Author Topic: Cms defination of group  (Read 2060 times)

Healthy

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Cms defination of group
« on: June 13, 2013, 12:24:09 PM »
Hi All
Can any one please provide me a link to "cms defination of group". I looked every where but didn't find any thing.
Thanks

Michele

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Re: Cms defination of group
« Reply #1 on: June 13, 2013, 12:39:24 PM »
Are you looking for the definition of group for an enrollment issue?
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Healthy

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Re: Cms defination of group
« Reply #2 on: June 13, 2013, 12:47:36 PM »
Yes please.

RichardP

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Re: Cms defination of group
« Reply #3 on: June 13, 2013, 02:55:34 PM »
90.4 - Group Practice Defined (Rev. 1, 09-11-02)

A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association:

  In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, facilities, equipment, and personnel;

  For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group;

  In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group; and

  Which meets such other standards as the Secretary may impose by regulation to implement 1877(h)(4) of the Social Security Act. The group practice definition also applies to health care practitioners.


Bottom of Page 38 here:  (Revised 03-09)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c05.pdf

A Physician's Group is any legal entity of two or more practitioners.  The legal entity must have it's own Taxpayer I.D. Number and it's own Type 2 NPI Number (who gets paid).  The legal entity must be the billing entity (must bill for payment under its own name) and its Type 2 NPI Number (who gets paid) would be entered in Box 33a of the CMS 1500 Form.  If billing Medicare, the Type 1 NPI Number (who did the work) of the physician who actually did the work would be entered in Box 24J of the CMS 1500 Form.  All payment is made to the name of the legal entity.  The legal entity, in turn, pays the physicians a salary.

Of particular note is this requirement - particularly if the Group is going to own an Ambulatory Surgical Center (ASC) or a Pathology or Radiology Laboratory, etc.  The originating documents of the legal entity must spell out how each physician is to be paid, calculated by formula.  Physician pay may not be tied in any way to the number of patients seen by any owned ASC or Lab.  My memory is a bit foggy on whether the pay also cannot be directly tied to the number of patients the physician sees.

These requirements are intended to be a guard against physician's enriching themselves through self-dealing.  State law may supercede the CMS requirements if the state law is more stringent.  It would be a good idea to consult with a Health Care Attorney who is well versed in your state law.

Michele

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Re: Cms defination of group
« Reply #4 on: June 13, 2013, 04:54:45 PM »
If you are trying to determine which CMS form to complete for enrollment give a brief description of your situation.  Sometimes it's hard to figure out when you need a CMS 855B or if you can just use the CMS 855I.

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Healthy

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Re: Cms defination of group
« Reply #5 on: June 13, 2013, 05:08:37 PM »
Thank you all. Michelle I wanted to know only defination of group by CMS.