I am writing this paper to urge schools and colleges of optometry to change from Student-Driven Clinical Training to a Teaching Physician-Centered Model to facilitate compliance with the Center for Medicare/Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents as the Guidelines pertain to Students. With the implementation of the Affordable Care Act (ACA), it is an opportune time for optometry schools and colleges to change to a Teaching Physician-Centered Model and reinforce their CMS compliance policy and Electronic Health Records (EHR) procedures for students. I realize such a dramatic change in optometric clinical training would have significant budgetary implications as teaching physician/faculty expense would increase and patient services revenues would likely decline. However, the current Student-Driven Training Model continues to pose a high risk of CMS violations with associated fines and other sanctions. It is anticipated that audits of Federal Health Care Programs will increase with the implementation of the Affordable Care Act (ACA).
The paper does not discuss the educational benefits of the Teaching Physician-Centered Model. However, the model has been successfully utilized in medical student education for many years.
Because the Department of Health and Human Services (HHS) does not consider optometry residents to be “real” residents, I do not address optometry residents’ compliance in this paper since CMS Teaching Guidelines do not technically apply. An optometry resident once licensed is no different than any licensed optometrist. Also, optometry residency programs do not qualify for the Graduate Medical Education (GME) program. Nor does optometry have a trainee classification that qualifies as intern. A teaching physician is defined as optometric school/college faculty, affiliate attending staff, or extern preceptor.
The CMS Teaching Guidelines apply to Medicare, other Federal Health Care Programs, Medicaid in most states, and most major private insurers.
Page 3 of the Teaching Guidelines state:
Evaluation and Management-Documentation Provided by Students—Any contribution of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident… the student may document in the medical record. However, the teaching physician may only refer to Review of Systems (ROS) and Past Family/Social History (PFSH)….the teaching physician may not refer to the students findings and must verify and re-document the history of present illness and perform (repeat) and re-document the examination and medical decision making (treatment plan).
Page 7 – Medicare does not pay for any services furnished by students.
I base my recommendation to change the teaching model on research and writing on the subject, consultation with American Optometric Association (AOA) Medicare experts, consultation with teaching physicians, interviews with medical students and residents and ongoing discussions with (AOA) Federal Relations staff and optometric academic administrators and faculty along with viewing the Office of the Inspector General (OIG) False and Fraudulent Claims Report, where CMS Teaching Guidelines violations are reported. I also have extensive experience in optometric clinical education and with Federal Health Care policy. See: Dr. Charles Mullen CV.
Compliance with CMS Teaching Guidelines and EHR Procedures
Failure to fully comply with the Teaching Guidelines and EHR procedures creates self-induced risk which could result in institutional fines, legal fees and other severe penalties. There is also the potential of individual liability and damage to the reputations of faculty members, affiliate attending staff or extern preceptors since Medicare/Medicaid Fraud and Abuse sanctions are reported to the National Practitioners Data Bank. Should an extern preceptor be sanctioned for Medicare fraud or abuse the damage to optometry school/college alumni relations would be extensive. HHS has intensified its efforts to identify and prosecute Medicare fraud by increasing the reward pool for “whistle blowers” to $10 million.
Student Notations Risks with Electronic Health Record (EHR)
If student notations are placed in the patient’s record (either written or EHR), they must be clearly delineated and not used to bill for services. Intentionally and knowingly using student examination findings to bill Medicare is considered a fraudulent claim. The Association of Academic Medical Centers (AAMC) issued a Compliance Advisory regarding students and Electronic Medical Records (EMR). The Compliance Advisory cautioned teaching physicians about the risks of student notations in the electronic medical record and delineated procedures to avoid Medicare violations and sanctions.
Optometry schools and colleges that suspect Medicare violations in their clinical operations may want to consider Self Disclosure rather than exposing the institution to an uninvited Medicare audit which could result in catastrophic fines, legal fees and severe sanctions. The OIG Self Disclosure program may permit the institution to negotiate any fines and potentially prevent higher fines and more severe penalties such as exclusion from all Federal Health Care Programs. Medicare Fraud and Abuse fines are up to $10,000 to $50,000 plus three times the damages for each violation. The Self Disclosure protocol requires the institution to furnish extensive information on the Medicare/Medicaid violations including how the school/college plans to prevent future violations. Suggested measures to prevent CMS violations are delineated in the next section of the paper.
Teaching Physician-Centered Model
The current optometric Student-Driven Clinical Training Model is not compatible with CMS Teaching Guidelines, while the Teaching Physician-Centered Model is consistent with all of the following CMS compliance expectations:
- that the teaching physician is in charge of the patient
- that patient care is personally rendered or repeated by the teaching physician and
- that the examination is personally documented in the medical record by the teaching physician including history of present illness, diagnosis and management/treatment plan.
This model is successfully utilized in medical student clerkships.
Optometry programs must clearly demonstrate how students are incorporated in the care of the patient to learn and practice clinical procedures and not to provide patient services. Also, programs must demonstrate how students participate when the care of the patient is actively and personally provided by the teaching physician. Schools and colleges should view student clinical placements as clerkships where the student can practice history taking and examination procedures along with assisting the supervising physician, but not provide patient services except ROS and PFSH.
Optometry schools and colleges must ensure:
- a CMS compliance policy is in place, including a EHR policy regarding student notations
- that the compliance policy is monitored and enforced by annual internal compliance audits
- that all clinical affiliates and extern preceptors receive copies of the institution’s compliance policy along with CMS and OIG supporting documents
- that regular briefings on compliance by senior school/college officials are presented to all external training venues
- that all college faculty and optometry students receive compliance training prior to participating in patient care
- that the school/college or teaching clinic has a Compliance Officer
- that lines of communications are open
The Veterans Health Administration (VHA) Eye Care Handbook also mandates compliance with CMS Teaching Guidelines in all optometric teaching programs. Annually, 1400 optometry student clinical rotations are available at VA facilities along with 186 residents and 3 research fellows. Although optometry residents are not considered residents by HHS, the VA requires compliance with CMS Teaching Guidelines for both optometry residents and students.
Although implementation of the Teaching Physician-Centered training model would be a major step forward in addressing optometry student compliance with CMS Teaching Guidelines, serious consideration should be given to the overall restructuring of optometric education by placing optometry in parallel with medicine for both student and postgraduate clinical training. Restructuring the curriculum would present the opportunity for inclusion in GME and further enhance CMS compliance. See: Restructuring the Profession of Optometry – The Next Bold Move.
- CMS Guidelines for Teaching Physicians, Interns and Residents (Students)
- OIG False and Fraudulent Claims Report
- OIG Self Reporting Protocol
- Medicare Fraud and Abuse Summary
- AAMC Compliance Advisory on Students and EMR
- Veterans Health Administration (VHA) Eye Care Handbook
- Restructuring the Profession of Optometry – The Next Bold Move