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Physician "Supervision" of Clinical Practice

Bryan Liang, MD, JD, PhD

June 6, 2005

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Question

My question is in regard to physician supervision and billing of insurance. I have seen organizations that bill services provided by audiologists and list a supervising physician on the claim. I would assume this is being done because the audiologist may not be a provider for that insurance but the physician is and this hopefully would allow for payment. My question is: Are there specific guidelines that regulate what constitutes working under physician supervision (i.e. so many hours of direct contact, chart review, etc.)? If the audiologist and physician work for the same organization but are working independently can this be done? Whether they are seeing a patient directly referred by that physician or a direct referral from another physician to the audiologist? Are there guidelines in regard to what constitutes physician supervision and audiologist like mentioned previously and if so what are they.

Answer

In general, "supervision" is not specifically defined as to direct contact or chart reviews. Clearly, physicians and audiologists can in fact be working independently in an organization, with a physician supervising the audiologist. However, of concern is the potential for Stark Self-Referral law violations, and is likely the major concern of group practice/organization relationships that are mentioned in the question. Since a "referral" to an audiologist within the same practice/organization may be considered a self-referral, both physicians and audiologists must fall within the "in office ancillary services" exception to avoid violating this fraud and abuse law. The focus of the exception is on the referring physician, the group practice/entity, the locale of service, and billing.

The exception allows the furnishing of designated health care services (including, for example, speech-language pathology services) that are ancillary to a referring physician's professional services where certain supervision, location and billing requirements are satisfied.

Supervision

To qualify for the in-office ancillary services exception, the services must be furnished personally by the referring physician, a physician who is a member of the same group practice as the referring physician, OR an individual who is "supervised" by the referring physician or by another physician in the group practice, under Medicare payment and coverage rules for the particular service.

Group practice

Under the exception, any physician who is "in a group practice," including independent contractor physicians, may satisfy the supervision requirements.

Building requirements

The services must be furnished in either the "same building" or a "centralized building." For the in-office ancillary services exception, the same building is a structure with, or combination of structures that share, a single street address as assigned by the U.S. Postal Service. It does not include a mobile vehicle, van or trailer. A centralized building is all or part of a building, including a mobile vehicle, van or trailer, owned or leased on a full-time basis by a group practice and that is used exclusively by the group practice.

Billing requirements

Under the exception, the services must be billed by the physician performing or supervising the service or the group practice of that physician (including independent contractor physicians), an entity that is wholly owned by the performing or supervising physician, or by that physician's group practice under that entity or organization's billing number or under the billing number assigned to the physician or group practice, or an independent third party billing company.

If these requirements are met, the physician and audiologist fall within the in office ancillary services ancillary services exception.

Bryan A. Liang, MD, PhD, JD is Professor and Director of the Institute of Health Law Studies, California Western School of Law and University of California San Diego School of Medicine, San Diego, CA. His research focus is on the interface of law, health care, and public policy, including ethics, fraud and abuse, and patient safety.


Bryan Liang, MD, JD, PhD

Professor and Director of the Institute of Health Law Studies at the California Western School of Law and the University of California San Diego School of Medicine in San Diego, CA

Bryan A. Liang is Professor and Director of the Institute of Health Law Studies at the California Western School of Law and the University of California San Diego School of Medicine in San Diego, CA. He received his B.S. from the Massachusetts Institute of Technology;his Ph.D. in health policy from the University of Chicago Harris School of Public Policy Studies his M.D. from Columbia University College of Physicians & Surgeons and his J.D. from Harvard Law School. His research focuses upon the interface of how law and health care practice interface, with particular attention to ethics, quality issues, and provider education. He does not have a high school diploma, which may explain a lot.


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