CHAPTER 1102. SHARED HEALTH FACILITIES
GENERAL PROVISIONS Sec.
1102.1. Policy.
1102.2. Definitions.
1102.3. Legal authority.
1102.4. Role of shared health facilities.
SHARED HEALTH FACILITY REGISTRATION REQUIREMENTS
1102.21. Registration procedures.
ADMINISTRATIVE RESPONSIBILITIES OF OPERATORS
1102.31. General responsibilities.
1102.32. Responsibilities relating to shared health facility management.
1102.33. Responsibilities relating to the provision of medical services.
1102.34. Responsibilities relating to provider performance.
1102.34a. Clarification of the term ‘‘written’’—statement of policy.
PROVIDER PARTICIPATION
1102.41. Provider participation and enrollment.
PAYMENT FOR SERVICES
1102.51. Reimbursement policy.
UTILIZATION CONTROL
1102.61. Inspection by the Department.
UTILIZATION REVIEW
1102.71. Scope of claims review procedures.
ADMINISTRATIVE SANCTIONS
1102.81. Prohibited acts of a shared health facility and providers practicing in the shared health facility.Authority The provisions of this Chapter 1102 issued under section 1410 of the Public Welfare Code (62 P. S. § 1410), unless otherwise noted.
Source The provisions of this Chapter 1102 adopted April 23, 1982, effective April 24, 1982, 12 Pa.B. 1336, unless otherwise noted.
Cross References This chapter cited in 55 Pa. Code § 1101.41 (relating to provider participation and registration of shared health facilities); 55 Pa. Code § 1101.43 (relating to enrollment and ownership reporting requirements); and 55 Pa. Code § 1101.95 (relating to conflicts between general and specific provisions).
GENERAL PROVISIONS
§ 1102.1. Policy.
This chapter sets forth the Medical Assistance regulations and policies which apply to shared health facilities. The purpose of this chapter is to eliminate fraudulent, abusive and deceptive conduct and practices that may occur in shared health facilities. Shared health facilities are subject to this chapter and Chapter 1101 (relating to general provisions).
§ 1102.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Administrator—An individual designated by a shared health facility operator to handle day-to-day operations of the facility.
Department—The Department of Human Services of the Commonwealth.
Medical care—Services or items covered under the Medical Assistance Program.
Operator—The person responsible for the central coordination and management of the activities of a shared health facility and for the compliance by the facility with applicable State law.
Practitioner—A medical doctor, doctor of osteopathy, dentist, optometrist, podiatrist, chiropractor or other medical professional who is licensed by the Commonwealth or by another state and is enrolled in the Medical Assistance Program.
Provider—An individual or medical facility which signs an agreement with the Department to participate in the Medical Assistance Program, including, but not limited to: licensed practitioners, pharmacies, hospitals, nursing homes, clinics, home health agencies and medical purveyors.
Public clinic—A health clinic operated by a Federal, State or local governmental agency.
Purveyor—A person other than a practitioner who, directly or indirectly, engages in the business of supplying to patients medical supplies, equipment or services for which reimbursement under the Medical Assistance Program is received, including, but not limited to: clinical laboratory services or supplies, X-ray laboratory services or supplies, inhalation therapy services or equipment, ambulance services, sick room supplies, physical therapy services or equipment and orthopedic or surgical appliances or supplies.
Shared health facility—An entity other than a licensed or approved hospital facility, skilled nursing facility, intermediate care facility, intermediate care facility for the mentally retarded, rural health clinic, public clinic or Health Maintenance Organization in which:(i) Medical services, either alone or together with support services, are provided at a single location.
(ii) Services are provided by three or more practitioners, two or more of whom are practicing within different professions.
(iii) Practitioners share common waiting areas, examining rooms, equipment, supporting staff or records.
(iv) At least one practitioner receives payment on a fee for service basis.
(v) A provider received more than $30,000 in payment from the Medical Assistance Program during the 12 month period prior to the date of the initial or renewal application of the shared health facility for registration in the Medical Assistance Program.
§ 1102.3. Legal authority.
Shared health facilities are registered and regulated by the Department of Human Services under Article XIV of the Public Welfare Code (62 P. S. § § 1401—1411).
§ 1102.4. Role of shared health facilities.
(a) A shared health facility is recognized by the Department as a source of common support services for providers participating in the Medical Assistance Program who render medical care at the facility to Medical Assistance recipients. The support services may include, but are not limited to: buildings, parking areas, space and utilities.
(b) The providers rendering medical care at the shared health facility reimburse the facility for the cost of the support services it furnishes.
SHARED HEALTH FACILITY REGISTRATION REQUIREMENTS
§ 1102.21. Registration procedures.
