The OIG issues an advisory opinion in favor of the health system’s use of nurses for services traditionally performed by primary care physicians.king & spalding

On December 19, 2022, the OIG will utilize employed nurse practitioners (NPs) submitted by acute care hospitals (hospitals) to provide services traditionally performed by patient nurses. Posted Advisory Opinions 22-20 in response to requests for implementation. The attending physician of her two general care units (units) in one of her hospital campuses. The OIG considered using hospital NPs to undertake duties for which physicians were responsible for paying “compensation” within the meaning of the Anti-Kickback Act (AKS), but the OIG ultimately , determined that the arrangement poses minimal risk. of fraud and abuse. Citing several factors that mitigate the risk of abuse in the arrangement, the OIG decided not to impose administrative sanctions in connection with the AKS or the Civil Penalty (CMP) Act.

arrange

Physicians who choose to participate in the arrangement can have NPs employed by hospitals provide specific care to inpatients or patients under observation on the unit. The OIG cited examples of such care as follows:

• Rapid initiation of care planning through existing protocols.
• Implement applicable care protocols established by the hospital (eg, stroke or community-acquired pneumonia protocols).
• Rotate assigned units while NPs address concerns of patients, their families, nurses, and other clinicians.
• Response to clinical or imaging studies. This includes arranging for expedited follow-up testing and responding to abnormal results, if necessary.
• Address rapid changes in patient conditions, such as adjusting care plans and ordering diagnostic tools or interventions in real time.
• Educate and support patients and families.
• Coaching, education, and other support for unit nurses, including the provision of accredited continuing education.
• Supervision and support of unit-based quality improvement projects.When
• Discharge planning may include obtaining insurance authorization for post-acute care and scheduling follow-up tests and appointments.

Hospitals should encourage physicians participating in the arrangement to make daily rounds, communicate with NPs, collaborate in providing patient care, and maintain the same accountability for patient care as nonparticipating physicians. are still demanding. Patients in the unit are undergoing active evaluations to determine the cause and extent of their illness, the hospital said. This often requires constant attention throughout the day and a real-time response to changing conditions. According to the OIG, hospital experience has shown that providing readily available NPs increases diagnostic and therapeutic efficiency and improves patient care.

Regarding the process for physicians to participate in this arrangement, the hospital shall make arrangements with all hospital privileged physicians who regularly admit patients to the unit, including physicians and physicians employed by hospital affiliates. I noted that I am sending out an annual offer letter explaining. in independent practice. The hospital has demonstrated that it does not consider the physician’s expectations or the volume or value of past referrals in offering this arrangement. The OIG states that there are no ancillary agreements with Participating Physicians to induce or reward referrals, and that compensation paid to Participating Physicians outside of the agreement does not take into account services performed by the NP under the agreement. says. A participating physician is not permitted to charge for services provided by an NP, nor to rely on her NP’s documentation in billing for her own services. Moreover, the hospital does not separately bill payers for her NP’s services.

OIG decision

The OIG serves patients of participating physicians, especially in the context of Medicare, where physicians are reimbursed for once-daily evaluation and management services, regardless of the number of visits they actually make. We advise that this proposal will involve AKS because of the rewarding value of NP. in a day. Such rewards may induce referrals from participating physicians, according to the OIG. However, the OIG has determined that because the proposed arrangement minimizes the risk of fraud and abuse under his AKS, the OIG will exercise its discretion and not impose sanctions under the AKS. did. The OIG has identified several factors supporting this decision.

1. This arrangement is limited to two non-surgical general care units on one of the hospital’s campuses. Because the unit is intended for primary care, potential referrals are not as beneficial to the hospital as if the unit were a surgical unit or specialized in nature. The OIG said it would look at the arrangement differently if the unit was specialized or otherwise offered hospitals more favorable opportunities.
2. Importantly, the hospital believes that compensation paid to participating physicians outside of this arrangement does not take into account the services performed by the NP under the arrangement and is based on the physician’s anticipated or past experience in providing the arrangement. has proven that it does not consider the amount or value of referrals.
3. AKS has safeguards in place to reduce the likelihood of fraud and abuse. For example, hospitals still require participating physicians to make daily rounds, communicate and collaborate with NPs to provide care to patients, and maintain accountability for patient care. Hospitals do not pay physicians by arrangement and have no ancillary agreements with participating physicians to induce or reward referrals. A participating physician is not permitted to bill for services provided by an NP, nor to rely on her NP’s documentation in billing services. The OIG considers these facts about the arrangement to be “for example, a hospital may allow an NP in which it is employed to provide services to the physician’s patients without the physician’s cost, and then the physician may be entitled to access, including federal health care programs.” “Dubious arrangement to charge the payer for the cost”. Services performed by these NPs. ”
4. The OIG found that the services provided by NPs in this arrangement appear rationally designed to improve patient care by making diagnosis and treatment more efficient. Additionally, hospitals do not bill for NP services, which reduces the risk of inappropriately increasing federal health program costs.

An advisory opinion contains a customary note that it should not be relied upon by anyone other than the requesting hospital. Copies of Advisory Opinions 22-20 are available here.