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.
