What are the regulatory requirements for physician visits?

SNFs are regulated by federal and state laws, with one crucial regulatory requirement demanding the presence of a medical director who can oversee that facility’s medical care.^[1] The medical care of each resident in a SNF must also be supervised by a physician.^[2] This means a physician is responsible for overseeing the care provided to each resident and ensuring they meet the mandatory medical standards. When the attending physician is unavailable, another physician must supervise the residents’ medical care.

There are also specific guidelines that must be followed to ensure the regularity and timeliness of physician visits. For the first 90 days after admission, a patient must be seen by a physician at least once every 30 days. After this initial period, a physician visit must occur at least once every 60 days. To be considered timely, physician visits should occur no later than 10 days after the required date. These regulations are in place to safeguard the well-being of residents in SNFs and maintain transparency in healthcare practices.

Tips to ensure regulatory compliance for physician visits

Tracking the frequency of physician visits is an important aspect of compliance, and the responsibility for tracking these visits typically falls on the administrative staff of the SNF. Staff must keep accurate records of each resident’s physician visits, including the date of the visit and the supervising physician. This information is imperative for both regulatory compliance and reimbursement purposes.

Routine reviews of physician visit metrics can also be conducted to identify any deviations or deficiencies. By regularly reviewing metrics, SNFs can ensure physician visits occur as required and address any potential gaps in care. This review process helps maintain the quality of medical care provided to residents and guarantees compliance with regulatory standards.

In cases where deficiencies are identified in physician visit metrics, it’s advisable to have an escalation process in place. This allows for timely intervention and corrective measures to rectify any issues. The facility should establish protocols for addressing deficiencies, which may include communication with the medical director or attending physician, additional training for staff, or implementing new systems to improve compliance with regulatory requirements.

Physician arrangements and Stark Law

Physician arrangements are critical in the healthcare industry, ensuring patients receive the needed care while maintaining ethical and legal practices. These arrangements are governed by the federal Physician Self-Referral Law, commonly known as the Stark Law.^[3] As a strict liability statute, Stark Law does not require proof of specific intent to violate the law, emphasizing the importance of adherence to its regulations.

Stark Law prohibits physicians from making referrals for certain “designated health services” payable by Medicare if the physician or their immediate family member has a financial relationship with the receiving entity unless an exception applies. Designated health services encompass a wide range of medical services, including lab services, physical, occupational, and speech therapy, durable medical equipment, prosthetics, radiology, home health, pharmaceuticals, and both inpatient and outpatient services.

One key aspect to consider in physician arrangements is the concept of “commercially reasonable” compensation. While Stark Law provides objective guidelines for compliance, determining commercially reasonable compensation is relatively subjective. The compensation offered to physicians must be fair and reasonable in relation to the services they provide and account for factors like the physician’s qualifications, experience, and the prevailing rates in the market.

Stark Law explicitly prohibits compensation arrangements based on the volume or value of referrals or other business the referring physician generates. This provision helps ensure that patient care remains a top priority by eliminating potential financial incentives that could compromise medical decision-making.

By adhering to the Stark Law, healthcare organizations can maintain the integrity of their physician arrangements. Compliance with the Stark Law fosters a fair and ethical healthcare environment and inspires trust among patients, healthcare providers, and regulatory bodies. Organizations need to stay updated with an ever-evolving legal landscape to ensure ongoing compliance and the delivery of high-quality, patient-centered care.

Compliance with medical director stipends, contracts, and agreements

Managing medical director stipends and contracts is another area of healthcare that requires careful adherence to laws and regulations. Medical directors are significant in various healthcare settings, including SNFs, hospices, and home health agencies. Their responsibilities differ based on the type of facility in which they work.

In SNFs, medical directors are accountable for the oversight of quality assurance and improvement, quality of care initiatives, as well as education and training as per regulatory requirements.^[4] In hospice, medical directors oversee the patient care program, including initial certifications and recertifications of a terminal illness.^[5] Home health agencies are not required to have medical directors, but it is advisable to outline specific duties in contracts, such as staff education and policy reviews.

Managing medical director stipends and contracts involves various fundamental considerations. One essential aspect is determining fair market value for the stipends. As with physician arrangements, there is not a one-size-fits-all approach. Thorough assessments and evaluations are needed to establish appropriate compensation levels that align with fair market value. When considering fair market value, organizations should consider factors like patient volume, facility size, and census.

