ASK FPM

The application of Stark to PAs can be confusing. Although PAs may substitute for physicians in many circumstances under the Medicare reimbursement rules, the Stark statute only pertains to physicians. Therefore, questions regarding PAs, their bonuses, compensation packages and the services they provide should be analyzed under the anti-kickback statute and not Stark. The only Stark implication to billing for PA services is whether they are billed incident to the physician or using the PA’s own provider number.

In general, a Medicare carrier cannot recover an overpayment discovered later than three full calendar years after the year of payment, unless there is evidence that the physician or beneficiary was at fault with respect to the overpayment. For example, suppose a doctor was notified on March 11, 2001, that he has been paid for services provided to a beneficiary, and on Jan. 12, 2005, the carrier determines that the doctor was overpaid for those services. The carrier will not recover the overpayment as long as there is no evidence that the physician was at fault because it was determined subsequent to the third year after notification of the payment. For more details, please see the Medicare Financial Management Manual, Pub. 100-6, Chapter 3 “Overpayments,” under Section 80, “Individual Overpayments Discovered Subsequent to the Third Year.” You may download the PDF at http://www.cms.hhs.gov/manuals/106_financial/fin106c03.pdf.

Once physician-patient relationships have been established, physicians are generally under both legal and ethical duties to provide care as long as care is needed. However, as provided in the AMA’s Code of Medical Ethics, there are appropriate circumstances for discharging patients for nonpayment.First, make and document all reasonable collection efforts, including at least one written warning that the physician-patient relationship will be terminated if payment is not received. Next, if discharge is appropriate, send the patient a written notice via first-class, certified mail. This notice should include a brief explanation for the termination and an offer to continue to provide services for a reasonable period of time (e.g., 30 days unless the patient’s circumstances warrant additional time). Encourage the patient to obtain the services of another physician promptly, and provide resources or recommendations that could help the patient locate another physician, such as a physician referral service. Finally, offer to transfer the patient’s records upon receipt of an appropriate authorization.Incorrect patient discharge could result in charges of patient abandonment and unprofessional conduct with attendant malpractice claims and licensure actions. If malpractice is proven, punitive damages could be awarded that may not be covered by your insurer. Each patient discharge should be addressed seriously and with consideration of each patient’s circumstances. Physicians should seek the counsel of their local attorneys prior to initiating the discharge.

There is no need to get a patient’s authorization for information that is shared for treatment. Once you have medical data about a patient that you have used in your treatment of the patient, it is part of your medical records, which you may share as you would any of your records.