,i #aacth ,,congress #ast ,session ,h4 ,r4 #bhja ,,in ,,the ,,house ,,of ,,representatives ,july #bc1 #bjac ,mrs4 ,noem 7for herself1 ,mr4 ,peterson1 ,mr4 ,cramer1 and ,mr4 ,daines7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committee on ,ways and ,means1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend title ,,xviii of the ,social ,security ,act with respect to physician supervision of therapeutic hospital outpatient services4 #a4 ,short title ,this ,act may be cited as the ,protecting ,access to ,rural ,therapy ,services 7,,parts7 ,act4 #b4 ,requirements for physician supervision of therapeutic hospital outpatient services 7a7 ,therapeutic hospital outpatient services 7#a7 ,supervision requirements ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is amended by adding at the end the following new subsection3 7z7 ,physician supervision requirements for therapeutic hospital outpatient services 7#a7 ,general supervision for therapeutic services ,except as may be provided under paragraph 7#b71 insofar as the ,secretary requires the supervision by a physician or a non-physician practitioner for payment for therapeutic hospital outpatient services 7as defined in paragraph 7#e77;,a77 furnished under this part1 such requirement shall be met if such services are furnished under the general supervision 7as defined in paragraph 7#e77;,b77 of the physician or non-physician practitioner1 as the case may be4 7#b7 ,exceptions process for high-risk or complex medical services requiring a direct level of supervision 7,a7 ,in general ,subject to the succeeding provisions of this paragraph1 the ,secretary shall establish a process for the designation of therapeutic hospital outpatient services furnished under this part that1 by reason of complexity or high risk1 require-- 7i7 direct supervision 7as defined in paragraph 7#e77;,c77 for the entire service2 or 7ii7 direct supervision during the initiation of the service followed by general supervision for the remainder of the service4 7,b7 ,consultation with clinical experts 7i7 ,in general ,under the process established under subparagraph 7,a71 before the designation of any therapeutic hospital outpatient service for which direct supervision may be required under this part1 the ,secretary shall consult with a panel of outside experts described in clause 7ii7 to advise the ,secretary with respect to each such designation4 7ii7 ,advisory panel on supervision of therapeutic hospital outpatient services ,for purposes of clause 7i71 a panel of outside experts described in this clause is a panel appointed by the ,secretary1 based on nominations submitted by hospital1 rural health1 and medical organizations representing physicians1 non-physician practitioners1 and hospital administrators1 as the case may be1 that meets the following requirements3 7,i7 ,composition ,the panel shall be composed of at least #ae physicians and non-physician practitioners who furnish therapeutic hospital outpatient services for which payment is made under this part and who collectively represent the medical specialties that furnish such services1 and of #d hospital administrators of hospitals located in rural areas 7as defined in section #ahhf7;d77#b77;,d77 or critical access hospitals4 7,,ii7 ,practical experience required for physicians and non-physician practitioners ,during the #ab-month period preceding appointment to the panel by the ,secretary1 each physician or non-physician practitioner described in subclause 7,i7 shall have furnished therapeutic hospital outpatient services for which payment was made under this part4 7,,iii7 ,minimum rural representation requirement for physicians and non-physician practitioners ,not less than #ej percent of the membership of the panel that is comprised of physicians and non-physician practitioners shall be physicians or non-physician practitioners described in subclause 7,i7 who practice in rural areas 7as defined in section #ahhf7;d77#b77;,d77 or who furnish such services in critical access hospitals4 7iii7 ,application of ,,faca ,the ,federal ,advisory ,committee ,act 7#e ,u4,s4,c4 #b ,app471 other than section #ad of such ,act1 shall apply to the panel of outside experts appointed by the ,secretary under clause 7ii74 7,c7 ,special rule for outpatient critical access hospital services ,insofar as a therapeutic outpatient hospital service that is an outpatient critical access hospital service is designated as requiring direct supervision under the process established under subparagraph 7,a71 the ,secretary shall deem the critical access hospital furnishing that service as having met the requirement for direct supervision for that service if1 when furnishing such service1 the critical access hospital meets the standard for personnel required as a condition of participation under section #dhe4fah7;d7 of title #db1 ,code of ,federal ,regulations 7as in effect on the date of the enactment of this subsection74 7,d7 ,consideration of compliance burdens ,under the process established under subparagraph 7,a71 the ,secretary shall take into account the impact on hospitals and critical access hospitals in complying with requirements for direct supervision in the furnishing of therapeutic hospital outpatient services1 including hospital resources1 availability of hospital-privileged physicians1 specialty physicians1 and non-physician practitioners1 and administrative burdens4 7,e7 ,requirement for notice and comment rulemaking ,under the process established under subparagraph 7,a71 the ,secretary shall only designate therapeutic hospital outpatient services requiring direct supervision under this part through proposed and final rulemaking that provides for public notice and opportunity for comment4 7,f7 ,rule of construction ,nothing in this subsection shall be construed as authorizing the ,secretary to apply or require any level of supervision other than general or direct supervision with respect to the furnishing of therapeutic hospital outpatient services4 7#c7 ,initial list of designated services ,the ,secretary shall include in the proposed and final regulation for payment for hospital outpatient services for #bjae under this part a list of initial therapeutic hospital outpatient services1 if any1 designated under