Healthcare Compliance Forms and Tools

Provide your annual registration report.

Provide a copy of the hospital license that lists the provider-based entity’s address, or a letter from the state notifying the provider that the entity is included in the hospital’s license. Note: If the state does not issue a separate license for the provider-based entity, please provide documentation that the state does not require the entity to be licensed separately (i.e., letter or email from the state indicating a separate license is not issued for provider-based entities or a copy of the state regulation).

Provide a list of key personnel (i.e., table of organization) working at the provider-based facility showing job titles.

Provide a list of all clinical staff (e.g., physicians, nurses, physical therapists, radiology technicians) working at the facility or organization showing job titles and name of employer. Also include whether professional staff have clinical privileges at the main provider.

Provide a written description of the level of monitoring and oversight of the facility by the main provider as compared to oversight for another department of the main provider.

Provide a description of the responsibilities and relationship between the medical director of the provider-based facility, the chief medical officer of the main provider, and the medical staff committees at the main provider.

Provide a written explanation of how inpatient and outpatient services of the facility and the main provider are integrated. Include examples of integration of services, including data on the frequency of referrals from inpatient to outpatient facilities of the provider or vice versa.

Provide a copy of the written policy in a place that is used in record retrieval from both the main provider and the provider-based facility.

Provide a copy of the appropriate section of the main provider’s chart of accounts showing that the facility is integrated with the hospital’s accounts and the entire trial balance that shows the location of the provider-based facility’s revenues and expenses within the trial balance. Clearly identify the cost centers on the trial balance.

Provider a copy of the filed CMS Form 2552-10 cost report indicating the provider-based facility on worksheet A, line 90.

Provide documentation that demonstrates the facility is held out to the public as part of the main provider. Examples of documentation that could satisfy this requirement are pictures of outside signage, entrance door, and interior. Mockup pictures are not acceptable. The pictures should be close enough to read the sign, yet far enough away to give the viewer a concept of the entire environment. Include examples that show the facility is clearly identified as part of the main provider (e.g., shared name, patient registration forms, letterheads, advertisements, signage, website). Note: Advertisements that show the facility to be part of or affiliated with the main provider’s network or healthcare system are not sufficient.

Provide a copy of the detailed floor plan of the facility with the provider-based space clearly marked as well as a floor plan of the building in which the provider-based facility is located.

Provide a copy of the main provider’s Emergency Medical Treatment and Labor Act (EMTALA) (anti-dumping) policies. Provide written policies with respect to the off-campus departments for appraisal of emergencies and referral when appropriate.

Provide staff policy to bill the site of service.

Provide documentation that physician services furnished at the center are billed with the correct site of services so that appropriate physician and practitioner payment amounts can be determined. The Health Insurance Claim Form 1500 (OMB-0938-1197 Form 1500) is the preferred verification for site-of-service coding.

Provide a copy of the facility’s nondiscrimination policy in accordance with the nondiscrimination provisions in 42 C.F.R. § 489.10(b) .

Provide the staff policy that all Medicare patients are billed as hospital outpatients and not as physician’s office patients.

Provide the staff policy for patients who received services at the hospital outpatient department and were admitted to the hospital as an inpatient.

Please provide a notice of beneficiary coinsurance form with an estimated or actual coinsurance cost for services.

Provide a copy of the policy regarding distribution of the notice of beneficiary coinsurance for the subject facility. The form and policy need to support the statement: “if beneficiary for any reason is unable to read and understand notice, the notice is provided to the patient’s authorized representative prior to the delivery of service, and in situations where emergency service is required, notice is given as soon as possible after emergency situation is stabilized.”

Provide a copy of the potential charges used to complete the beneficiary coinsurance financial form.

Provide written notice to the beneficiary of potential financial liability, and policy needs to support that: if the beneficiary is unconscious, under great duress, or for any other reason unable to read a written notice and understand and act on their own rights, the notice must be provided, before the delivery of services, to the beneficiary’s authorized representative; and in situations where emergency service is required, notice is given as soon as possible after emergency situation is stabilized.

Provide the articles of incorporation and bylaws (aka code of regulations) for the main provider and provider-based facility if separate documents exist.

Provide a copy of the provider-based facility lease.

Provide a list of the key administrative staff (position/titles only) at the main provider and the provider-based facility that reflects a reporting relationship.

Provide a copy of the organizational chart. The chart must include the main provider and the entity requesting provider-based status showing which department of the main provider the entity is included in.

Submit a written description of the facility director’s reporting requirements and accountability procedures for day-to-day operation.

Describe who has final approval for administrative decisions, contracts with outside parties, personnel policies, and medical staff appointments for the facility.

A list of various administrative functions (e.g., billing services, laundry, payroll) at the facility that are integrated with the main provider. Also, include copies of any contracts for administrative functions that are completed under arrangements for the main provider and/or facility.

A detailed map indicating the mileage separating the provider-based facility and the main provider to verify distance from the main provider to the entity seeking provider-based status. An online service such as Google Maps may be used.

A copy of any relevant management contracts for the facility.

Who owns the building?

Date department originally opened.

Does the location have separate suite numbers?

What is the department’s suite number?

Need a copy of most recent Healthcare Facilities Accreditation Program/The Joint Commission accreditation document.

Need a copy of original 855A that was used for the original address (if moved).

Need a copy of change of location 855A for the new address.

Make sure main provider organization chart shows leadership responsibility at main provider and hospital-based outpatient department.

Verify that all employees (nursing staff, leadership, administrative, etc.) of the infusion center are employees of the hospital (and is identified on documents such as income/expense reports).

Proof that all expenses are rolling to main provider.

Verify that all employees are paid from main provider.

Validate if any physician services are performed AND/OR billed from the hospital-based outpatient department.

Specific dates of opening at new location.

Determine who should sign attestation document (typically main provider chief financial officer or authorized official that signs 855s).

Written certification from CEO or chief operating officer of the main provider that the department met the mid-build exception.

Does the location have a separate phone number (and do they answer the phone as a department of main provider)?