Data Monitoring and Medical Billing Terms and Conditions
1. THE SERVICES.
a) Clinical Staff Review. The Group’s Clinical Staff (defined below) will review Participating Patient data collected by Devices, Participating Patient answers to questionnaires, and incoming Participating Patient calls Patient App on an ongoing basis between the hours of 8:00 am and 5:00 pm Eastern Time (ET), five (5) days per week (“Business Hours”). During Business Hours, the Group Clinical Staff will provide Physician with notification under the Participating Patient escalation Clinical Protocol. For each Participating Patient, the Group will let the designated Clinical Contact (defined below) know if/when intervention, including the reason for escalation, is needed through the Care App and Provider-facing Dashboard.
b) No 24/7 or Emergency Monitoring. The Group is not responsible for the accuracy of any data transmitted or monitored. Further, Clinical Staff services are not intended to provide 24-hour monitoring or to identify medical emergencies and cannot be used or construed as such.
c) Medical Billing Services. The Group will submit claims to Medicare on behalf of Physician only for CPT codes 99453, 99454, 99457, 99458, and 99091 (the “RPM Codes”), 98975, 98976, 98977, 98980, 98981, and 98978 (the “RTM Codes”), G0506, 99490, 99489, and 99487 (the “CCM Codes”), and 99212 and 99215 (the “Telemedicine Codes”), as applicable, with respect to Participating Patients (“Medical Billing Service(s)”). The Group will not submit claims for other codes or services provided by Physician to Participating Patients or otherwise, and the Group will not be responsible to Physician for Physician’s failure to receive reimbursement for any submitted claims for reasons outside of the Group’s control.
2.Physician RESPONSIBILITIES.
a) Identify Clinical Contact. Physician is responsible for identifying a point of contact (“Clinical Contact”) within Physician’s practice to remain available to communicate with the Group as needed. There must be at least one Clinical Contact available at all times during Business Hours to be responsible for taking calls from the Group Clinical Staff and escalating interventions to a physician, as necessary.
b) Identify Clinical Protocol. Physician is responsible for establishing monitoring parameters for each Participating Patient via the Software and must enter relevant parameters for each Participating Patient enrolled in the Services. Physician is solely responsible for the accuracy and appropriateness of these parameters. The Group Clinical Staff will monitor PHI according to the parameters established by the Physician.
c) Identify Participating Patients. Physician is responsible for identifying high-risk patients who will benefit from Virtual Care Services and providing the Group with required Participating Patient information including but not limited to Participating Patient demographic information, insurance information, disease state, and other data required by the Group to enroll Participating Patients.
d) Obtain Consent from Participating Patients. Physician is responsible for obtaining face-to-face Participating Patient consent to participate in the Services as required by and defined by The Centers for Medicare and Medicaid Services (“CMS”). Physician shall obtain and document this consent and any other necessary patient consent, authorization, or other agreements that are required to enroll a Participating Patient in the Services.
e) Patient Copay and Deductible. Physician is responsible for collecting any required patient copay, coinsurance, or deductible required by the Patient Participant’s health insurance plan.
f) Participate in Rapid Enrollment of Participating Patients. Physician and Authorized Users must participate in the Group Rapid Enrollment process. This includes but is not limited to, providing all required recordings for patient Rapid Enrollment, and attending patient review meetings initially and at thirty (30), sixty (60), and ninety (90) day intervals throughout the patient Rapid Enrollment period.
g) Supervision. Physician is responsible for General Supervision of the Group Clinical Staff as needed, where “General Supervision” is defined as a physician or other billing provider providing overall direction and control in accordance with applicable billing requirements set forth under Medicare. Under General Supervision, Physician remains ultimately responsible for oversight of the monitoring services.
h) Electronic Medical Record Access and Documentation.
1) Access for Patient Identification and Onboarding. Physician is responsible for providing the Group with view-only administrator-level access to the Physician’s Electronic Medical Record (“EMR”) and Electronic Practice Management Software to provide the Group with patient demographic, patient data required to provide the Services, and insurance information in a Consolidated-Clinical Document Architecture (C-CDA) or comma-separated values (CSV) electronic format to assist the Group and Physician in identifying and enrolling Participating Patients. Physician is responsible for ensuring the accuracy, quality, integrity, legality, reliability, and appropriateness of data accessed through the Physician’s EMR.
