalties of $15,000 per claim as well as potential False Claims Act liability.  For these reasons, it is critical that physician arrangements be structured to comply with Stark and to fit within the above-listed safe harbors.

In addition to Stark, entities must ensure that their space and equipment arrangements comply with other relevant laws, including the federal Anti-Kickback Statute and any applicable state laws. The Anti-Kickback Statute generally prohibits offering, paying, soliciting, or receiving compensation to induce or reward referrals for items or services payable by government programs, such as Medicare and Medicaid. The federal Anti-Kickback Statute is violated if even one purpose of the transaction is to induce prohibited referrals unless the arrangement is structured to fit within a regulatory safe harbor.  However, unlike Stark, the Anti-Kickback Statute is a criminal statute and requires intent.  Although the Anti-Kickback safe harbor for space and equipment rentals requirements vary to some extent from those in Stark, entities are likely to be in compliance with the Anti-Kickback Statute if they structure their arrangements to comply with Stark.

As you can see, entities and physicians alike must diligently review their leases and subleases to ensure compliance with the applicable laws.  Please contact Ashley S. Wagner, Esq. at 412-594-5550 or awagner@tuckerlaw.com if you have questions.


[1] Stark also applies to a member of the physician’s family.

[2] A holdover month-to-month rental is permitted for up to six months immediately following the expiration of an agreement that otherwise complied with Stark requirements, provided that the holdover rental is on the same terms and conditions as the immediately preceding agreement

[3] The agreement may provide for renewal terms, but the adjusted base rent during any renewal term should be based upon a new appraisal at the time of each renewal.

CMS Policy Summary: 2022 Medicare Physician Fee Schedule, Telehealth Originating Site Facility Fee and Services List, and Physician Assistant Billing

In MLN Matters article MM 12159, CMS has published summaries of the following:

  • Updates to payment policies and Medicare payment rates for services provided by physicians and non-physician practitioners (NPP)
  • Updates to Medicare telehealth services and telehealth originating site facility fee payment amounts
  • Billing for a physician assistant (PA) services

 

Will AI Work for Diagnostic Medicine?

A recent Wall Street Journal article in their “The Future of Everything” commentary stream discusses the use of artificial intelligence (AI) to “tap the treasure trove of information locked in electronic health records to treat people in real time”.

An interesting concept.  Not all that long ago this would have been disparaged as “cookie-cutter medicine”.  Now it is being touted as being able to generate a report summarizing how “thousands of patients just like you were treated in the past”.

The conflict obviously has not been eliminated.  Obviously, research of this nature could keep somebody from a making serious mistake, but it could also be a serious mistake to use the law of averages as your sole diagnostic tool.

Mandatory COVID Vaccine for Healthcare Workers

The Centers for Medicare & Medicaid Services (CMS) issued an interim final rule requiring COVID-19 vaccinations for workers in most institutional care settings.  A copy of the CMS press release can be found at https://www.cms.gov/newsroom/press-releases/biden-harris-administration-issues-emergency-regulation-requiring-covid-19-vaccination-health-care.

This rule applies to those facilities subject to CMS regulations. Several facilities are regulated by the CMS, but this does not include private practices.  A full list of these facilities can be found at the CMS published FAQ found at https://www.cms.gov/files/document/cms-omnibus-staff-vax-requirements-2021.pdf.

Under the rule, all eligible staff of CMS regulated facilities must receive the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine or requested and/or been granted a lawful exemption by December 5, 2021.  Also, all eligible workers must be fully vaccinated by January 4, 2022.

The CMS Rule also requires all facilities to have appropriate policies and procedures developed and implemented by December 5, 2021.  Some policies noted in the rule include a policy for ensuring staff are vaccinated by the applicable deadlines; a policy for requesting accommodations, where exemptions from the vaccination requirements are sought; and a policy for ensuring additional precautions to mitigate the spread of COVID-19 for staff who are not fully vaccinated, just to name some.  Therefore, it is important that facilities understand what policies they need to implement in order to not miss this important December 5 policy deadline.

For more information on this, please feel free to reach out to Mike Cassidy at mcassidy@tuckerlaw.com, Albert Lee at alee@tuckerlaw.com or Anthony Judice at ajudice@tuckerlaw.com from Tucker Arensberg, P.C.

PA Senate Approves Another Telemedicine Bill

The Pennsylvania Senate announced on October 26, 2021 that it has passed Senate Bill 705, and a copy of the Senate Press Release can be found at https://www.pasenategop.com/blog/senate-approves-telemedicine-bill/.

A previous telemedicine bill was passed in Pennsylvania in July of 2018, when the Pennsylvania Senate approved Bill 780, which was discussed in my MedLaw Blog article of July 30, 2018 .

This legislation obviously requires passage by both the State House of Representatives and signature by the governor.

The most significant obvious difference, as you can see in the markup, is that the new bill would define health care provider not only as any licensed or certified individual, but one who is “otherwise regulated to provide health care services under the laws of this Commonwealth”, which is certainly a broader and less definitive definition.

Tucker Arensberg Attorneys to Speak at the PBI Health Law Institute

Tucker Attorneys Mike Cassidy and Jerry Russo have been named as presenters for the Pennsylvania Bar Institute (PBI) 2022 Health Law Institute. They will be presenting a program entitled “Federal Telehealth Enforcement: Policy Through Prosecution”.  Stay tuned for more information on this PBI Health Law Institute program as the date draws nearer.

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