Referrals and Billing Flashcards
If a licensed person offers any rebate, refund, commission as a compensation for referring the patient, does it regard as unlawful?
Yes
T/F Payment/receipt of consideration for services other than the referral of patients which is based on a % of gross revenue/similar type of contractual arrangement shall not be unlawful if it is commensurate with the value of the services furnished or with the fair rental value of any premises/equipment leased/provided by the recipient to the payer
True
Can federally qualified health center and any individual providing goods and services have a contract, lease, loan or other agreement under what circumstances?
Yes; the ability to provide medically underserved population served by the health center and permitted by the federal law
Under which circumstances can a person refer a patient to any lab, pharmacy, clinic or health care facility with the sole interest or co-ownership to those facilities?
The investment or interest is not based on the amount of referrals.
If there is no valid medical need for the referral, it can be deemed as unlawful
T/F It is not unlawful to provide non monetary remuneration (money paid for service) in form of hardware, software or info tech and training services
True
T/F A clinician offers or sells services through a 3rd party advertiser is not constitute a referral of patients when the 3rd party advertiser does not itself recommend
True
T/F A clinician needs to disclose in the advertisement that the consultation is required and the purchaser will receive a refund if not eligible to receive the service
True
T/F The advertisements needs to disclose the discount price as well as the regular price
True
What is the consequences violating rebates for patient referrals?
First time: Public offense; imprisonment in county jail no more than 1 yr or $50,000 fine or both
Multiple time: imprisonment and $50,000 fine
Violation of unearned rebates, refund and discount article constitute as __________ and _________; punishable with imprisonment of no more than _________, by fine not exceeding $___________ or both
Unprofessional conduct
Misdemeanor
6 months
2,500
It is ________ for licensee to refer a person for lab, diagnostic nuclear medicine, radiation oncology, physical therapy, physical rehabilitation, psychometric testing, home infusion therapy or diagnostic imaging goods or services if the licensee or his/her _____ _______ has a financial interest with the person that receives the referral
Unlawful
Immediate family
What constitute as “financial interest”?
Ownership interest, debt, loan, lease, compensation, remuneration, discount, rebat, refund, dividend, distribution, subsidy or other form of direct/indirect payment between a licensee and a person whom a licensee refers to
What does not constitute “financial interest”?
- Receipt of capitation payment/other fixed amount that are prepaid in exchange for promise of a licensee to provide specific health services to specified beneficiaries
- The receipt of remuneration by a medical director of a hospice if arrangement is set out in writing and specifies all services to be provided by the medical director, the term of arrangement is for at least 1 yr and the compensation is set is advance but not exceed fair market value
Cross referral arrangement is ____________
Unlawful
What should a licensee disclose when referring someone in which the licensee has a financial interest but not to immediate family members?
Financial interest to patient in writing at the time of the referral request
T/F Licensee under contact with Department of Corrections/California Youth Authority needs to disclose financial interest to either of the departments
True
Violation of referral to immediate family members is ___________ and punishable with the fine of ___________
Misdemeanor; $5,000
Violation of cross referral arrangement is ________ and punishable with fine of ___________
Public offense; $15,000
It is _______ to charge or solicit payment from a patient on behalf of or refer a patient to an organization in which the licensee/licensee’s immediate family has a significant beneficial interest, unless discloses in writing
Unlawful
What constitute as “significant beneficial interest”?
- 5% of the whole
2. $5,000
What constitute as “ 3rd party payer”?
- Health care service plan
- Self insured employee welfare benefit plan
- Disability insurer
- Nonprofit hospital service plan
- Private group/indemnification insurance program
T/F It does not apply to “significant beneficial interest” where there is a limit ownership of a building that the space is leased to the organization at the prevailing (exist) rate under a straight lease agreement or to any interest held in publicly traded stocks
True
T/F The disclosure requirement are not required to be given to any patient if the licensee is providing health care services to a prepaid capitated contract with the State Department of Health Services
True
Can an optometrist have any membership, proprietary interest, co-ownership or any profit sharing arrangement with any registered dispensing optician or any optical company?
No
T/F Registered dispensing optician cannot directly employ optometrist to provide optometric services
True
Can an optometrist be employed by a health care plan as a clinical director for the health plan but cannot employ optometrist to provide health care services
Yes
Consumers file complaint to _________ and it will forward to __________
Department of Managed Health Care
State Board of Optometry
T/F The practice shall be owned by the optometrist with his/her exclusive control (staff, schedule, amount of time spent with pt, fees for product and services)
True
T/F Optometrist can permit to sell therapeutic ophthalmic product if the optician/health plan or optical company located on or adjacent to the lease space does not offer similar product for sale
True
T/F Optometrist records are property of the optometrist
True
T/F Optometrist’s lease space shall be definite and distinct from space occupied by other occupants
True
T/F It is not required to have a separate entrance to the optometrist’s leased space
True
What word needs to be prominently displayed in connection to other occupants?
Optometrist
T/F Optician or optical company cannot link its advertising with the optometrist’s name, practice or fees
True
A health plan cannot advertise optometrist’s fees for product/services that are not included in the contract
Yes
A landlord may terminate the lease if……
- Fail to maintain a license or became ineligible to participate in state or federal government funded programs
- Subleased the space
- Termination of provider agreement between health plan and the optometrist
- Other reasons under Civil Code
The lease terms and payments shall not be based on what?
- Number of exams performed
- Rx written
- Referrals or sales or promotion of products of optician or optical company
How many days should the landlord notify the optometrist of lease expiration date?
60 days
Who inspect the lease agreement?
State Board of Optometry
Failure or refusal to comply with request for lease agreement within 30 days of receiving the request constitutes ___________
Unprofessional conduct
T/F Professional corporation can contract with or employ optometrist, ophthalmologists, or optometric assistants
True
Violation of Business Arrangements can lead to __________
Misdemeanor
Violation of Business Arrangements has a fine of _________
$50,000 per investigation
The assessment of amount of fine due to violation of Business Arrangement can be considered by ……
- Gravity of the violation
- Good faith of the cited person or entity
- History of previous violation of same or similar nature
- Evidence that the violation was or was not willful
- Extent to which the cited person or entity has cooperated with the board’s investigation
- Extent to which the cited person has mitigated or attempted to mitigate any damage caused by the violation
- Any other factors as justice may require
How many days should the hearing be requested by written notice?
30 days
Californian spend more than ________ annually on health care
100 billion dollars
In 1994, estimated ____ million of California’s _____ million residents do not have any health insurance and ineligible for Medi-Cal
6.6
32
T/F It is unlawful for a registered dispensing optician who engages in business of, or holds oneself out to be, to do any of the following: advertise the services of a clinician, to directly employ a clinician for the purpose of any examination or treatment of the eyes, or duplicate or change lenses without an rx
True
