© 2003 International Foundation of Employee Benefit Plans, Inc.




                   Physician’s Fees
In General

      ...
© 2003 International Foundation of Employee Benefit Plans, Inc.




        •   Dermatology                  Nephrology   ...
© 2003 International Foundation of Employee Benefit Plans, Inc.




        •   Tendonitis.
        *Surgery is standard t...
© 2003 International Foundation of Employee Benefit Plans, Inc.




Physician’s Office Within an Institution
         A ph...
© 2003 International Foundation of Employee Benefit Plans, Inc.




distinct from the hospital's emergency room) and which...
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Physician's Fees

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Physician's Fees

  1. 1. © 2003 International Foundation of Employee Benefit Plans, Inc. Physician’s Fees In General These fees are for home, office, hospital or clinic care. The schedule of Benefits shows any per visit deductibles which may be applicable. Physicians Fees. These fees include certain medical supplies provided such items are: • Actually furnished by physician and incidental to his professional services • Of the type usually furnished in physician’s office or clinic • Usually either furnished without charge or included in physician’s bill. Examples of such medical supplies include gauze, ointments, bandages, oxygen, tetanus antitoxin inoculations and injections for anemia and arthritis. Benefits are not payable for these items when physician simply orders a supply item or prescribes drug and medicines. Physicians Recognized These are the physicians whose fees are normally covered: • Medical doctor or surgeon • Dentist of dental doctor • Chiropractor • Osteopath • Chiropodist or podiatrist • Optometrist. Branches Of Medical Practice • Allergy Gynecology Psychiatry • Abdominal Surg. Hematology Pharmacology • Aerospace Medicine Head & Neck Surgery Pediatrics • Anesthesiology Hand Surgery Pediatrics, Allergy • Broncho-Esoph. Hypnosis Pediatrics, Cardiology • Cardiovascular Dis. Infectious Disease Pediatric Radiology • Cardiovas. Surgery Internal Medicine Pediatric Surgery • Child Neurology Laryngology Public Health • Child Psychiatry Legal Medicine Phys. Med. & Rehab. • Clinical Pathology Neurology Plastic Surgery • Colon, Rectal Surg. Neoplastic Disease Pathology Physician’s Fees 1
  2. 2. © 2003 International Foundation of Employee Benefit Plans, Inc. • Dermatology Nephrology Pulmonary Diseases • Diabetes Nuclear Medicine Psychoanalysis • Diagnostic Roentg. Neurological Surgery Psychosomatic Med • Endocrinology Nutrition Radiology • Forensic Pathology Obstetrics and Gyn. Rhinology • Family Practice Obstetrics Rheumatology • Gastroenterology Occupational Medicine Therapeutic Radiology • Geriatrics Ophthalmology Traumatic Surgery • General Practice Orthopedic Surgery Thoracic Surgery • Gen’l Prevent. Med. Otology Urological Surgery • General Surgery Otolanyngology Chiropractic Care Chiropractors treats the nervous system by manipulation of the structures of the body especially the spine. The basis of the practice is that disease is caused by abnormal functioning of the nervous system. Frequent treatments are the norm. Maintenance Therapy. Chiropractors may provide periodic (monthly) treatment for the purpose of maintenance of good health. As this is preventive medicine, charges are not covered. Acupuncture. At the present time, there is some concern over new or changing practices employed by some chiropractors. One of these practices is the use of acupuncture which is not currently a usual or customary procedure in the practice chiropractic. Chiropractic Intensive Care. This is a pattern of treatment followed by some chiropractors. This technique requires the patient to undergo an intensive series of treatments during one or more days with retention of the patient in an intensive day care facility operated by the chiropractor. Podiatric Care Foot care is provided by those especially trained in podiatry or chiropody. Such training is obtained at special schools offering courses in this medical field. General surgeons also provide podiatric care. Special podiatric problems. These are the specific medical problems normally treated by the podiatrist. • Flat feet; high arched feet • Corns and calluses • Bunions • Birth abnormality - vertical talus * • Hammertoe * • Morton's toe * • Bone spur • Bursitis Physician’s Fees 2
  3. 3. © 2003 International Foundation of Employee Benefit Plans, Inc. • Tendonitis. *Surgery is standard treatment. Examiner Alerts. Podiatric claims often present special problems for the examiner. Examples are: • Several procedure codes in one anatomical area • Surgeries done in series to inflate the charges • Use of needless assistant surgeons • Needless studies (plethysmography and temperature gradient, e.g.) • Inflated fees • Large fees • Doubtful services. Optometric Care The optometrist is concerned with the measurement of the power of vision and the adaption of lenses or prisms, utilizing any means other than drugs. Since a doctor of optometry is not duly licensed to treat an injury or disease, such doctor is not a physician. Psychological Care A psychologist provides psychological services in connection with the diagnosis and treatment of mental, psychoneurotic, and personality disorders. A clinical psychologist may use the letters, MA, MS, or Ph.D to indicate that such person is a licensed or certified psychologist. Other Practitioners There are other practitioners to healing acts who may or may not be paid as physicians. Christian Scientist Practitioners. Christian Science treatment is defined as a spiritually scientific method of prayer based on a systematic metaphysical approach to healing disease or sickness. A Christian Scientist Practitioner will be provided on the same basis as treatment by an M.D., provided the practitioner meets the following criteria: • The covered person is suffering from an illness or injury which would normally require medical attention. • Treatment is not being provided concurrently by another type of practitioner such as an M.D. or D.O. Intern. Charges for interns are not a covered expense. Nurse Midwife. No special charges accepted by the nurse-midwife because such midwife is an extension of the attending physician. Physician’s Fees 3