2) Access for Medical Billing Services. Physician will provide access to its Electronic Medical Record (“EMR”) and Electronic Practice Management Software to the Group and its subcontractor(s) as necessary to allow the Group to provide Medical Billing Services. If Physician’s EMR is not compatible with the Group’s billing practices or processes, Physician will work with the Group and its subcontractor(s) to integrate its billing system with the Group’s billing practices and processes as necessary to allow the Group to provide the Billing Services.
i ) Provide Patient Escalation Protocol. Physician will provide the Group with a written patient escalation protocol without unreasonable delay and within five (5) business days of the Order Form.
j) Provide Credentialing Access. Physician must provide the Group and its subcontractor(s) with credentialing access and all necessary and reasonably requested documentation to allow for the Group and subcontractor(s) to submit claims to health insurance providers, including Medicaid and Medicare on Physician’s behalf (“Documentation”). Such Documentation may include without limitation Physician’s National Provider Identifier (“NPI”), Provider Transaction Access Number (“PTAN”), and/or Physician’s Tax Identification Number (“TIN”). Physician is responsible for confirming the accuracy and completeness of all documents and information provided.
k) Claim Approval. Physician is responsible for approving all claims submitted by the Group to healthcare insurance providers, including Medicare and Medicaid.
l) Medical Treatment and Advice. Physician is responsible for making all treatment decisions and providing medical care with respect to all Participating Patients and any escalations forwarded to Physician by the Group. The Group and its Clinical Staff are not medical providers and are not intended to replace the relationship between Participating Patients and their healthcare provider(s). the Group CAN NOT BE HELD RESPONSIBLE FOR SUB-STANDARD TREATMENT OR MEDICAL MALPRACTICE WITH RESPECT TO ANY PARTICIPATING PATIENT. Please review the Software License & General Terms and Device Terms & Conditions for additional disclaimers.
3. The Group RESPONSIBILITIES.
a) Commencement of Services. The Group will commence Services within thirty (30) days of the start date indicated on the Order Form.
b) Clinical Staff. The Group will provide appropriately trained and qualified personnel to monitor Participating Patient data.
c) Virtual Care Management Services. The Group will provide Virtual Care Management Services as indicated on the Order Form to include Remote Patient Monitoring (“RPM”), Remote Therapeutic Monitoring (“RTM”), and/or Chronic Care Management (“CCM”) services, as defined by CMS. The Group Clinical Staff will perform RPM, RTM, or CCM data collection by collecting biological data electronically from Devices that monitor Participating Patients. The Group Clinical Staff will manage collected data, provide alerts to the Physician’s Authorized User, and send information to the Physician based on predetermined patient intervention and escalation protocols.
d) Care Manager. The Group will assign a Care Manager from the multilingual, international call center to monitor Participating Patient use of the Device, to speak with Participating Patients as necessary, and provide non-clinical intervention or escalation where necessary.
e) Reimbursement and Coding. The Group Care Manager will accurately code the professional services rendered by Physician and the Group under the terms of this agreement. The Group will ensure that the Care Manager is trained and remains up-to-date on coding accuracy as consistent with industry standards.
f) Revenue Cycle Management. The Group will provide revenue cycle management and medical coding support services. Under these Data Monitoring and Medical Billing Terms & Conditions, the Group will work with a billing vendor to use data from the Group Platform and the Physician’s EMR to bill appropriate healthcare insurance, Medicare, and Medicaid services for care enabled through the Group’s Platform and Services.
g) Physician Training. The Group will provide Clinical Staff for a maximum of two (2) eight-hour (8-hr) days to provide training and Device education to the Physician and Physician’s Authorized Users. Further training may be provided at a rate of $35 USD per hour per Clinical Staff.
h) Correction of Mistakes. The Group and its subcontractor(s) will reasonably correct any mistakes on an original claim submission that the Group is responsible for and that result in denial of reimbursement, provided that such mistake is not due to an inaccuracy in the Documentation or otherwise made at the fault of Physician.