Referrals and Billing

Question 1

If a licensed person offers any rebate, refund, commission as a compensation for referring the patient, does it regard as unlawful?

Answer 1

Yes

Question 2

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

Answer 2

True

Question 3

Can federally qualified health center and any individual providing goods and services have a contract, lease, loan or other agreement under what circumstances?

Answer 3

Yes; the ability to provide medically underserved population served by the health center and permitted by the federal law

Question 4

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?

Answer 4

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

Question 5

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

Answer 5

True

Question 6

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

Answer 6

True

Question 7

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

Answer 7

True

Question 8

T/F The advertisements needs to disclose the discount price as well as the regular price

Answer 8

True

Question 9

What is the consequences violating rebates for patient referrals?

Answer 9

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

Question 10

Violation of unearned rebates, refund and discount article constitute as __________ and _________; punishable with imprisonment of no more than _________, by fine not exceeding $___________ or both

Answer 10

Unprofessional conduct

Misdemeanor

6 months

2,500

Question 11

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

Answer 11

Unlawful

Immediate family

Question 12

What constitute as “financial interest”?

Answer 12

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

Question 13

What does not constitute “financial interest”?

Answer 13

1. 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
2. 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

Question 14

Cross referral arrangement is ____________

Answer 14

Unlawful

Question 15

What should a licensee disclose when referring someone in which the licensee has a financial interest but not to immediate family members?

Answer 15

Financial interest to patient in writing at the time of the referral request

Question 16

T/F Licensee under contact with Department of Corrections/California Youth Authority needs to disclose financial interest to either of the departments

Answer 16

True

Question 17

Violation of referral to immediate family members is ___________ and punishable with the fine of ___________

Answer 17

Misdemeanor; $5,000

Question 18

Violation of cross referral arrangement is ________ and punishable with fine of ___________

Answer 18

Public offense; $15,000

Question 19

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

Answer 19

Unlawful

Question 20

What constitute as “significant beneficial interest”?

Answer 20

1. 5% of the whole

2. $5,000

Question 21

What constitute as “ 3rd party payer”?

Answer 21

1. Health care service plan
2. Self insured employee welfare benefit plan
3. Disability insurer
4. Nonprofit hospital service plan
5. Private group/indemnification insurance program

Question 22

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

Answer 22

True

Question 23

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

Answer 23

True

Question 24

Can an optometrist have any membership, proprietary interest, co-ownership or any profit sharing arrangement with any registered dispensing optician or any optical company?

Answer 24

No

Question 25

T/F Registered dispensing optician cannot directly employ optometrist to provide optometric services

Answer 25

True

Question 26

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

Answer 26

Yes

Question 27

Consumers file complaint to _________ and it will forward to __________

Answer 27

Department of Managed Health Care

State Board of Optometry

Question 28

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)

Answer 28

True

Question 29

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

Answer 29

True

Question 30

T/F Optometrist records are property of the optometrist

Answer 30

True

Question 31

T/F Optometrist’s lease space shall be definite and distinct from space occupied by other occupants

Answer 31

True

Question 32

T/F It is not required to have a separate entrance to the optometrist’s leased space

Answer 32

True

Question 33

What word needs to be prominently displayed in connection to other occupants?

Answer 33

Optometrist

Question 34

T/F Optician or optical company cannot link its advertising with the optometrist’s name, practice or fees

Answer 34

True

Question 35

A health plan cannot advertise optometrist’s fees for product/services that are not included in the contract

Answer 35

Yes

Question 36

A landlord may terminate the lease if……

Answer 36

1. Fail to maintain a license or became ineligible to participate in state or federal government funded programs
2. Subleased the space
3. Termination of provider agreement between health plan and the optometrist
4. Other reasons under Civil Code

Question 37

The lease terms and payments shall not be based on what?

Answer 37

1. Number of exams performed
2. Rx written
3. Referrals or sales or promotion of products of optician or optical company

Question 38

How many days should the landlord notify the optometrist of lease expiration date?

Answer 38

60 days

Question 39

Who inspect the lease agreement?

Answer 39

State Board of Optometry

Question 40

Failure or refusal to comply with request for lease agreement within 30 days of receiving the request constitutes ___________

Answer 40

Unprofessional conduct

Question 41

T/F Professional corporation can contract with or employ optometrist, ophthalmologists, or optometric assistants

Answer 41

True

Question 42

Violation of Business Arrangements can lead to __________

Answer 42

Misdemeanor

Question 43

Violation of Business Arrangements has a fine of _________

Answer 43

$50,000 per investigation

Question 44

The assessment of amount of fine due to violation of Business Arrangement can be considered by ……

Answer 44

1. Gravity of the violation
2. Good faith of the cited person or entity
3. History of previous violation of same or similar nature
4. Evidence that the violation was or was not willful
5. Extent to which the cited person or entity has cooperated with the board’s investigation
6. Extent to which the cited person has mitigated or attempted to mitigate any damage caused by the violation
7. Any other factors as justice may require

Question 45

How many days should the hearing be requested by written notice?

Answer 45

30 days

Question 46

Californian spend more than ________ annually on health care

Answer 46

100 billion dollars

Question 47

In 1994, estimated ____ million of California’s _____ million residents do not have any health insurance and ineligible for Medi-Cal

Answer 47

6.6

32

Question 48

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

Answer 48

True