Direct supervision

[firewicket]

I am trying to find an answer to rules concerning direct supervision.

There is an Astro 2018 white paper stating that there is an exemption to direct supervision for CAH ( critical access hospital‘s) and rural hospitals less than 100 beds.

There is a clear definition for a critical access hospital by CMS (and a searchable list of hospitals meeting this designation).

There does not appear to be a distinct list for classification as a “rural hospital.”

How can someone find out if a hospital meets this definition?

Please feel free to PM me or post in the thread.

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[medgator]

Nope unless specifically classified as a CAH imo. But maybe you could swing a np if you're hospital based. I wouldn't do it personally

What are the rules for when a Rad Onc has to be in the building?

I love my job, and I don't mind being on site through the treatment day. But there is a full gym across the street, and it'd be nice to go when my therapists are just plowing through breast treatments, I have nothing to do, and they could just call me back for issues. Anyway ... does anyone know...

forums.studentdoctor.net

 

[firewicket]

Whoa..so an NP is fine in a hospital based setting...

But...what about this rural based setting...how can you be SURE you are exempt from any direct supervision??

 

[medgator]

Whoa..so an NP is fine in a hospital based setting...

But...what about this rural based setting...how can you be SURE you are exempt from any direct supervision??

You can't unless Medicare has designated your hospital as a CAH

 

[scarbrtj]

Two schools of thought. One is the loose school. In this school, the hospital says well we have radiologists and medical oncologists here. And Medicare allows for any physician to supervise, technically it doesn't have to be a rad onc. Also NPs (or PAs even) may supervise; this is well codified. In this loose school, the supervising physician, according to the courts, doesn't even need to be aware that he/she is supervising ("...in any given administration of an incident to service, the supervising physician may not and need not be aware that she is supervising a particular incident to service").

Then there is another school that says to heck with all that loose bunk. It's a rad onc and only a rad onc that can supervise. Elsewise is illegality of the highest and most heinous degree. In this school, I think the only iron-clad 100% sure way to get an answer which completely covers oneself in these situations is get an OIG advisory opinion tailored to your exact scenario. Even if your hospital were a CAH or designated rural, I would still explore getting an OIG advisory opinion expressly stating it will be OK to provide general instead of direct supervision. (Trivia qu of day: you can turn the MV beam on a patient in one particular scenario ie CPT code and it not require direct supervision, just general supervision required; what is that CPT code?)

 

[evilbooyaa]

My understanding was that the hospital had to be classified as having a 'rural exemption' which may be the same as a CAH designation, in order to use NPs/PAs as 'supervising'

 

[Bequerel]

Hospital based can (not saying should) use credentialed NP/PAs to cover. CMS regulations are outlined in white paper on ASTRO website. There is a distinction made between hospital based and free standing centers.

 

[medgator]

Sure. Without knowing the Full details of those cases, it’s hard to comment. my guess is obvious and blatant fraud was taking place in all of them.

But if it ever were the case, I’d probably submit the CMS rule allowing physician or non-physician providers to supervise treatments. More likely, the case would never be heard in the absence of other offenses because that rule exists.

Fresh in my mailbox from ASTRO:

"In the HOPPS final rule starting in 2020, CMS extended existing general supervision requirements to all hospital outpatient therapeutic services, thereby reducing the supervision for radiation therapy services. ASTRO opposed such a broad reduction that could risk patient safety. The Agency noted that facilities and physicians have the flexibility to adhere to higher standards"

Yup, not what you want to hear if you're a graduating resident.

And who is ASTRO kidding with that "flexibility" comment??

 

[deleted1002574]

Alligator, how do you interpret? Or others?

 

[medgator]

Alligator, how do you interpret? Or others?

If I'm a hospital based pro group with multiple centers, why would I need to hire more associates to cover all those satellites now if there is only a "general supervision" requirement from CMS? That basically means you don't need to be physically present for treatment.

Bottom line, you want to be as busy as possible with consults, planning and otvs, and you don't need to be physically present for the daily professional igrt charges is how I interpret it.

 

[BobbyHeenan]

If I'm a hospital based pro group with multiple centers, why would I need to hire more associates to cover all those satellites now if there is only a "general supervision" requirement from CMS? That basically means you don't need to be physically present for treatment.

Basically you want to be as busy as possible with consults, planning and otvs, you don't need to be physically present for the daily professional igrt charges is how I interpret it.

THis is my understanding.

From my first glance this seems like a seismic shift in language from CMS on this issue - which used to be kind of gray - seeming to give more of an endorsement to mid level coverage.

I ahve this exact scenario - hospital based pro group - and it presents a major change potentially for our group and our multiple hospital based centers.

 

[deleted1002574]

That’s sort of how I read it, too.
So, this still would not apply to freestanding ?