the process established under paragraph 7#b77;,a7 as requiring direct supervision under this part4 7#d7 ,direct supervision by non-physician practitioners for certain hospital outpatient services permitted 7,a7 ,in general ,subject to the succeeding provisions of this subsection1 a non-physician practitioner may directly supervise the furnishing of-- 7i7 therapeutic hospital outpatient services under this part1 including cardiac rehabilitation services 7under section #ahfa7;eee77#a771 intensive cardiac rehabilitation services 7under section #ahfa7;eee77#d771 and pulmonary rehabilitation services 7under section #ahfa7;fff77#a772 and 7ii7 those hospital outpatient diagnostic services 7described in section #ahfa7s77#b77;,c77 that require direct supervision under the fee schedule established under section #ahdh4 7,b7 ,requirements ,subparagraph 7,a7 shall apply insofar as the non-physician practitioner involved meets the following requirements3 7i7 ,scope of practice ,the non-physician practitioner is acting within the scope of practice under ,state law applicable to the practitioner4 7ii7 ,additional requirements ,the non-physician practitioner meets such requirements as the ,secretary may specify4 7#e7 ,definitions ,in this subsection3 7,a7 ,therapeutic hospital outpatient services ,the term therapeutic hospital outpatient services means hospital services described in section #ahfa7s77#b77;,b7 furnished by a hospital or critical access hospital and includes-- 7i7 cardiac rehabilitation services and intensive cardiac rehabilitation services 7as defined in paragraphs 7#a7 and 7#d71 respectively1 of section #ahfa7;eee772 and 7ii7 pulmonary rehabilitation services 7as defined in section #ahfa7;fff77#a774 7,b7 ,general supervision 7i7 ,overall direction and control of physician ,subject to clause 7ii71 with respect to the furnishing of therapeutic hospital outpatient services for which payment may be made under this part1 the term general supervision means such services that are furnished under the overall direction and control of a physician or non-physician practitioner1 as the case may be4 7ii7 ,presence not required ,for purposes of clause 7i71 the presence of a physician or non-physician practitioner is not required during the performance of the procedure involved4 7,c7 ,direct supervision 7i7 ,provision of assistance and direction ,subject to clause 7ii71 with respect to the furnishing of therapeutic hospital outpatient services for which payment may be made under this part1 the term direct supervision means that a physician or non-physician practitioner1 as the case may be1 is immediately available 7including by telephone or other means7 to furnish assistance and direction throughout the furnishing of such services4 ,such term includes1 with respect to the furnishing of a therapeutic hospital outpatient service for which payment may be made under this part1 direct supervision during the initiation of the service followed by general supervision for the remainder of the service 7as described in paragraph 7#b77;,a77ii774 7ii7 ,presence in room not required ,for purposes of clause 7i71 a physician or non-physician practitioner1 as the case may be1 is not required to be present in the room during the performance of the procedure involved or within any other physical boundary as long as the physician or non-physician practitioner1 as the case may be1 is immediately available4 7,d7 ,non-physician practitioner defined ,the term non-physician practitioner means an individual who-- 7i7 is a physician assistant1 a nurse practitioner1 a clinical nurse specialist1 a clinical social worker1 a clinical psychologist1 a certified nurse midwife1 or a certified registered nurse anesthetist1 and includes such other practitioners as the ,secretary may specify2 and 7ii7 with respect to the furnishing of therapeutic outpatient hospital services1 meets the requirements of paragraph 7#d77;,b74 4 7#b7 ,conforming amendment ,section #ahfa7;eee77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7eee77#b77;,b77 is amended by inserting 1 and a non-physician practitioner 7as defined in section #ahcc7z77#e77;,d77 may supervise the furnishing of such items and services in the hospital after in the case of items and services furnished under such a program in a hospital1 such availability shall be presumed4 7b7 ,prohibition on retroactive enforcement of revised interpretation 7#a7 ,repeal of regulatory clarification ,the restatement and clarification under the final rulemaking changes to the ,medicare hospital outpatient prospective payment system and calendar year #bjji payment rates 7published in the ,federal ,register on ,november #ah1 #bjjh1 #gc ,fed4 ,reg4 #fhgjb through #fhgjd7 with respect to requirements for direct supervision by physicians for therapeutic hospital outpatient services 7as defined in paragraph 7#c77 for purposes of payment for such services under the ,medicare program shall have no force or effect in law4 7#b7 ,hold harmless ,a hospital or critical access hospital that furnishes therapeutic hospital outpatient services during the period beginning on ,january #a1 #bjja1 and ending on the later of ,december #ca1 #bjad1 or the date on which the final regulation promulgated by the ,secretary of ,health and ,human ,services to carry out this ,act takes effect1 for which a claim for payment is made under part ,b of title ,,xviii of the ,social ,security ,act shall not be subject to any civil or criminal action or penalty under ,federal law for failure to meet supervision requirements under the regulation described in paragraph 7#a71 under program manuals1 or otherwise4 7#c7 ,therapeutic hospital outpatient services defined ,in this subsection1 the term therapeutic hospital outpatient services means medical and other health services furnished by a hospital or critical access hospital that are-- 7,a7 hospital services described in subsection 7s77#b77;,b7 of section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex72 7,b7 cardiac rehabilitation services or intensive cardiac rehabilitation services 7as defined in paragraphs 7#a7 and 7#d71 respectively1 of subsection 7eee7 of such section72 or 7,c7 pulmonary rehabilitation services 7as defined in subsection 7fff77#a7 of such section74