Another important consideration involves defining the services expected from medical directors in their contracts. This includes detailing responsibilities such as attending meetings, providing education to staff, and participating in quality improvement initiatives. Explicitly outlining the duties and responsibilities can ensure clarity and avoid misunderstandings between the medical director and the facility, establish expectations, and ensure compliance.

Documenting and proving the delivery of services is another key part of payment substantiation and compliance. Organizations should maintain appropriate records, including time sheets, attestations, meeting minutes, and/or medical record documentation. Thorough recordkeeping practices enable organizations to demonstrate that the stipends are supported by the services rendered and that they align with contractual obligations and regulatory requirements.

Organizations should also pay attention to any changes to their medical director’s responsibilities. Any modifications to the agreement should be communicated in writing and executed entirely. Organizations should consider coordinating with their accounts payable departments as well. This can help ensure accurate and appropriate processing of stipend payments.

How to ensure your providers are properly credentialed

Properly credentialing medical directors and physicians is imperative to ensure your patients receive care from qualified providers. By following a systematic approach, healthcare organizations can ensure that only credentialed individuals provide care at their facilities.

The first step in the credentialing process is to request the necessary documentation from the medical directors and physicians. This typically includes a valid license to practice, a conflict of interest form to disclose potential conflicts that could affect their ability to provide unbiased care, and a Drug Enforcement Administration (DEA) card to ensure compliance with controlled substance regulations.

Conducting thorough background checks is one of the most vital parts of the credentialing process. The National Practitioner Data Bank can help ensure no previous disciplinary actions or malpractice claims against the practitioner, and the DEA verification can confirm the physician’s authority to prescribe controlled substances. Screening for U.S. Department of Health and Human Services Office of Inspector General sanctions is another essential background screen to help your organization identify any past or present excluded individuals from federal healthcare programs.

Medical directors are typically responsible for approving completed credentialing papers. This task involves carefully reviewing the submitted documentation, ensuring that all requirements are met, and assessing the qualifications and competence of the provider. The medical director plays a significant role in upholding the standards of care within the facility by ensuring that only qualified individuals are granted privileges.

After the initial credentialing process, the concept of privileging comes into play. Privileging is specific to each location where services are provided, considering the unique needs and capabilities of the facility. A facility’s medical director is responsible for signing the endorsement or approval for privileges, indicating their confidence in the practitioner's abilities, and ensuring alignment with the facility’s requirements and standards.

The governing body of the healthcare organization has the ultimate responsibility of granting final approval for privileges. This is often done with the endorsement or approval of a representative of the governing body. The governing body’s involvement ensures additional oversight and accountability in credentialing.

Conclusion

Regulatory requirements for physician visits play a critical role in promoting resident well-being and upholding the highest standards of care. The presence of a medical director in healthcare facilities ensures proper oversight and guidance in medical decision-making, allowing residents to receive an appropriate level of care tailored to their needs. Likewise, supervising attending physician visits guarantees the quality and continuity of care throughout a resident’s stay in the facility.

Healthcare organizations can demonstrate their commitment to patient-centered care and regulatory compliance by adhering to federal and state regulations. Maintaining adherence to these requirements and continually evaluating and improving practices will help post-acute facilities provide exceptional care, enhance resident satisfaction, and contribute to the overall well-being of their communities.

Takeaways

• Skilled nursing facilities must have medical directors, ensure timely physician visits, and maintain transparency to safeguard resident well-being.

• Accurate tracking, recordkeeping, and routine reviews of physician visit metrics are crucial for regulatory compliance and reimbursement purposes.

• Organizations must adhere to the federal Physician Self-Referral Law to maintain ethical and legal physician arrangements.

• Proper management of medical director contracts requires considerations like fair market value, defining services, and communicating changes to responsibilities.

• Thoroughly verifying documentation, conducting background checks, and involving medical directors and governing bodies help guarantee qualified providers and adherence to standards.

*Donna Thiel is Chief Compliance Officer at ProviderTrust in Nashville, TN, and Laura Carrico is Chief Compliance & Privacy Officer at American Health Partners, Franklin, TN.

1 42 C.F.R. § 418.102.

2 42 C.F.R. § 483.30.

3 Centers for Medicare & Medicaid Services, “Physician Self Referral,” last modified February 13, 2023, https://www.cms.gov/medicare/fraud-and-abuse/physicianselfreferral/index.

4 42 C.F.R. § 483.70(h).

5 42 C.F.R. § 418.102.