Medical Practice Requirements
CONTENT:
AMA’s Practice Management Tips
The AMA Private Sector Advocacy Practice Management Center has compiled a set of useful Practice Management Tips to help physicians and the practice staff deal with various office issues, such as negotiating contracts, collecting payments, and dealing with the claims submission process.
Contact Information
Department of Banking and Insurance (DOBI): www.njdobi.org
Lee Barry, Assistant Commissioner
Office of Consumer Protection Services
New Jersey Department of Banking and Insurance
P.O. Box 329 Trenton, NJ 08625-0329
Tel: (609) 292-5316 x50160
Fax: (609) 292-5337
E-Mail: lee.barry@dobi.state.nj.us
Veronica Schmitt, RN, BSN, MSA, Special Investigator
New Jersey Department of Banking & Insurance
Office of Consumer Protection Services
P.O. Box 329 Trenton, NJ 08625-0329
Email: veronica.schmitt@dobi.state.nj.us
MAXIMUS – ARBITRATION: www.njpicpa.maximus.com
NJ Provider Appeals
Maximus Inc.
50 Square Dr. Suite 210
Victor, NY 14564
Phone: 585-425-5245
Fax: 585-425-5296
E-mail: njpicpa@maximus.com
To Contact your US Senators and Representatives:
AMA’s Hotline – 800-833-6354
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Chaperone Requirements
Chaperones During Examinations
The Board of Medical Examiners’ rules grant physicians and patients the right to have a chaperone present:
- during breast and pelvic examinations of females; and
- during genitalia and rectal examinations of both males and females.
Under these circumstances, physicians must provide this chaperone if they or their patients want one. The bme’s rules also require that physicians provide notice to patients of this right.
The regulatory requirement of notice is met by either providing written notice to each patient or by a conspicuous posting, stating the right of the patient to request a chaperone and to decline care if an acceptable chaperone is not available. The physician must use other means to ensure that the patient to be examined understands the right to a chaperone, if the written notice or posting does not adequately convey that right.
The regulatory requirement of notice is met by either providing written notice to each patient or by a conspicuous posting, stating the right of the patient to request a chaperone and to decline care if an acceptable chaperone is not available. The physician must use other means to ensure that the patient to be examined understands the right to a chaperone, if the written notice or posting does not adequately convey that right.
If the chaperone provided is not acceptable to the patient, the physician is not obligated to provide further care for the immediate problem presented. If the patient refuses to have a chaperone present, but the physician wishes to have one present, the physician is not obligated to provide further care for the immediate problem presented. However, in both of these circumstances, the physician must discuss with the patient the risks of not receiving care.
The chaperone rule was passed to protect both patients and physicians. Patients are protected from inappropriate conduct by physicians; physicians are protected from patients’ false claims of inappropriate sexual conduct. Msnj supported the rule’s adoption because it balances the interests of patients and physicians, and it is relatively simple to apply. Msnj encourages physicians to err on the side of having chaperones present. Professional risk managers also recommend the use of chaperones. (Physician Advocate [August 2005] 1, no. 4)
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Doctor–Patient Relationships
Severing the Physician–Patient Relationship
There are circumstances under which physicians may believe that they should sever the physician-patient relationship. These include situations in which: the patient consistently refuses to heed medical advice; or the patient is abusive to the physician and staff.
Physicians must give adequate notice of any decision to sever the relationship and, if asked, must assist patients in finding another treating physician. These obligations are codified in the state Board of Medical Examiners’ (bme) regulations at N.J.A.C. 13:35-6.22 and are summarized below.
- The physician must notify the patient in writing that care will be terminated by a certain date. The letter should be sent to the patient’s last known address via certified mail, return receipt requested. The termination date must be at least thirty days from the date of the notice.
- The physician must continue to provide emergency care until the date on which services are terminated. This includes the obligation to write necessary prescriptions.
- If asked, the physician must make reasonable efforts to assist the patient in finding a new physician who is qualified to meet the patient’s medical needs. This may include providing referrals.
- However, it is unlawful to sever the physician-patient relationship if it is being done for any discriminatory purpose or otherwise violates any laws or regulations that prohibit discrimination, or if physicians know, or reasonably should know, that no other physician will be able to provide the type of medical treatment that they have been providing.
