2. Self Referrals 3 Flashcards
What is Section 139.3 regarding physician referrals?
Section 139.3 prohibits a facility from compensating a referring physician for referrals to that facility. This rule aims to minimize conflicts of interest and ensure that patient referrals are made based on medical necessity rather than financial incentives.
What are the exceptions to the Prohibition of Section 139.3?
The prohibitions of Section 139.3 do not apply to services for a specific patient performed within a physician’s office or the office of a group practice. This allows physicians to deliver in-office goods or services as per their scope of practice without interference from Section 139.3.
Does Section 139.3 impact a physician’s ability to deliver services?
No Section 139.3 does not alter limit or expand a physician’s ability to deliver or supervise the delivery of in-office goods or services according to the relevant laws rules and regulations governing their scope of practice.
What types of diagnostic imaging services are mentioned in Section 139.3?
Diagnostic imaging services performed with equipment that originally had a commercial retail price of four hundred thousand dollars ($400000) or more are explicitly mentioned in Section 139.3.
What services are included under conditions set by the administrative director?
Physical therapy services and psychometric testing that exceed routine screening battery protocols with a time limit set by the administrative director ranging from two to five hours are included under the conditions that Section 139.3 addresses.
What is the significance of the commercial retail price threshold in Section 139.3?
The $400000 threshold for the commercial retail price of diagnostic imaging equipment serves to define the scope of services affected by Section 139.3 potentially influencing which imaging services fall under the prohibitions regarding referral compensation.
What are the regulations governing in-office services provided by physicians?
In-office services provided by physicians must comply with the laws rules and regulations that govern their specific scope of practice which are unaffected by Section 139.3.
Can a physician receive compensation for referrals to a facility?
No according to Section 139.3 a facility cannot compensate referring physicians for referrals to maintain compliance with legal and ethical standards.
What is psychometric testing as referenced in Section 139.3?
Psychometric testing refers to the assessment processes that measure psychological constructs typically involving a battery of tests that evaluate cognitive abilities personality traits and other psychological attributes exceeding routine screening protocols in this context.
What is the role of the administrative director in relation to psychometric testing and physical therapy services mentioned in Section 139.3?
The administrative director has the authority to establish time limits for psychometric testing and physical therapy services determining the parameters under which these services may be offered when they exceed routine standards.
What is required when a physician obtains an oral preauthorization for a service from an insurer?
Any oral authorization shall be memorialized in writing within five business days.
Under what circumstances does the prohibition of Section 139.3 not apply to a physician?
The prohibition of Section 139.3 shall not apply where the physician is in a group practice and refers a person to a multispecialty clinic for services specified in Section 139.3.
How is a group practice defined according to Section 139.3?
A group practice is defined in Section 139.3 within the legal context and regulations pertaining to medical practice.
What constitutes a multispecialty clinic as per the document?
A multispecialty clinic is defined in subdivision I of Section 1206 of the Health and Safety Code.
For what types of services is a referring physician required to obtain service preauthorization from an insurer or self-insured employer?
Service preauthorization is required for diagnostic imaging services performed with equipment priced at $400000 or more physical therapy services and psychometric testing exceeding routine screening battery protocols.
What is the time limit established by the administrative director for psychometric testing?
The time limit for psychometric testing is two to five hours.
What is the significance of the commercial retail price threshold mentioned in the context of diagnostic imaging services?
The commercial retail price threshold of $400000 or more determines whether preauthorization is needed for specific diagnostic imaging services.
What role does the administrative director play regarding psychometric testing?
The administrative director establishes the time limit for psychometric testing which is two to five hours beyond the routine screening battery protocols.
What is required for any oral authorization by an employer according to Section 139.3?
Any oral authorization shall be memorialized in writing within five business days.
What is an exception to the requirement for preauthorization in certain sections according to the text?
The requirement for preauthorization does not apply to a patient for whom the physician or group accepts payment on a capitated risk basis.
Under what condition does the prohibition of Section 139.3 not apply to health care facilities?
The prohibition of Section 139.3 does not apply when providing health care services to an enrollee of a health care service plan licensed under the Knox-Keene Health Care Service Plan Act of 1975.
What type of facility is exempt from the prohibition of Section 139.3?
An outpatient surgical center is exempt from the prohibition of Section 139.3 if the referring physician obtains a service preauthorization from the insurer or self-insured employer after disclosure of the financial relationship.
What must a referring physician do in order to be compliant with Section 139.3 when sending a patient to an outpatient surgical center?
The referring physician must obtain a service preauthorization from the insurer or self-insured employer after disclosing the financial relationship.
Which act is referenced in relation to health care service plan enrollees?
The Knox-Keene Health Care Service Plan Act of 1975.
What is the purpose of memorializing an oral authorization in writing according to employer regulations?
To ensure there is a documented record of the authorization within five business days promoting accountability and clarity.
Define ‘capitated risk basis’ in the context of healthcare payments.
Capitated risk basis refers to a payment arrangement where a physician or group receives a fixed amount of payment per patient regardless of the number of services provided.
What does Section 139.3 prohibit generally?
Section 139.3 generally prohibits certain actions or requirements related to preauthorization in healthcare services.
In what scenarios does Section 139.3 allow for exceptions?
