Corporate Compliance

Primary Exception rules

Compliance Monitor, December 23, 2005

Q: How do you handle a situation when a teaching physician does not see the patient but the resident reviews and discusses the case with the teaching physician when dealing with a commercial payer? Would the Primary Care Exception rules apply and are commercial carriers okay with Primary Care exception rules?

A: It depends on the individual contract with the third party payors. Many carriers do not accept Primary Care exception rules. If there are no contracts involved I would say that Medicare sets the prevailing standard of care. So in that case, yes the Primary Care Exception would apply. Similarly if the contract is silent on this issue, I would also say that this exception can be used, provided the contract does not include general provisions covering special billing arrangements.

Thanks to John Reiss, Esq., partner at Saul Ewing, LLP, in Philadelphia.