 

[medgator]

That’s sort of how I read it, too.
So, this still would not apply to freestanding ?

Nope. But who knows, maybe with all this site-neutrality stuff going on with APM, it might be in the cards in the future.... further seismic shift, further need for less ROs to Tx the same number of patients

 

[medgator]

That’s it folks - we are ****ed. Those 150 kids in the match this year should get out while they still can.

You know, it's hard to say that's hyperbole, because I don't see how this ends well for anyone getting out of training now.... We may need <100 graduating residents from here on out assuming CMS follows through with the plan to change things from Direct to General supervision in hospital based RO.

If that includes freestanding one day, we'll need even less. You won't need locums if you have another partner around, even if they are in a different center, geographically

 

[BobbyHeenan]

You know, it's hard to say that's hyperbole, because I don't see how this ends well for anyone getting out of training now.... We may need <100 graduating residents from here on out assuming CMS follows through with the plan to change things from Direct to General supervision.

I wonder if light volume academic satellites could be staffed with senior residents a couple days a week. He/she would have a medical license, etc after an internship.

Honest question.

 

[Burt Radnolds]

Attached the full text PDF on the final rule, interesting but lengthy read that starts on page 676. Conclusion below


After reviewing all of the public comments, we are finalizing our proposal for CY 2020 and subsequent years to change the generally applicable minimum required level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision for services furnished by all hospitals and CAHs without modification. We also note all of the policy safeguards that have been in place to ensure the safety, health, and quality standards of the outpatient therapeutic services that beneficiaries receive will continue to be in place under our new policy. These safeguards include allowing providers and physicians the discretion to require a higher level of supervision to ensure a therapeutic outpatient procedure is performed without risking a beneficiary’s safety or their quality of the care, as well as the presence outpatient hospital and CAH CoPs, and other state and federal laws and regulations. We are also finalizing the accompanying changes we proposed to the regulatory text at §410.27 with several
technical changes.

 

[Neuronix]

I wonder if light volume academic satellites could be staffed with senior residents a couple days a week. He/she would have a medical license, etc after an internship.

Honest question.

I used to locums on my vacation days doing this as a resident for local PP groups. These groups took a liberal interpretation of the supervision rules.

None of these same groups ever hired the residents of course. We talked about it, but offers were ~$300k salary with maybe some day sharing professional only collections.

 

[BobbyHeenan]

I used to locums on my vacation days doing this as a resident for local PP groups. These groups took a liberal interpretation of the supervision rules.

None of these same groups ever hired the residents of course. We talked about it, but offers were ~$300k salary with maybe some day sharing professional only collections.

I did this too as a resident at some adjacent rural PP clinics.

At one point our NCI designated CCC was using a med onc to cover 1-2 days/week at the lighter satellites but then stopped that (this was like 10-15 years ago). I suspect they will go back to that.

 

[Mandelin Rain]

As a first year, first month resident, I was supervising an academic satellite for my department during vacations/PTO days by the attending.

 

[Burt Radnolds]

If you want to capitalize on this, you'll have to drop ASTRO APEx, they mandate direct supervision I believe. Wonder if they will revise their requirements.

 

[medgator]

If you want to capitalize on this, you'll have to drop ASTRO APEx, they mandate direct supervision I believe. Wonder if they will revise their requirements.

Not sure if ACR or ACRO or does. We are ACR certified and I don't remember physical presence ever coming up during the reaccreditation process.

 

[Burt Radnolds]

Not sure if ACR or ACRO or does. We are ACR certified and I don't remember physical presence ever coming up during the reaccreditation process.

Pretty sure both do not specify and either would be congruent with latest ruling.

 

[deleted1002574]

ACR does not (have been reviewer within last 3 years)

 

[Mandelin Rain]

APEX and ACRO do not. ACR does.

 

[Burt Radnolds]

APEX and ACRO do not. ACR does.

We've evaluated all three and I was told ASTRO was the only one that explicitly required it and it was part of the reason we chose to pursue ACR. Not ruling out that I am incorrect as I have not personally reviewed the source material.

 

[Mandelin Rain]

We've evaluated all three and I was told ASTRO was the only one that explicitly required it and it was part of the reason we chose to pursue ACR. Not ruling out that I am incorrect as I have not personally reviewed the source material.

You are indeed incorrect.

Page 12.

https://www.acraccreditation.org/-/media/ACRAccreditation/Documents/ROPA/Requirements.pdf?la=en

 

[Burt Radnolds]

You are indeed incorrect.

Page 12.

https://www.acraccreditation.org/-/media/ACRAccreditation/Documents/ROPA/Requirements.pdf?la=en

Thank you! This will guide decision making on our end. Happen to know for sure on the other two?

Also there appears to be some dissent here, including from established ACR reviewers. Additionally I was told by someone who had done many ACR reviews that they did not require mandated direct supervision. What gives?

