Statutory Obligations – Practitioner’s or Others Person’s Services

9020.2 – Statutory Obligations – Practitioner’s or Others Person’s Services (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The following are examples of potential violations that may form the basis for the initiation of a sanction action: 1. Standard: Services or items ordered or furnished to Medicare patients are to be provided economically and only when, and to the extent, medically necessary. EXAMPLE: Ordering or furnishing inappropriate or unnecessary invasive procedures. Practitioners who implant permanent cardiac pacemakers without clear and appropriate indications may be in violation of their obligation to provide only services that are medically necessary. 2. Standard: Services or items ordered or furnished are supported by evidence of medical necessity and quality in the form and fashion (and at such time) that you may reasonably require for review (including copies) in exercising your duties and responsibilities. EXAMPLE: When the QIO conducts reviews to make decisions about the medical necessity of services, a certain provider consistently has insufficient documentation to support the medical necessity of the services furnished. 3. Standard: Items or services ordered or furnished are to be of a quality that meets professionally recognized standards of care. EXAMPLE: Hospital readmissions resulting from premature discharges. Practitioners and other persons who discharge patients prematurely may be in violation of their obligation to provide services of a quality that meets professionally recognized standards.