ACT MODEL
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Procedure Name: |
Provider Employment Policy – ACT Model and Incident to |
SOP #:1 |
1 |
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Department: |
Operations |
Revision #: |
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Employees Affected |
Physicians and APPs (Providers) |
Implementation Date: |
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Date Last Updated: |
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SOP Owner: |
HR |
Approval Date: |
4/14/2025 |
Standard Operating Procedure
Purpose
To provide clarity on the employment duties and obligations of providers (physicians and APPs) as it related to the ACT Model and Incident to.
This SOP serves to:
· Ensure that all providers deliver services in accordance with the highest standards of accountability, quality, and integrity as outlined by Epic Health’s ACT Model.
· By following the ACT Model, we ensure compliance with:
o Applicable statutes and regulations safeguarding the accuracy and integrity of our billing practices, your professional licenses, and the safety of our patients.
o Protect Epic Health and providers from exposure to legal, financial, or reputational risks associated with non-compliance.
Scope
This applies to all providers (physicians and APPs).
Policies and Procedure
1. Commitment to the ACT Model
The Provider agrees to uphold Epic Health’s ACT Model which emphasizes:
· Accountability: Delivering care consistently with ethical and professional standards while adhering to legal requirements.
· Collaboration: Ensuring seamless communication and coordination with supervising physicians and other team members.
· Transparency: Maintaining clarity in all aspects of patient care, documentation, and billing practices.
· Non-compliance with the ACT Model constitutes a breach of this Acknowledgment and may result in disciplinary action as outlined in Section 5.
2. Incident-To Billing Requirements (for Medicare)
The Provider acknowledges their responsibility to comply with all Incident-To Billing Requirements, as defined by CMS, including but not limited to:
· 2.1 General Requirements:
o Supervision: The supervising physician (“Super Doc”) who is immediately available and provides direct supervision during all incident-to services, must be contacted and integrated into APP’s medical decision-making. The Super Doc is physically present in the office suite where the services are rendered to provide guidance and supervision to APPs who are administrating care to patients. In December 2023, CMS extended for another year (ending December 21, 2025) the exception implemented during COVID that broadens the definition of direct supervision to include audio/visual and not just “in suite.”
o Initiation of Care: The Super Doc must conduct/participate (in the exam room) in the initial visit to establish the patient's treatment plan, assess medical necessity, and determine appropriate follow-up care. APP and Super Doc must collaborate to ensure proper care is provided.
o Change in Care: In the event of a change in care plan, the Super Doc must conduct/patriciate in the patient visit (in the exam room), establish a treatment plan, assess medical necessity and determine appropriate follow up care. APP and Super Doc must collaborate together to ensure proper care is provided.
o Other Visits: The Super Doc needs to be “immediately available” to provide supervision in person or via audio/visual technology.
o Plan of Care: Services billed incident-to must adhere to the treatment plan established by the Super Doc. Any deviation must be pre-approved and documented by the supervising physician.
· 2.2 Provider Eligibility:
o Incident-to services are be performed by authorized personnel, including physician assistants, nurse practitioners, or other licensed healthcare providers operating within their scope of practice as defined by state and federal law who are supervised by Super Docs.
· 2.3 Documentation Standards:
o Comprehensive Documentation:
§ Records must explicitly show:
· The supervising physician’s presence and availability during the service.
· Conformance to the treatment plan established during the initial visit.
· Medical necessity for the services provided.
o Documentation failures may result in denied claims, financial penalties, and potential audits.
o Charts must be signed off within 23 hours of a patient visit. (This applies to all charting and not just Incident To)
3. Medical Chart Review under the ACT Model.
The Provider acknowledges they will perform all medical charting in a timely manner and according to the ACT Model.
o APPs have 23 hours from the time of the patent visit to complete their charting.
o Super Docs have 38 hours from the time of the patient visit to complete their charting.
o APP and Super Doc will work together to pre-chart prior to the patient visit.
4. Legal and Financial Accountability
The Provider acknowledges that any deviation from the ACT Model, including but not limited to SOP Pathways or Incident-To Billing Requirements, may subject Epic Health, and the Provider, to:
o Civil Penalties: Including fines, recoupments, or repayment demands from CMS or other regulatory authorities.
o Criminal Penalties: For deliberate or fraudulent billing practices, including imprisonment and fines as stipulated by federal law.
o Reputational Harm: Resulting from regulatory scrutiny, audits, or public disclosure of non-compliance.
o The Provider further acknowledges their personal liability for intentional acts of non-compliance that jeopardize Epic Health’s standing or lead to penalties.
5. Enforcement and Disciplinary Actions
Epic Health reserves the right to enforce compliance through:
o Corrective Measures: Including retraining, additional supervision, and monitoring of billing practices.
o Disciplinary Actions: Up to and including termination of employment or contractual relationship for violations.
o Reporting to Authorities: As required, Epic Health will report a Provider’s deliberate or fraudulent non-compliance to state and federal authorities, including CMS and the Office of Inspector General (OIG).
o For more information, please refer to the SOP - ACT Model Accountability (attached for reference). This SOP outlines the disciplinary action for ACT Model violations. A brief summary is provided below:
o First Violation - Identification and Initial review of ACT Model violations and Counseling Discussion
o Second Violation - Formal Review Process and Corrective Action Plan
o Third Violation – Final Determination
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