 

[Mandelin Rain]

Thank you! This will guide decision making on our end. Happen to know for sure on the other two?

Unless something has changed in the past 6 months, I'm 99.999% sure APEX does not. ACRO is the easiest to get though.

Here is the ACRO standard:

6.1.2. A Radiation Oncologist should be available for patient care and quality review on a daily basis. The Radiation Oncologist, practice, and support staff should be available to initiate urgent treatment within a medically appropriate response time on a 24-hour basis, 365 days per year. When not physically present within the practice, the Radiation Oncologist should be available by cell phone, pager, or other designated means. When unavailable, the Radiation Oncologist is responsible for arranging appropriate coverage.

 

[deleted1002574]

Wasn’t on the checklist for ACR up to 2016, as far as I know. Must be new.

Heck, when we were being reviewed one year, we drove the reviewer to the 2nd facility and clearly the docs were not on site (since we were driving the reviewer).

EDIT: that PDF is unchanged for a long time, so you’re right, it is very specific (more strict than Medicare). But, it wasn’t on the report anywhere.

 

[medgator]

You are indeed incorrect.

Page 12.

https://www.acraccreditation.org/-/media/ACRAccreditation/Documents/ROPA/Requirements.pdf?la=en

I think if you showed up every day for the acr review, you'd be fine. There are some ACR accredited practices that have gotten caught up in supervision lawsuits before

 

[Haybrant]

I think if you showed up every day for the acr review, you'd be fine. There are some ACR accredited practices that have gotten caught up in supervision lawsuits before

No it’s fairly clear when it says ‘on premises whenever treatments are being delivered’ and they don’t distinguish between hospital based and free standing center. ACR can do whatever they want? They don’t have to follow CMS? Astro follows cms and distinguishes between the centers

 

[medgator]

Astro follows cms and distinguishes between the centers

Except the rules haven't been finalized yet, so pretty much everyone needs to be providing direct supervision as of now. The only thing to distinguish at this point is whether a hospital based facility is using an np to cover instead of an MD.

 

[Mandelin Rain]

My take on accreditating agencies: they just want your money.

I’ve never had patient ask if we were ACR/APEX/ACRO accredited. Apparently reviewers don’t even know their criteria. It’s a mechanism to get your money into their pocket.

Still, we do it.

 

[medgator]

My take on accreditating agencies: they just want your money.

I’ve never had patient ask if we were ACR/APEX/ACRO accredited. Apparently reviewers don’t even know their criteria. It’s a mechanism to get your money into their pocket.

Still, we do it.

Yup. Maybe they will step up on physical presence requirements to differentiate practices further? I think some centers use accreditation as a feather in their cap to stand out, esp if there is a lot of competition in the area.

IIRC, doesn't a diagnostic rads facility need ACR accreditation to get paid by Medicare?

 

[radoncgrad2019]

I think it is almost a sure thing that these accreditation agencies will start looking a direct supervision as part of their criteria if they hadn’t prior

 

[Mandelin Rain]

I think it is almost a sure thing that these accreditation agencies will start looking a direct supervision as part of their criteria if they hadn’t prior

Maybe ASTRO will, but ACR will almost certainly drop it. A whole lot of ACR accredited facilities about to move away from direct supervision, and they won’t be giving up those dues/reaccreditation fees.

 

[deleted1002574]

Yeah, if not enforcing it before the rule got dropped, highly unlikely to enforce it after.

 

[radoncgrad2019]

If ACR makes their bones by differentiating places from each other, I was thinking that this would be an easy criteria to look at and use to make places seem ‘special’?

 

[medgator]

If ACR makes their bones by differentiating places from each other, I was thinking that this would be an easy criteria to look at and use to make places seem ‘special’?

Yup.... Do you want to go to the center where a BC RO is always present for treatments or not? I don't think patients will know enough to care in many cases, but who knows, it would be a way to further differentiate centers out...

 

[Mandelin Rain]

Does ACR require radiologists to be present for direct supervision of CT for CT accreditation?

 

[medgator]

Does ACR require radiologists to be present for direct supervision of CT for CT accreditation?

Can be any MD. Very common moonlighting gig in many residencies was to babysit while iv contrast was being administered for studies

 

[RickyScott]

Can be any MD. Very common moonlighting gig in many residencies was to babysit while iv contrast was being administered for studies

Know of plenty medonc practices where npp provider present at times for chemo, a situation where there are actual codes, reactions/ infiltrations /hospitalizations on a yearly basis in any facility. Given this,cms ruling totally reasonable.

 

[medgator]

Know of plenty medonc practices where npp provider present for chemo, a situation where there are actual codes, reactions on a yearly basis in any facility.

They bill less but I've also seen some med onc practices who have NPs insist on MD coverage to the point of using retired internists, maybe trying to capture the higher billing.