(a) Upon notification by the Department that the facility has been determined to be a shared health facility, the operator of the shared health facility shall:
(1) Sign and submit to the Department two copies of the Shared Health Facility Provider Agreement.
(2) Register the shared health facility with the Department and specify the support and medical services to be provided at the facility.
(b) The operator shall apply for initial registration on forms prescribed by the Department and submit the application to the Office of Medical Assistance, Bureau of Provider Relations, Park Penn Building, Post Office Box 8024, Harrisburg, Pennsylvania 17105. At a minimum, the completed application shall contain:
(1) The name of the shared health facility.
(2) The kind of support services to be supplied by the shared health facility and the medical services to be rendered by the providers at the shared health facility.
(3) The location and physical description of the shared health facility.
(4) The name, social security number and residence address of every person, partnership or corporation having a financial interest in the ownership, including leasehold ownership, of the shared health facility and the structure in which the facility is located.
(5) The name, social security number and residence address of every person, partnership or corporation holding a mortgage, lien, leasehold or another security interest in the shared health facility or in equipment located in and used in connection with the shared health facility and a brief description of the lien or security interest.
(6) The name, residence address and professional license number of every practitioner rendering services at the shared health facility.
(7) The name, social security number and residence address of the administrator of the shared health facility.
(8) The name, social security number and residence address of the operators of the shared health facility.
(c) The operator shall submit, with the application for registration, copies of all:
(1) Certificates of good standing filed with the Commonwealth Department of State.
(2) Agreements pertaining to the acquisition of the building where the Shared Health Facility is located.
(3) Existing contracts, leases, agreements or service arrangements, and subsequent revisions thereto, with providers within the facility or related to the facility but located outside of the facility.
(d) The operator shall forward to the Department, upon request, a description of how the salary or rental amounts were determined between the operator and each provider. The description shall include a projected business volume or other statistics which were used to establish the salary or rental amount.
(e) The Department will evaluate the application of the shared health facility for registration and will, within 60 days after receipt of the initial or renewal application, notify the applicant in writing that the shared health facility has either been approved for or denied registration.
(f) If the facility is approved, the Department will issue a Registration Certificate to the shared health facility. The certificate is valid for a 1-year period and shall be posted conspicuously in the general reception area of the facility. The Department will also return to the shared health facility one fully executed copy of the Shared Health Facility Agreement.
(g) If a shared health facility is denied registration or if the registration and agreement of a shared health facility are cancelled by the Department, providers at the shared health facility will be ineligible to participate in the program at that shared health facility.
(h) The operator of a shared health facility shall submit an annual application for renewal of registration of the shared health facility on forms prescribed by the Department at least 60 days prior to the expiration date of the existing registration.
ADMINISTRATIVE RESPONSIBILITIES OF OPERATORS
§ 1102.31. General responsibilities.
The operator of a shared health facility is responsible for the overall management and operation of the shared health facility and for insuring the quality, continuity and proper coordination of medical care provided by providers at the shared health facility to Medical Assistance recipients. The operator shall, accordingly, comply with § § 1102.32, 1102.33 and 1102.34 (relating to responsibilities relating to shared health facility management; responsibilities relating to the provision of medical services; and responsibilities relating to provider performance).
§ 1102.32. Responsibilities relating to shared health facility management.
The operator of a registered shared health facility shall:
(1) Apply, upon notification by the Department that the facility has been determined to be a shared health facility, for an initial registration and for renewal of the registration annually thereafter.
(2) Insure that accurate and complete information and documentation are furnished on the application for registration of the shared health facility.
(3) Designate an administrator and hold the administrator responsible for handling the day-to-day operations of the shared health facility and supervise the activities of the administrator to insure that the shared health facility is properly operated.
(4) Insure that providers at the shared health facility will practice without influence by the operator or administrator or both.
(5) Insure that the administrative requirements and minimum care standards under this chapter are being met continuously by the shared health facility and its providers.
(6) Notify the Department of the termination of the services of an operator, administrator or of a provider in the shared health facility within 15 days of the date of termination. The notice shall include:
(i) The professional qualifications of an individual newly appointed to assume the position of administrator.
(ii) The professional license number of a provider newly participating in the facility.
(iii) For either the administrator or provider:
(A) The name.
(B) Social security number.
(C) Residence address.
(7) Establish a system of internal audits, controls and reports to insure the procedures for proper operation of the facility are effective.
(8) Notify the Bureau of Provider Relations within 15 days of changes in:
(i) The persons, partnerships or corporations having a financial interest in the shared health facility.
(ii) The persons, partnerships or corporations holding a mortgage, lien, leasehold or other security interests in the shared health facility or in equipment located in and used in connection with a shared health facility. A statement describing the monetary and repayment provisions of the lien or security interest shall accompany the notification.