The 2005 changes to the BME’s rules, which became effective April 18, 2005, make it clear that physicians may not charge patients for a copy of their medical records when the physician has severed the relationship consistent with the steps outlined above.
Form letters that may be useful for documenting the severance of a physician–patient relationship can be found on the MSNJ web site. [click here].
This information is provided as general advice to msnj members and should not be considered specific legal advice. If you anticipate litigation over a physician-patient relationship you should consider engaging counsel before you begin to sever the relationship. (Physician Advocate [June 2005] 1, no. 2)
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Drug Importation
Whenever the supply of a vaccine is low, members ask if they may procure the vaccine from Canada. The answer is NO.
The U.S. Food and Drug Administration (FDA) has issued clear guidance on the issue of drug importation, including vaccines, from foreign countries. The FDA is concerned about the quality of drugs manufactured in foreign countries and whether drugs delivered from foreign countries are the same products as those approved by the FDA. Moreover, the FDA is concerned about whether imported drugs will comply with all federal laws and regulations.
The reason is that FDA approvals are manufacturer- and product-specific and include many requirements, such as manufacturing location, formulation, source, and specifications of active ingredients, processing methods, manufacturing controls, container/closure system, and appearance (21 cfr 314.50). Frequently, drugs sold outside of the U.S. are not manufactured by a firm that has FDA approval for that drug. Moreover, even if the manufacturer has FDA approval for a particular drug, the version produced for foreign markets usually does not meet all of the U. S. requirements, and, thus, it is considered to be unapproved. (21 usc 355.) (Letter to Robert P. Lombardi, Esq. from fda, William K. Hubbard, associate commissioner for Policy and Planning [Feb. 12, 2003].)
There are both civil and criminal penalties for violating the federal laws that regulate the distribution of pharmaceuticals. Those who aid and abet or conspire to violate the laws can be prosecuted criminally. (Physician Advocate [December 2005] 1, no. 8)
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Hearing-Impaired Patients: Physicians' Obligations
John Zen Jackson, “Health Care Providers’ Responsibilities toward Hearing-Impaired Patients,” New Jersey Medicine (January–February 2003) 100, no. 1–2: 22–27; and John Zen Jackson, “Hearing-Impaired Patients,” Physician Advocate (July 2005) 1, no. 3: 3.
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HIPAA
Standard Unique Health Identifier
The Centers for Medicare & Medicaid Services (CMS) adopted the National Provider Identifier (NPI) as the standard unique health identifier for health care providers. The intent of the NPI rule is to improve effectiveness and efficiency by “simplifying the administration of the health care system and enabling the efficient electronic transmission of certain health information.” The effective date of the rule is May 23, 2005, at which time providers can begin to apply for their unique NPIs. Providers will be assigned one NPI for all health care transactions including, federal, state and private programs. The NPI will replace “legacy” identifiers and is required by HIPAA.
The NPI requirement does not change the covered entity status of providers for purposes of hipaa’s privacy standard or the transactions and code set standards. Providers will be required to use their npi for filing and processing all health care claims by May 23,ÿ2007.ÿ(reprinted from MSNJ e-News dated 2-11-04)
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Medical Records: Releasing and Copying for Patients
Most of our members work in small or medium-sized medical practices. Often, office staff is stretched with the myriad of practice-management questions that can be asked on any given day. Some are about mixed medical-legal issues; some raise ethical or regulatory concerns. This column will answer some of the most frequently asked of these questions each month.
Question
What are the rules and obligations governing the release and copying of records for patients? What if the patient has an outstanding balance?
Answer
A physician may charge a reasonable fee for copying records. However, it is considered inappropriate for a physician to make a profit from the fee charged for the records, and there is a limitation on the fee amount.
Physicians may charge no more than $1 per page or $100 for the entire record, whichever is less. If the record is less than ten pages, the physician may charge up to $10 to cover the costs of postage and incidental expenses associated with the retrieval of the record. Physicians may charge a fee for the copying of records off-site. This is limited to x-rays or other documents that are not easily copied on an office copy machine. Physicians may charge the actual cost of off-site copying plus $10 or 10% of the actual cost, whichever is less, to cover staff time.
A physician may require that the records request be in writing.
