From the Desk of the MAC Medical Directors: Caring for Medicare Patients is a Partnership

As a patient’s treating physician or nonphysician practitioner, you may order, refer and/or give health care services for your patient in partnership with other providers (i.e., DME Suppliers or Home Health Agencies). Understanding the applicable Medicare coverage criteria (for example, medical necessity) and documentation guidelines for those services is extremely important for the accurate and timely processing and payment of both your claims and the claims of other entities, including physicians, other health care providers and suppliers who give services for your patient.

Other physicians and health care providers may need your documentation or certification supporting the medical necessity of the services they give secondary to your referral or order. Audits conducted by the CERT program, RACs, RAs and MACs have frequently shown that available documentation lacks information to establish medical necessity. Audits also have consistently shown that the medical records given by physicians lack sufficient documentation to justify an item or service ordered by them. This lack of physician documentation is causing a lack of payment for services, and may result in denied or delayed care for your patient.

Cooperation of all providers of services to supply the necessary documentation and information is a requirement outlined in Section 1842(p)(4) of the Social Security Act. It states in part: in case of an item or service...ordered by a physician or a practitioner...but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner. The HIPAA Privacy Rule permits disclosure of protected health information without patient authorization to carry out treatment, payment, or health care operations. Giving requested documentation cannot be charged for and is not a HIPAA violation.

For more information regarding your role and the supporting documentation necessary, please see the MLN Matters Fact Sheet® Caring for Medicare Patients is a Partnership.

Posted 12/17/2020