(a)
Recipient freedom of choice of providers. A recipient may
obtain services from any institution, agency, pharmacy, person or organization
that is approved by the Department to provide them. Therefore, the provider
shall not make any direct or indirect referral arrangements between
practitioners and other providers of medical services or supplies but may
recommend the services of another provider or practitioner; automatic referrals
between providers are, however, prohibited.
(b)
Nondiscrimination.
Federal regulations require that programs receiving Federal assistance through
HHS comply fully with Title VI of the Civil Rights Act of 1964 (
42 U.S.C.A. §
§ 2000d-2000d-4 ), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C.A. §
794), and the Pennsylvania Human Relations
Act (43 P. S. §
§ 951-963). Providers are prohibited from denying services or
otherwise discriminating against an MA recipient on the grounds of race, color,
national origin or handicap.
(c)
Interrelationship of providers. Providers are prohibited from
making the following arrangements with other providers:
(1) The referral of MA recipients directly or
indirectly to other practitioners or providers for financial consideration or
the solicitation of MA recipients from other providers.
(2) The offering of, or paying, or the
acceptance of remuneration to or from other providers for the referral of MA
recipients for services or supplies under the MA Program.
(3) [Reserved].
(4) The solicitation or receipt or offer of a
kickback, payment, gift, bribe or rebate for purchasing, leasing, ordering or
arranging for or recommending purchasing, leasing, ordering or arranging for or
recommending purchasing, leasing or ordering a good, facility, service or item
for which payment is made under MA. This does not preclude discounts or other
reductions in charges by a provider to a practitioner for services, that is,
laboratory and x-ray, so long as the price is properly disclosed and
appropriately reflected in the costs claimed or charges made by a
practitioner.
(5) A participating
practitioner or professional corporation may not refer a MA recipient to an
independent laboratory, pharmacy, radiology or other ancillary medical service
in which the practitioner or professional corporation has an ownership
interest.
(d)
Standards of practice. In addition to licensing standards,
every practitioner providing medical care to MA recipients is required to
adhere to the basic standards of practice listed in this subsection. Payment
will not be made when the Department's review of a practitioner's medical
records reveals instances where these standards have not been met.
(1) A proper record shall be maintained for
each patient. This record shall contain, at a minimum, all of the following:
(i) A complete medical history of the
patient.
(ii) The patient's
complaints accompanied by the findings of a physical examination.
(iii) The information set forth in subsection
(e)(1).
(2) A diagnosis,
provisional or final, shall be reasonably based on the history and physical
examination.
(3) Treatment,
including prescribed drugs, shall be appropriate to the diagnosis.
(4) Diagnostic procedures and laboratory
tests ordered shall be appropriate to confirm or establish the
diagnosis.
(5) Consultations
ordered shall be relevant to findings in the history, physical examination or
laboratory studies.
(6) The
principles of medical ethics shall be adhered to.
(e)
Record keeping requirements and
onsite access. Providers shall retain, for at least 4 years, unless
otherwise specified in the provider regulations, medical and fiscal records
that fully disclose the nature and extent of the services rendered to MA
recipients and that meet the criteria established in this section and
additional requirements established in the provider regulations. Providers
shall make those records readily available for review and copying by State and
Federal officials or their authorized agents. Readily available means that the
records shall be made available at the provider's place of business or, upon
written request, shall be forwarded, without charge, to the Department.
Providers who are subject to an annual audit shall submit their cost reports
within 90 days following the close of their fiscal years. If the Department
terminates its written agreement with a provider, the records relating to
services rendered up to the effective date of the termination remain subject to
the requirements in this section.
(1)
General standards for medical records. A provider, with the
exception of pharmacies, laboratories, ambulance services and suppliers of
medical goods and equipment shall keep patient records that meet all of the
following standards:
(i) The record shall be
legible throughout.
(ii) The record
shall identify the patient on each page.
(iii) Entries shall be signed and dated by
the responsible licensed provider. Care rendered by ancillary personnel shall
be countersigned by the responsible licensed provider. Alterations of the
record shall be signed and dated.
(iv) The record shall contain a preliminary
working diagnosis as well as a final diagnosis and the elements of a history
and physical examination upon which the diagnosis is based.
(v) Treatments as well as the treatment plan
shall be entered in the record. Drugs prescribed as part of the treatment,
including the quantities and dosages shall be entered in the record. If a
prescription is telephoned to a pharmacist, the prescriber's record shall have
a notation to this effect.
(vi) The
record shall indicate the progress at each visit, change in diagnosis, change
in treatment and response to treatment.
(vii) The record shall contain summaries of
hospitalizations and reports of operative procedures and excised
tissues.
(viii) The record shall
contain the results, including interpretations of diagnostic tests and reports
of consultations.
(ix) The
disposition of the case shall be entered in the record.
(x) The record shall contain documentation of
the medical necessity of a rendered, ordered or prescribed service.
(2)
Fiscal
records. Providers shall retain fiscal records relating to services
they have rendered to MA recipients regardless of whether the records have been
produced manually or by computer. This may include, but is not necessarily
limited to, purchase invoices, prescriptions, the pricing system used for
services rendered to patients who are not on MA, either the originals or copies
of Departmental invoices and records of payments made by other third party
payors.
(3)
Additional
record keeping requirements for providers in a shared health facility.
In addition to the record keeping and access requirements specified in this
subsection, practitioners and purveyors in a shared health facility shall meet
1102.61 (relating to inspection by the Department).
(4)
Penalties for
noncompliance. The Department may terminate its written agreement with
a provider for noncompliance with the record keeping requirements of this
chapter or for noncompliance with other record keeping requirements imposed by
applicable Federal and State statutes and
regulations.
