Chapter 11 Disclosure Requirements of Nevada Physicians
INTRODUCTION
NEVADA LAW
Hospital Disclosure Requirements Relating to Physicians
FEDERAL MEDICARE DISCLOSURE REQUIREMENTS
Disclosure of Ownership Arrangements When Furnishing Medicare Services
Disclosure of Referring Physician on Claims for Medicare Covered Services
Disclosure to Beneficiaries
Disclosure by Physicians and Other “Disclosing Part B Providers”
INTRODUCTION
State and federal law require physicians in Nevada to make numerous disclosures to patients, third-party payors, or the state or federal government about certain interests and financial matters which could affect the care of patients.
NEVADA LAW
Unless certain disclosure and statutory conditions are met, a physician in Nevada may not refer a patient to a health facility or service in which he has a financial interest. Financial interest is defined to include any ownership or other interest that provides compensation based, in whole or in part, upon the value of goods and services provided as a result of referrals. Financial interests include debt instruments, income-sharing agreements, or a lease or rental agreement. NAC 439B.530.
The Nevada Administrative Code specifies the restrictions on the referral by a practitioner of a patient to a health facility, medical laboratory, diagnostic imaging or radiation oncology center, or commercial establishment in which the practitioner has a financial interest, by specifying that the following conditions must be met:
- a) the service or goods required by the patient are not otherwise available within a 30-mile radius of the practitioner;
- b) the service or goods are provided pursuant to a referral to a practitioner who is participating in the health care plan of a health maintenance organization;
the practitioner is a member of a group practice and the referral is made to that group practice;
- c) the referral is made to a surgical center for ambulatory patients;
- d) the referral is made by a urologist for lithotrispy services or by a nephrologist for services and supplies for a renal dialysis; or
- e) the financial interest represents an investment in a corporation that has shareholder equity of more than $100,000,000.
NRS 439B.425.
Violation of the self-referral provisions could result in the practitioner being charged with a misdemeanor and facing disciplinary action by the Board of Medical Examiners.
Hospital Disclosure Requirements Relating to Physicians
Hospitals are subject to numerous additional disclosure requirements by both federal and state law. Of interest to physicians, hospitals are required to maintain a listing of all contracts between the hospital and a practitioner, and must submit this information to the state Department of Human Resources upon request. NAC 439B.470.
The contracts and agreements hospitals must disclose include, among others:
- 4) all rental agreements between the hospital and a physician or an entity that employs physicians;
- b) all agreements relating to physicians concerning the subsidization of rent;
- 5) all agreements relating to the hospital acting as a practitioners billing agent; and
- d) all agreements for the selling of goods or services from the hospital to a physician. NAC 439B.480
Hospitals are prohibited from referring a patient to an health facility or service in which the referring party has a financial interest unless the referring party first discloses the interest to the patient. NRS 439B.420. This disclosure statement should be in writing. NAC 439B.455.
FEDERAL MEDICARE DISCLOSURE REQUIREMENTS
The federal Medicare disclosure requirements are quite complex. Because penalties for violations of the disclosure rules are harsh, physicians should seek legal assistance if they have any questions while negotiating this area of the law.
Disclosure of Ownership Arrangements When Furnishing Medicare Services
Federal law requires certain entities, including physicians, who provide services for which payment may be made by the Medicare program to provide the Secretary of the Department of Health and Human Services with information concerning the entitys ownership, investment interests, and compensation arrangements. 42 U.S.C. 1395nn(f).
Under this law, each reporting entitys fiscal intermediary or carrier is required to provide the entity with a survey form, which must be completed and returned to the carrier within thirty days. The required information includes the name, address, Medicare provider identification/billing number of the reporting entity, the covered items and services provided by the entity, the names and unique physician identification numbers of all physicians (and immediate relatives) with an ownership or investment interest or compensation arrangement in an entity, and information on the type of financial interest. 42 U.S.C. 1395nn(f). This reporting requirement does not apply to entities that provide twenty or fewer Part A and Part B items and services during a calendar year. 42 C.F.R. 411.361.
Health care entities are responsible for obtaining the appropriate form from their Medicare carriers or intermediary. Entities must retain documentation sufficient to verify the information provided and must make that documentation available to the Secretary of Health and Human Services or the OIG upon request. The failure to comply with this reporting requirement could result in denial of Medicare payment, exclusion from the Medicare program, and civil penalties. 42 U.S.C. 1395nn(g)(5).
Disclosure of Referring Physician on Claims for Medicare Covered Services
Each request for payment or bill submitted for any item or service for which payment may be made by Medicare and for which an entity, including a physician, knows or has reason to believe that there has been a referral by a referring physician shall include the name and provider number for the referring physician and indicate whether or not the referring physician is an interested investor. 42 U.S.C. 1395L(q)(1). Where the request for payment is made on an assignment related basis, payment may be denied if this information is not provided. When, however, the request for payment is not submitted on an assignment related basis, if the entity knowingly and willfully fails to provide such information, the entity is subject to a civil fine. If the entity knowingly and willfully and in repeated cases, after being notified of these obligations by the Secretary, fails to provide the required information, the entity may be excluded from the Medicare program for five years. 42 U.S.C. 1395l(q)(2).
Disclosure to Beneficiaries
A Medicare beneficiary may submit a written request to any physician for an itemized statement for any item or services provided to the beneficiary by the physician with respect to which payment has been made under the Medicare program. 42 U.S.C. 1395b-7. Physicians then have thirty days after the date on which a request was made to furnish an itemized statement describing each item or service provided to the individual. A knowing failure to do so shall subject a physician to a civil monetary penalty of not more than $100 for each such failure. The beneficiary has ninety days after the receipt of the itemized statement to submit a written request for review of the itemized statement to the Secretary. A request for review of the itemized statement shall identify:
1) specific items or services that the individual believes were not provided as claimed; or
2) any other billing irregularity (such as duplicate billing).
The Secretary shall then determine whether the itemized statement identifies specific items or services that were not provided as claimed, or if any other billing irregularity has resulted in unnecessary overpayments. The Secretary must then take all appropriate measures to recover the inappropriately paid amounts. 42 U.S.C. 1395b-2.
Disclosure by Physicians and Other Disclosing Part B Providers
No payment will be made for services provided by Disclosing Part B Providers unless such provider has given the secretary full and complete information on the name, address, employer identification number, and social security number of each person with an ownership or control interest in the provider or in any subcontractor in which the provider directly or indirectly has a five percent or more ownership interest. Additionally, any person identified above or any managing employee of the provider must provide information concerning:
(a) the identity of any other entities providing items or services for which Medicare payment may be made with respect to which such person or managing employee is a person with an ownership or control interest at the time such information is supplied or at any time during the three year period ending on the date such information is supplied, and
(b) whether any penalties, assessments, or exclusions have been assessed against such person under the Medicare program. 42 U.S.C. 1320a-3a.