Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 107. Hospital-based physicians

7 AAC 43.107. Hospital-based physicians

(a) Reimbursement by the department under this section for the services provided by a hospital-based physician is subject to the following limitations:

(1) reimbursable services shall include the following services furnished directly to individual patients: clinic services; outpatient services; anatomical pathology services; consultive pathology services; physician administered laboratory tests; anesthesiology services; radiology services which are separately identifiable for billing purposes; and diagnostic or therapeutic services which are direct and discrete, such as interpretation of x-rays, angiograms, myelograms, pyelograms, or ultrasound procedures;

(2) reimbursable services must be personally furnished by the physician, contribute directly to the diagnosis or treatment of the individual patient, and ordinarily require the action of a physician;

(3) the department will not reimburse the physician for services provided by the physician to the hospital;

(4) the department will not reimburse for costs attributable to the time the physician spends performing hospital administrative duties, supervising professional or technical personnel, or performing other hospital-wide activities that are not covered physician services under this section.

(b) Laboratory or pathology services provided by a hospital-based physician for which a Medicare fee schedule has been established in 42 C.F.R. 405.515 will be reimbursed in accordance with the methodology in 7 AAC 43.125. Medical services furnished in accordance with this chapter by a hospital-based physician will be reimbursed at the lesser of billed charges or 100 percent of the rate identified in the fee schedule established under 7 AAC 43.108 for that service.

(c) For purposes of this section, a "hospital-based physician" is a physician who individually enrolls in the medicaid program, provides services to individual patients in the hospital, and is either a salaried employee of the hospital or through an agreement with the hospital receives compensation in cash or in kind from or through the hospital. "Compensation" includes an arrangement in which the physician is paid by the hospital through a set amount of compensation or the physician recovers a percentage or part of the hospital collections. A "hospital-based physician" includes a physician

(1) who is an employee of the hospital providing services to patient in the hospital,

(2) who receives a salary, a portion of collections, fringe benefits, or deferred compensation from the hospital,

(3) whose malpractice insurance, continuing medical costs, or 30 percent or more of on-going professional business costs is paid for by the hospital, or

(4) who receives payment from patients, and returns all or a portion of the payments received from patients to the hospital.

(d) A physician who is employed by an approved medical residency program in accordance with 42 C.F.R. 413.86 is not a hospital-based physician for purposes of reimbursement under this chapter.

History: Eff. 10/21/92, Register 124; readopt 8/7/96, Register 139; am 2/1/97, Register 141; am 12/30/2000, Register 156; am 9/1/2002, Register 163; am 1/1/2004, Register 168

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.070

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.107 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.