Exceptions are allowed for capitated risk patients and for health care service plan enrollees as well as specific outpatient surgical centers under certain conditions.
What are the conditions under which a physician’s financial interest in a retailer of prescription drugs does not apply?
The rules shall not apply if the physician’s financial interest is in a retailer of prescription drugs sold by a physical retail outlet commonly accessed by the public or a mail-order pharmacy serving a broad national or regional market provided that the majority of the physician’s practice in terms of income time and number of patients does not relate to occupational medicine and the physician receives no remuneration from the retailer to market or solicit occupational injury or disease patients.
What must a physician seeking appointment as a Qualified Medical Evaluator (QME) disclose?
Every physician seeking appointment or reappointment as a QME must disclose specified financial interests as defined in section 1 dd and 29b of Title 8 of the California Code of Regulations.
What is meant by ‘Specified Financial Interests’ according to Title 8 of the California Code of Regulations?
‘Specified Financial Interests’ means being a general partner or limited partner in having an interest of five percent or more in or receiving or being entitled to receive remuneration from a business or entity that has financial interests related to the physician’s practice.
What types of financial interests must be disclosed by physicians according to the regulations discussed?
Physicians must disclose interests such as general or limited partnerships interests of five percent or more in related businesses and any remuneration received from these entities when seeking to be appointed as QME.
What is the significance of the physician’s practice majority in relation to occupational medicine?
The significance is that if a physician’s majority practice related to income time and number of patients does not involve occupational medicine then their financial interests in certain drug retailers may be exempt from specific regulations.
What is the legal reference that defines the ‘Specified Financial Interests’ for QMEs?
‘Specified Financial Interests’ is defined in section 1 dd and 29b of Title 8 of the California Code of Regulations.
In what situations is a physician potentially allowed to have financial interests in drug retailers without being in violation of these regulations?
A physician may have financial interests in drug retailers without violation when they do not derive the majority of their income time and patient care from occupational medicine and do not receive payment to solicit occupational health patients.
Why is the disclosure of financial interests important for Qualified Medical Evaluators?
Disclosure of financial interests is important for QMEs to ensure transparency and prevent conflicts of interest in the evaluation process thereby maintaining the integrity of medical evaluations related to workers’ compensation.
What percentage of profits entitles an individual legally to receive a share from entities providing services within the California workers’ compensation system?
An individual is legally entitled to receive a share of five (5) percent or more of the profits from any medical practice group practice medical group professional corporation limited liability corporation clinic or other entity that provides treatment or medical evaluation goods or services for use in the California workers’ compensation system.
What is the ‘SFI Form 124’ in the context of California workers’ compensation?
The ‘SFI Form 124’ is a form used in sections 1 through 159 of Title 8 of the California Code of Regulations. It refers to the ‘QME SFI Form 124’ which is completed and filed as an attachment to QME Form 100 103 or 104 by the physician or Qualified Medical Evaluator (QME) with the Medical Director of the Division of Workers’ Compensation.
When must specified financial interests be disclosed on QME SFI Form 124?
Specified financial interests must be disclosed on QME SFI Form 124 when applying for appointment on QME Form 100 at the time of paying the annual fee on QME Form 103 or when applying for reappointment on QME Form 104.
What forms are associated with the QME SFI Form 124 and what is their purpose?
The QME SFI Form 124 is associated with QME Form 100 (application for appointment) QME Form 103 (annual fee payment) and QME Form 104 (application for reappointment). It is required to be filed along with these forms to disclose specified financial interests.
Who is responsible for filing the QME SFI Form 124?
The responsibility of filing the QME SFI Form 124 lies with the physician or Qualified Medical Evaluator (QME) who must submit it along with the appropriate QME forms to the Medical Director of the Division of Workers’ Compensation.
What is the role of the Medical Director of the Division of Workers’ Compensation in California?
The Medical Director of the Division of Workers’ Compensation oversees the administration and regulation of the workers’ compensation system in California including the management of Qualified Medical Evaluators (QMEs) and ensuring adherence to established laws and ethical standards.
What are the consequences if a Qualified Medical Evaluator (QME) fails to file a QME SFI Form 124?
Failure of a Qualified Medical Evaluator to complete and file a QME SFI Form 124 with the Medical Director when required may result in disciplinary action as outlined in section 60 of Title 8 of the California Code of Regulations.
What information does the Administrative Director use to avoid assigning QMEs to the same panel?
The Administrative Director uses information provided by physicians to avoid assigning QMEs who share specified financial interests to the same QME panel.
What happens if two or more QMEs assigned to a panel share specified financial interests?
If two or more QMEs assigned to a panel share specified financial interests any party has the right to request a replacement QME.
What is the procedure if three QMEs on a panel have specified financial interests?
If three QMEs share specified financial interests two of the QMEs shall be replaced.
What is done if two QMEs share specified financial interests according to the section?
If two QMEs share specified financial interests one of the QMEs shall be replaced.
How are the QMEs that must be replaced chosen?
The QMEs that must be replaced shall be randomly selected by the Medical Director.
What is meant by ‘ethical standards’ in the context of QMEs in California?
Ethical standards refer to the principles and expectations that govern the professional conduct of Qualified Medical Evaluators ensuring fairness impartiality and integrity in their evaluations and decisions.