Cross References This section cited in 55 Pa. Code § 1102.31 (relating to general responsibilities).
§ 1102.33. Responsibilities relating to the provision of medical services.
The operator of a registered shared health facility shall:
(1) Insure that a recipient is treated by a practitioner who is familiar with the medical history of the recipient.
(2) Assign a clearly identified general practitioner to each recipient, the assignment of whom may be changed at any time at the request of the recipient.
(3) Insure the freedom of the recipient to choose a provider at the shared health facility or elsewhere.
(4) Post conspicuously the names and scheduled office hours of practitioners rendering services in the facility.
(5) Make available to patients either the telephone number of the central answering service of the designated practitioner of the recipient or of the colleague of the practitioner as designated by the practitioner or the telephone number of a centralized 24-hour-a-day, 7 day-a-week answering service for recipient off-hour questions.
(6) Maintain a central registry that contains a daily record of the name and Medical Assistance record number of each recipient receiving services at the facility, the major complaint of each recipient and the name of a provider the services of whom were requested by the recipient or to whom the recipient was referred.
(7) Through the administrator, insure that recipient records and summaries of all recipient visits include the diagnosis and any pharmaceuticals prescribed and are at all times available at either the facility or at a place immediately available to all providers at the facility.
(8) Insure that the physical facilities of the shared health facility provide privacy for each recipient during examination, interview and treatment and that the treatment rooms, equipment and medical supplies and instruments are clean and properly maintained at all times.
(9) Post conspicuously the telephone number of the Bureau of Utilization Review of the Office of Medical Assistance along with a statement that the Bureau is responsible for providing information concerning shared health facilities and for receiving complaints concerning the provision of health care services at shared health facilities.
Cross References This section cited in 55 Pa. Code § 1102.31 (relating to general responsibilities).
§ 1102.34. Responsibilities relating to provider performance.
The operator of a shared health facility shall insure, either directly or through the administrator, that providers rendering services to recipients at a shared health facility and persons employed by the facility shall:
(1) Refer a recipient to another provider located inside or outside the shared health facility only when there is medical justification for the referral and the medical records of the referring practitioner clearly set forth the medical justification for the referral.
(2) Whenever treating a recipient referred by another provider inside or outside the shared health facility, communicate in writing to the referring practitioner the diagnostic evaluation and therapy rendered and incorporate this information into the record of the recipient.
(3) Obtain the signature of the recipient on outpatient orders or prescriptions written for the recipient by practitioners at a shared health facility.
(4) Maintain proper recipient records, for a minimum of 4 years, which contain at least:
(i) The full name, address and Medical Assistance record number of each recipient.
(ii) The dates of visits by a recipient to providers in the shared health facility and a statement as to whether the recipient is instructed to return for further treatment and the dates of return visits.
(iii) The major complaint and diagnostic impressions for each visit to a provider in the shared health facility.
(iv) Pertinent history and physical examinations rendered by each provider in the shared health facility;
(v) A listing of medications prescribed by a provider in the shared health facility.
(vi) The precise dosage and prescription regimens for each medication prescribed by a provider in the shared health facility.
(vii) Orders for X-rays, laboratory work and diagnostic tests written by or under the direction of a provider at the shared health facility.
(viii) The results of the tests ordered under subparagraph (vii).
(ix) The medical documentation justifying the necessity of diagnostic procedures ordered by a practitioner in a shared health facility regardless of whether the procedure is performed directly by the onlining practioner or by someone under the direct supervision of the practitioner or is referred to another practioner or purveyor.
(x) Referrals by practitioners in the shared health facility to other providers and the reasons for the referrals.
Cross References This section cited in 55 Pa. Code § 1102.31 (relating to general responsibilities); and 55 Pa. Code § 1102.34a (relating to clarification of the term ‘‘written’’—statement of policy).
§ 1102.34a. Clarification of the term ‘‘written’’—statement of policy.
(a) The term ‘‘written’’ in § 1102.34(3) (relating to responsibilities relating to provider performance) includes orders and prescriptions that are handwritten or transmitted by electronic means.
(b) Written orders and prescriptions transmitted by electronic means must be electronically encrypted or transmitted by other technological means designed to protect and prevent access, alteration, manipulation or use by any unauthorized person.
Source The provisions of this § 1102.34a adopted July 16, 2010, effective July 17, 2010, 40 Pa.B. 3963.
PROVIDER PARTICIPATION
§ 1102.41. Provider participation and enrollment.
(a) Providers at a registered shared health facility shall enroll and participate individually in the Medical Assistance Program in accordance with Chapter 1101 (relating to general provisions) and the appropriate separate chapters relating to each provider type.
