Title XVIII § 1833 ( q ) of the Social Security Act requires the referring / ordering physician information be submitted on a Medicare claim when the billing provider / supplier has received a referral or order for the referred / ordered service ( s ) or item . Section 1842 ( p )( 4 ) of the Act requires the referring / ordering physician provide documentation to the billing provider / supplier based on a referral / order :
In the case of an item or service defined in paragraph ( 3 ), ( 6 ), ( 8 ), or ( 9 ) of subsection 1861 ( s ) ordered by a physician or a practitioner specified in subsection ( b )( 18 ) ( C ), but furnished by another entity , if the Secretary ( or fiscal agent of the Secretary ) 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 .
Pursuant to 42 Code of Federal Regulations ( CFR ) § 424.535 , a referring / ordering physician ’ s failure to provide the above required documentation may result in the revocation of enrollment and billing privileges in the Medicare program :
( a ) Reasons for revocation . CMS may revoke a currently enrolled provider or supplier ’ s Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons :
( 10 ) Failure to document or provide CMS access to documentation . ( i ) The provider or supplier ( as described in section 1866 ( j ) of the Act ) did not comply with the documentation or CMS access requirements specified in § 424.516 ( f ) of this subpart .
Regulation 42 CFR § 424.516 sets forth the types of documentation that are required to be provided by impacted provider / suppliers :
Additional provider and supplier requirements for enrolling and maintaining active enrollment status in
Working with the DMEPOS supplier increases the level of care your patient ( s ) receive as well as ensures only services and / or items that are legitimately prescribed by you are provided to your patient ( s ).
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 .
Also , 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 referring / ordering physician you may not ask and / or require providers / suppliers or beneficiaries to pay for or refuse to provide documentation when requested .
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 .
To report potential Medicare fraud and abuse please review the OIG or Stop Medicare Fraud websites for multiple ways to report :
http :// oig . hhs . gov / fraud / report-fraud / index . asp
http :// www . stopmedicarefraud . gov / index . html
You can also call the OIG Hotline at 1-800-HHS-TIPS ( 1-800-447-8477 ).
Working with the DMEPOS supplier increases the level of care your patient ( s ) receive as well as ensures only services and / or items that are legitimately prescribed by you are provided to your patient ( s ).
Sincerely ,
Zone 5 ZPIC ■
1
The definition of physician is found at http :// www . socialsecurity . gov / OP _ Home / ssact / title18 / 1861 . htm # act-1861-r .
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