A physician must provide the copied records to the patient within thirty days of the request.
If a physician elects to provide a summary of the record, in lieu of the actual record, the charge may not exceed the cost that would have been charged for the actual record.
It is important to note that physicians may not charge a fee for the copying of records in these instances:
- when the physician has affirmatively terminated a patient, or
- when the physician leaves a practice and a patient requests that his/her medical care be continued by the physician at the new practice. ÿ(N.J.A.C. 13:35-6.5 [amendments effective April 18, 2005])
If the patient’s record request is for the purpose of continuing medical treatment, then you may not refuse the request because of an unpaid balance. However, if the request is for a reason other than medical treatment (for example, a lawsuit) you may refuse. This is a narrow exception to the general obligation to provide patient records. Members are encouraged to err on the side of providing records if appropriately requested.
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Medicare
2007 fee schedules:
Area 01 | Area 99
Claims Processing Instructions
On March 24, 2004, Centers for Medicare & Medicaid Services (CMS) reminded Medicare providers of the deadline which becomes effective on April 1, 2004, concerning payment jurisdiction. CMS advises thatÿ“for any place of service EXCEPT patient’s home (place of service 12), it will be imperative for the actual name, street address and zip code of the place of service where the Medicare patient received services to be in Block 32 on a paper claims form or as directed in the article for electronic billing [Letter from Empire Medicare Services to Provider Communications Advisory Group (March 24, 2004)]. If you need more information, go to www.empiremedicare.com
Mediation Program
The Centers for Medicare & Medicaid Services (CMS) recently implemented a mediation program for resolving non-confirmed quality-of-care complaints filed by Medicare patients involving a Medicare-certified practitioner or healthcare provider. Healthcare Quality Strategies, Inc. (HQSI) is the quality improvement organization responsible for implementing CMS’s mediation program in New Jersey. HQSI will review the matter and, if no quality of care concern is found, it may be eligible for mediation. HQSI believes that resolution of issues by mediation may reduce the risk of malpractice claims.
PRONJ, the organization that preceded HQSI, developed a Physician/Provider Mediation Fact Sheet. For more information visit the HQSI web site at: www.hqsi.org. (reprinted fromÿMSNJ e-News dated July 2, 2004)
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Prescription Blanks
Rules on Prescription Blanks
The Uniform Prescription Blanks law became effective on March 1, 1997. Regulations implementing the law became effective on June 21, 2004. Since the regulations became effective, all physicians are required to use state-sanctioned prescription blanks and to implement stringent security controls over the blanks to deter drug abuse and forgery.
Uniform prescription blank pads may be purchased only through printers and vendors that are approved by the New Jersey Division of Consumer Affairs (dca). A list of approved vendors can be found on the DCA’s web site or by calling the customer service center at 973.504.6558.
Physicians are required to keep records that reflect the order, receipt, maintenance, and distribution of uniform prescription blank pads. The records must include:
- The name and address of the vendor;
- The date that pads were ordered and received;
- The batch number of the pads;
- The date, quantity, and physician to whom the pads were distributed in a group practice;
- The name of the person responsible for the order, receipt, storage, maintenance, and distribution of the pads; and
- A designation of the secure storage area.
Prescription pad orders should be checked when received to ensure that all ordered pads, in fact, are received. If an order is filled incorrectly, a call should be placed promptly to the Office of Drug Control, New Jersey Prescription Blank Unit at 973.504.6558 and an incident report should be completed.
Uniform prescription blank pads must be stored in a secure location. In all cases, the pads must be stored where unauthorized persons cannot gain accessed to them. In an environment in which pilferage or forgery is likely, it may be necessary to order blanks that are numbered sequentially to help ensure appropriate control and security.
Physicians must call the Office of Drug Control, New Jersey Prescription Blank Unit within 72 hours of the discovery that a prescription blank has been lost, stolen, or forged. The phone number is 973.504.6558. Physicians must also complete an incident report and file the report within seven days of the notification. The incident report form can be found on MSNJ’s web site [click here].
The complete regulations on uniform prescription blanks are codified at N.J.A.C. 13:45a-27.1.
Forgery and theft of prescription blanks are crimes of the third degree and may be punishable by a prison term of three to five years. (Physician Advocate [December 2005] 1, no. 8)
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