A hospital/provider may have others furnish certain covered items and services to their patients through arrangements under which receipt of payment by the hospital/provider for the services discharges the liability of the beneficiary or any other person to pay for the service. In permitting hospitals/providers to furnish services under arrangements, it is not intended that the hospital/provider merely serve as a billing mechanism for the other party. Accordingly, for services provided under arrangements to be covered, the hospital/provider must exercise professional responsibility over the arranged-for services.
The hospital/provider’s professional supervision over arranged-for services requires application of many of the same quality controls as are applied to services furnished by salaried employees. The hospital/provider must accept the patient for treatment in accordance with its admission policies; maintain a complete and timely clinical record on the patient, which includes diagnoses, medical history, physician’s orders and progress notes relating to all services received; and must maintain liaison with the attending physician regarding the progress of the patient and the need for revised orders.
Additionally, the hospital/provider (other than a SNF) must ensure the medical necessity of such services is reviewed on a sample basis by the Utilization Review (UR) committee if one is in place, the facility’s health professional staff or an outside UR group. The provider, including an SNF that conducts optional UR services, is responsible for medical necessity decisions made under arrangement by an outside group.