The OIG approves hospital provision of nurse services in an advisory opinion. Base, Berry, Sims PLC

The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services recently issued Advisory Opinions 22-20 advocating that employed nurse practitioners provide certain services traditionally provided by a patient’s primary care physician. Approved an acute care hospital arrangement to Although limited in scope, this favorable opinion is worth noting. Because this represents a departure from the OIG’s typical approach to arrangements involving hospital-to-referring physician compensation, and the OIG’s emphasis on providers who provide quality care to beneficiaries of federal health care programs. because it shows Importantly, the Advisory Opinion addresses only federal anti-kickback statutes. Other laws, such as the Federal Physician Self-Introduction Act, commonly referred to as the Stark Act, can pose significant obstacles to similar arrangements.

arrange

Requestors are emergency hospitals that provide inpatient and outpatient hospital-based services. Under this arrangement, the hospital uses an employed nurse practitioner to perform a variety of tasks for participating physicians’ patients who are inpatients or under observation in her two designated medical units. . Participating physicians are primarily primary care physicians, but the hospital makes the service available to all physicians who regularly admit patients to designated medical units. The hospital does not consider the quantity or value of a physician’s expectations or past referrals when considering a physician’s participation.

This arrangement is limited to two general care rooms and does not apply to surgical or specialty care rooms. Under this arrangement, nurse practitioners perform a variety of tasks in communicating and collaborating with physicians that physicians would normally perform. Tasks include:

• Begin planning care through existing protocols.
• Implementation of care protocols.
• Arrange for follow-up testing or imaging.
• Educate patients and families.
• Support other nurses in the unit.
• Support for quality improvement projects.
• discharge plan.

Patients seen by nurse practitioners are being actively evaluated and require ongoing medical attention. This arrangement allows for faster treatment and diagnosis. The treating physician is ultimately responsible for the patient’s care and must see the patient daily. Physicians also cannot bill for the services of nurse practitioners. The hospital does not pay the treating physician under an arrangement, nor does it bill the payer separately for the services of a nurse practitioner.

Analysis of OIG

The OIG believes that this arrangement is anti-kick because, in the OIG’s view, hospitals provide remuneration in the form of nurse practitioner services to the attending physician who is the source of the referral to the hospital and is usually responsible for the treatment. I conclude that it has to do with the back law. Tasks provided by a nurse practitioner.

Nevertheless, the OIG concludes that this arrangement is low risk for the following reasons.

1. Arrangements are limited to non-surgical and non-specialized hospital unitsThe OIG sees the arrangement’s focus on general primary care as mitigating the risk that the arrangement is designed to induce referrals and that the arrangement provides patients in surgical or specialty units. In addition, the hospital does not target specific referral physicians and offers services to all physicians with privilege. Hospitals also do not consider the quantity or value of physician referrals when providing arrangements.
2. There are safety nets in the arrangementThe OIG lists several safeguards that reduce the risk of fraud and abuse of the arrangement. For example, nurse practitioners perform their duties by communicating and collaborating with doctors, who still have to make daily rounds and take ultimate responsibility for their patients. Further, a doctor may only bill for services performed personally by him/herself, not for work performed by a nurse’s practitioner. The OIG noted that this arrangement could be distinguished from dubious arrangements that allow physicians to bill payers, including federal health programs, for services performed by nurse practitioners at no cost. .
3. This arrangement is unlikely to increase costs and improve patient careThe fact that hospitals do not charge payers, including federal health care programs, for the services of nurse practitioners, while improving patient care, risks that this arrangement inappropriately increases the cost of federal health care programs. mitigate. Additionally, proactive monitoring of care units by nurse practitioners may improve patient care through more timely assessment.

important point

This favorable advisory opinion is a departure from the OIG’s typical approach of limiting arrangements involving potential compensation from hospitals to their referring physicians. However, the scope of the arrangement and its focus on promoting high-quality patient care allow requesting hospitals to provide more timely access to patients in need of medical attention, and thus the OIG’s value-based care. consistent with the general push to

The OIG ultimately concludes that the fraud and abuse risk of this arrangement is low, but it is limited in some aspects, which narrows its relevance to other scenarios. For example, this placement is limited to general care units and specifically excludes surgical or specialty care units. This limitation is understandable given the factors supporting OIG’s analysis. Not only is surgery more lucrative, but surgeons are generally paid worldwide for surgery, which already includes post-operative follow-up, which requires doctors to conduct follow-up hospital visits. Physicians who provide care in general care units typically receive different coverage, reducing the risks associated with the arrangement.

Further, based on the conclusion that the provision of nurse practitioner services constitutes remuneration under the arrangement in question, the Advisory Opinion is made primarily for the benefit of hospitals and patients, but incidentally It may raise questions as to whether similar arrangements that benefit physicians constitute compensation to hospitals.Physicians.

Finally, Advisory Opinions 22-20 address the issue of enforcement risk under the Anti-Kickback Act, but not the Stark Act. If the provision of nurse practitioner services to participating physicians constitutes compensation under the Stark Act, comply with applicable Stark Act exceptions, as the OIG claims under the anti-kickback statute You need to configure the arrangement so that To do so, the value of the nurse practitioner’s services must be considered and, in some cases, the physician may be required to pay the hospital fair market value compensation for their services.