  4. 4. © 2003 International Foundation of Employee Benefit Plans, Inc. Physician’s Office Within an Institution A physician's office within an institution must be confined to a separately identified part of the facility which is used solely as the physician's office and cannot be construed to extend throughout the entire institution. Thus, services performed outside the office area would be subject to the coverage rules applicable to services furnished outside the office setting. Institution is a hospital, convalescent care center, e.g. The examiner should give consideration to the physical proximity of the institution and physician's office. When such office is located within a facility, a physician may not be reimbursed for services, supplies, and use of equipment which fall outside the scope of services commonly furnished in physician's offices generally, even though such services may be furnished in his institutional office. Additionally, make a distinction between the physician's office practice and the institution, especially when the physician is administrator or owner of the facility. Thus, for their services to be covered, the auxiliary medical personnel must be members of the office staff rather than of the institution's staff, and the cost of supplies must represent an expense to the physician's office practice. Finally, services performed by the employees of the physician outside the office area must be directly supervised by the physician; the physician’s presence in the facility as a whole would not suffice to meet this requirement. (In any setting, of course, supervision of auxiliary personnel in and of itself is not considered a physician's professional service to which the services of the auxiliary personnel could be an incidental part, i.e., in addition to supervision, the physician must perform or have performed a personal professional service to the patient to which the services of the auxiliary personnel could be considered an incidental part.) Establishment of an office within an institution would not modify rules otherwise applicable for determining coverage of the physician's personal professional services within the institution. However, in view of the opportunity afforded to a physician who maintains such an office for rendering services to a sizeable number of patients in a short period of time or for performing frequent services for the same patient, claims for physician's services rendered under such circumstances would require careful evaluation by the examiner to assure that payment is made only for services that are reasonable and necessary. Emergency Care Centers Clinics and emergency care centers have become more prevalent in the past decade in response to the public demand for accessible convenient, and high quality medical care. Such facilities, also referred to as freestanding emergency centers, emergicenters, emergency care clinics, minor emergency centers, and urgent treatment centers can be described as follows: Health care facilities which may or may not be hospital-affiliated (but which are Physician’s Fees 4
  5. 5. © 2003 International Foundation of Employee Benefit Plans, Inc. distinct from the hospital's emergency room) and which provide both primary and emergency care for a range of medical problems that can best be described as urgent (that is, from the patient's point of view requiring immediate treatment), and usually limited follow-up care. Care is provided on a non-appointment, extended hours basis in a setting similar to a private physician’s office. Physician’s Fees Billed by the Hospital If the hospital bills for services provided by a staff physician, such expense will be covered under the miscellaneous hospital expense provisions. When a hospital is in the practice of billing for the services of staff physicians, examiners must be alert to additional billing for the same services generated by the physicians themselves. These should be denied as duplicate charges. A physician may have a right to practice at a given hospital, but not actually be on their staff. This type of physician would not be covered under the miscellaneous expense provision. His or her services would be considered under the appropriate physician's benefits (e.g. surgery, calls in hospital, radiology, etc.). Examples of such fees would include: • Pathology • Radiology • Anesthesiology. Rural Health Clinic Rural health clinics are facilities primarily engaged in furnishing to outpatients services of a physician, drugs and biologicals, and services of physician assistants, nurse practitioners, and clinical psychologists as would otherwise be covered if furnished by a physician or as an incident to a physician's service. In areas where a shortage of home health agencies exists, these clinics may also provide part-time or intermittent nursing care and related medical supplies furnished by a registered professional nurse or licensed practical nurse to homebound individuals under written plans of treatment established by a physician, nurse practitioner, or physician assistant, provided the plans are periodically reviewed by a physician. Physician’s Fees 5

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