(b) Providers at a registered shared health facility shall comply with Chapter 1101, the applicable provisions of this chapter and the provisions contained in the appropriate separate chapters relating to each provider type.
Cross References This section cited in 55 Pa. Code § 1101.41 (relating to provider participation and registration of shared health facilities)
PAYMENT FOR SERVICES
§ 1102.51. Reimbursement policy.
(a) Payment for services provided to Medical Assistance recipients is made by the Department directly to providers in a registered shared health facility. Payment is not made to another payee including the shared health facility.
(b) Payment is made to a provider only if the provider renders the service directly or if an employe of the provider renders the service under the direct supervision of the provider. For example, if a practitioner orders an X-ray and the X-ray is taken by someone other than the practitioner or an employe of the practitioner under the direct supervision of the practitioner, payment is not made to the practitioner for the ordered services.
(c) Payment is made only to enrolled physicians for radiology services and to enrolled laboratories for laboratory services.
UTILIZATION CONTROL
§ 1102.61. Inspection by the Department.
The Department may inspect the premises, business records, recipient records, leases and other contracts executed by the operator or a provider in a shared health facility. The inspections may be onsite visits to the shared health facility.
Cross References This section cited in 55 Pa. Code § 1101.51 (relating to ongoing responsibilities of providers).
UTILIZATION REVIEW
§ 1102.71. Scope of claims review procedures.
Claims submitted for payment under the Medical Assistance Program are subject to the utilization review procedures established in Chapter 1101 (relating to general provisions).
ADMINISTRATIVE SANCTIONS
§ 1102.81. Prohibited acts of a shared health facility and providers practicing in the shared health facility.
(a) Prohibited acts of shared health facilities, their owners, operators and administrators and providers practicing in the shared health facility are as follows:
(1) The rental fee for letting space to providers in a shared health facility may not be calculated wholly or partially, directly or indirectly, as a percentage of earnings or billings of the provider for services rendered on the premises in which the shared health facility is located. The operator of each facility shall file a copy of each lease and a renewal thereof with the Department.
(2) No purveyor, whether or not located in a building which houses a shared health facility, shall directly or indirectly offer, pay or give to a shared health facility or its providers, and no shared health facility or its providers may solicit, request, receive or accept from a purveyor, either directly or indirectly, a sum of money, credit or other valuable consideration for:
(i) Recommending or procuring goods, services or equipment of the purveyor.
(ii) Directing patronage or clientele to the purveyor.
(iii) Influencing a person to refrain from using or utilizing goods, services or equipment of a purveyor.
(3) No provider or purveyor may demand or collect a reimbursement contrary to the payment policy of the Medical Assistance Program.
(4) No purveyor may provide to a recipient services, equipment, pharmaceuticals or other medical supplies differing in quantity or in another respect from that described in the payment invoice submitted by the provider to the Department. No purveyor may provide to a recipient services, equipment, pharmaceutical or medical supplies differing in quality, quantity or in another respect from that prescribed.
(5) No recipient may be referred by a provider in a shared health facility or by a person employed in the facility to another provider in the shared health facility except under the following circumstances and restrictions:
(i) The referral shall be medically justified and the record maintained by the referring provider shall clearly indicate the justification for the referral.
(ii) A provider in a shared health facility to whom a recipient is referred shall communicate in writing to the referring provider the diagnostic evaluation and therapy rendered. The referring provider shall incorporate this information into the permanent medical record of the recipient.
(iii) The invoices submitted to the Department by the provider to whom a recipient has been referred shall contain the name and provider number of the referring provider and identify the medical problem which necessitated the referral.
(6) If a pharmacy is located in, or adjacent to, the building in which a shared health facility is located, no recipient may be required to purchase pharmaceuticals at the pharmacy. The shared health facility shall prominently post a notice in the common waiting area informing recipients that all pharmaceuticals prescribed by providers in the facility may be obtained at any participating pharmacy of the choice of the recipient.
(7) No provider may submit an invoice for services or items rendered at a shared health facility which does not contain the provider number of the provider who rendered the service or item and is not signed by the provider after the service or item has been rendered.
(8) No order may be issued by a provider for ancillary clinical services, including, but not limited to X-rays, electrocardiograms, clinical laboratory services, electroencephalograms or medical supplies and equipment which does not contain the professional license number and the medical assistance identification number of the prescriber and the provider number assigned to the facility at which the order was written.
(9) Each provider shall submit a true bill or invoice for services rendered under the program.
(b) In addition to the prohibited acts specified in this section, providers at a shared health facility are subject to the prohibited acts and criminal and civil penalties specified in Chapter 1101 (relating to general provisions).
Cross References This section cited in 55 Pa. Code § 1101.75 (relating to provider prohibited acts).
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