Frequently Asked Questions (FAQ)

What should a Health Care Provider or Department do if a letter is received from Medicare, Medicaid, Centers for Medicare and Medicaid Services, or any other government entity, requesting copies of medical records for a review or audit?

It is important to promptly and accurately act upon correspondence from governmental entities.  If a Health Care Provider or Department employee receives this type of correspondence, it should be presented promptly to the Department Manager for reporting and forwarding to the Office of Health Care Compliance. The contact information is Telephone (954) 262-4241 and Fax (954) 262-4043.

The Office of Health Care Compliance in conjunction with our General Counsel, if deemed necessary, will provide coordination of the response and may perform an internal review, including but not limited to:

• review of billing processes and documentation;
• drafting of cover letters and other appropriate correspondence;
• facilitation of timeline extensions, as needed; and communication with the payor for any clarification needed.

An individual from a Medicare contractor review vendor (e.g., the CERT or RAC) walks into your office and states that they would like to speak to one of our health care providers about his/her documentation. What should you do?

Please immediately call the Office of Health Care Compliance at (954) 262-4241, or our General Counsel at (954) 390-0100 so that someone from either office can talk to the representative to ascertain the purpose of the visit.

When is a patient considered "new" for professional billing purposes?

A new patient is one who has not received any professional services, such as an Evaluation and Management (E/M) service or other face-to-face service (e.g., surgical procedure) from the same physician or physician group practice (same physician specialty and subspecialty) within the previous (3) three years.

For example, if a professional component of a previous procedure is billed in a 3-year time period, (e.g., lab interpretation) and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or electrocardiogram (EKG) etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. If this patient sees another physician of the same specialty and subspecialty at a location where the first physician also practices, this is also an established patient situation.