RESPONSIBILITIES
§ 1101.51. Ongoing responsibilities of providers.
(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.
Authority The provisions of this § 1101.51 amended under section 403.1(a)(6) of the Human Services Code (62 P.S. § 403.1(a)(6)).
Source The provisions of this § 1101.51 amended November 18, 1983, effective November 19, 1983, 13 Pa.B. 3653; amended January 13, 2023, effective January 14, 2023, 53 Pa.B. 376. Immediately preceding text appears at serial pages (201237) to (201238) and (399385) to (399387).
Notes of Decisions Penalties
Although termination of the written provider agreement is the only sanction expressly provided for in subsection (e)(4), the Department has the right to impose a lesser included penalty of suspension of that agreement. Del Borrello v. Department of Public Welfare, 508 A.2d 368 (Pa. Cmwlth. 1986).
Recordkeeping Requirements
The fact that this section requires physicians to maintain records for 4 years does not preclude the Department of Public Welfare from using available records which are more than 4 years old in the course of a civil proceeding leading to the termination of a physician’s participation in the MA Program. Clark v. Department of Public Welfare, 540 A.2d 996 (Pa. Cmwlth. 1988); appeal denied 569 A.2d 1370 (Pa. 1989).
Since subsection (e)(1) adequately sets forth minimum standards for medical provider records and since a health provider is charged with knowledge of applicable Department regulations, regardless of whether a copy has been supplied by the Department, order of restitution for keeping inadequate records did not violate due process or fundamental principle of fairness. Del Borrello v. Department of Public Welfare, 508 A.2d 368 (Pa. Cmwlth. 1986).
Cross References This section cited in 55 Pa. Code § 52.15 (relating to provider records); 55 Pa. Code § 1101.51a (relating to clarification of the term ‘‘within a provider’s office’’—statement of policy); 55 Pa. Code § 1101.71 (relating to utilization control); 55 Pa. Code § 1121.41 (relating to participation requirements); 55 Pa. Code § 1123.41 (relating to participation requirements); 55 Pa. Code § 1126.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1127.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1127.51 (relating to general payment policy); 55 Pa. Code § 1128.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1128.51 (relating to general payment policy); 55 Pa. Code § 1130.52 (relating to ongoing responsibilities of hospice providers); 55 Pa. Code § 1149.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1150.56b (relating to payment policy for observation services—statement of policy); 55 Pa. Code § 1153.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1155.22 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1181.542 (relating to who is required to be screened); 55 Pa. Code § 1230.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1243.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1247.42 (relating to ongoing responsibilities of providers); 55 Pa. Code § 1251.42 (relating to ongoing responsibilities of providers); and 55 Pa. Code § 5100.90a (relating to State mental hospital admission of involuntarily committed individuals—statement of policy).
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