Issue 1 - January 2003

Ask Deborah Green
How does Medicare define ‘small provider’?

Q It’s my understanding that Medicare claims that are not submitted electronically after Oct. 16, 2003, will not be paid unless the U.S. Department of Health and Human Services (HHS) grants a waiver – that is, the office cannot submit electronically, or the entity is a “small” provider and does not make electronic transactions. There are five doctors working in my office, and we submit bills by mail. Do I qualify for the exception?

A A “small provider” has been defined as a provider of services with fewer than 25 full-time employees; or a physician, practitioner, facility, or supplier (other than a provider of services) with fewer than 10 full-time employees. Therefore, you fall under the exception and do not need to provide electronic Medicare claims after Oct. 16, 2003. However, it is in your best interest to do so because electronic claims get paid faster. Also, bear in mind that even if you do not send or receive electronic transactions, the use of a clearinghouse makes you a covered entity, and you must therefore comply will all HIPAA requirements.

Q I am considering leasing a mobile unit lab and parking it in the parking lot of my practice one day a month to perform dexa scan tests (a test that measures the density of bones for osteoporosis). I know that the Centers for Medicare and Medicaid Services (CMS) say that mobile units are not part of the “centralized building” and such an arrangement is potentially fraudulent. However, the people who want to lease me the unit say there is an exception for preventive services that are legislatively mandated. Does this mean that I can safely lease this mobile unit, and, if so, may I bill for the technical as well as the professional component?

A Your threshold problem is the definition of “centralized building.” CMS defines “centralized building” as being all or part of a building, including, for purposes of this definition only, a mobile vehicle, van, or trailer that is owned or leased on a full-time basis (that is, 24 hours per day, seven days per week, for a term of not less than six months) by a group practice and that is used exclusively by the group practice.

Space in a building or a mobile vehicle, van, or trailer that is shared by more than one group practice, by a group practice and one or more solo practitioners, or by a group practice and another provider (for example, a diagnostic imaging facility) is not a centralized building for purposes of this rule. This provision does not preclude a group practice from providing services to other providers (for example, purchased diagnostic tests) in the group practice’s centralized building. Furthermore, a group practice may have more than one centralized building. Since a one-day-a-month rental would not comply with the above requirements, I would suggest that you do not enter into this lease.

If you require clarificaton on these questions or have any questions will regard to other legal health-care issues, please contact the law office of Deborah Green. Her number is 954-236-8282; fax, 954-236-6939; or e-mail, healthattorney@aol.com. She will answer questions in this column that are of interest to the broadest audience.

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