Sec. 10.14.02.04. Physician Services

A. To be considered a participating physician in the Program, the provider shall:

(1) Provide a medical procedure or service related to the diagnosis and treatment of breast cancer, cervical cancer, or a precancerous cervical lesion;

(2) Have a current license to practice medicine in Maryland or a jurisdiction bordering Maryland;

(3) Agree to accept, for each covered medical procedure performed or service provided, the following reimbursement including, if applicable, a medical management fee as described in Regulation .15 of this chapter:

(a) The current Medical Assistance approved rate in the State for an eligible patient who is uninsured or who has insurance that does not provide coverage for a reimbursed procedure or service;

(b) The reimbursement rate approved by the insurer plus the payment of the outstanding deductible and patient contribution amount by the Department for an eligible patient who has insurance, other than Medicare, that provides coverage for a reimbursed procedure or service;

(c) The reimbursement rate approved by Medicare plus the payment of the outstanding deductible and the patient contribution amount by the Department for an eligible patient who is covered by Medicare; or

(d) For an eligible patient who has insurance that provides reimbursement for a covered procedure or service that is less than the current Medical Assistance approved rate, the reimbursement rate approved by the insurer plus the difference between the reimbursement rate approved by the insurer and the current Medical Assistance approved rate in the State plus the payment of the outstanding deductible by the Department;

(4) Agree to abide by the provisions set forth in §A of this regulation by signing and sending to the Department the designated Departmental form;

(5) Agree not to bill an eligible patient, who is uninsured or is covered by Medicare or other insurance, for an additional charge for the reimbursed medical procedure performed or service provided;

(6) Agree to:

(a) Be the medical case manager for an eligible patient; or

(b) Coordinate the reimbursed medical procedure or service with the designated medical case manager and submit the result of the procedure to the medical case manager;

(7) Agree to the following medical guidelines:

(a) That a negative mammogram alone is not sufficient to evaluate a clinically significant mass, and to perform or arrange for further diagnostic evaluation of the mass;

(b) That a surgeon shall examine the patient and make the final determination of further diagnostic and treatment procedures needed when a needle biopsy performed by a non-surgeon is negative for cancer;

(c) To perform or arrange for needle localization of the mass before excisional biopsy;

(d) To perform or arrange for radiological examination of the breast surgical specimen after biopsy to accurately identify the mass;

(e) To refer an eligible patient with a mammography assessment recommending biopsy to a surgeon for evaluation and a decision regarding the ultimate course of action;

(f) To implement the diagnostic tests or procedures required for cancer staging determination in keeping with the best interests of the patient and to determine staging on the cancer found;

(g) To consult an oncologist before any treatment is initiated for Stage I or greater breast cancer or invasive cervical cancer; and

(h) To consult with a radiation oncologist if radiation treatment is a medical option;

(8) Agree to maintain the results of the reimbursed medical procedures performed as set forth in §E(6)-(9) of this regulation;

(9) Agree to maintain administrative and health records, including medical records, to document compliance with this chapter for a minimum of 6 years and, upon request, allow the Department access to the records; and

(10) Place no restriction on the eligible patient's right to choose a provider.

B. An eligible medical provider may be, but is not limited to, one of the following:

(1) Anesthesiologist;

(2) Clinical-anatomical or cytopathological pathologist;

(3) Diagnostic, therapeutic, or nuclear radiologist;

(4) Family practitioner;

(5) Medical internist;

(6) Medical or gynecological oncologist;

(7) Obstetrician-gynecologist; or

(8) Surgeon.

C. Reimbursed medical procedures include, but are not limited to, the following:

(1) Breast cancer diagnostic procedures including, but not limited to:

(a) Cyst aspiration;

(b) Diagnostic ultrasound;

(c) Incisional, excisional, or other breast biopsy;

(d) Needle biopsy; and

(e) Needle localization;

(2) Breast cancer treatment procedures including, but not limited to:

(a) Adjuvant hormonal therapy;

(b) Adjuvant or sole chemotherapy;

(c) Adjuvant or sole radiation therapy;

(d) Lumpectomy with radiation;

(e) Lymph node dissection;

(f) Modified radical mastectomy;

(g) Radical mastectomy; and

(h) Simple mastectomy;

(3) Contingent upon available funds, breast reconstruction procedures including, but not limited to:

(a) Construction of breast mound;

(b) Augmentation mammoplasty;

(c) Reduction mammoplasty; and

(d) Mastopexy;

(4) Cervical cancer or precancerous cervical lesion diagnostic procedures including, but not limited to:

(a) Colposcopically directed cervical or vaginal biopsy, or both;

(b) Colposcopy;

(c) Endocervical curettage; and

(d) Endometrial biopsy if the patient has taken Tamoxifen for the treatment of breast cancer or has had cervical cancer documented;

(5) Cervical cancer or precancerous cervical lesion treatment procedures including, but not limited to:

(a) Conization;

(b) Cryosurgery;

(c) Dilation and curettage;

(d) Electric loop resection;

(e) Hysterectomy; and

(f) Laser treatment; and

(6) Follow-up to treatment for breast cancer, cervical cancer, or a precancerous cervical lesion including, but not limited to:

(a) Follow-up office visits with the medical case manager; and

(b) Medical and laboratory tests ordered by the medical case manager.

D. Non-reimbursed medical procedures and services include but are not limited to:

(1) A screening mammogram;

(2) A Pap or human papilloma virus test;

(3) An experimental treatment other than a Phase-III controlled clinical trial for breast or cervical cancer;

(4) A procedure or service not related to the diagnosis and treatment of breast and cervical cancer;

(5) Organ transplants; and

(6) Nipple reconstruction or tattooing, or both.

E. The participating physician is responsible for the following:

(1) Medical liability for the medical procedure performed on a referred, eligible patient;

(2) Accepting a referral of an eligible patient from a local health department, hospital, or other health care provider;

(3) Performing a medical test needed by the eligible patient;

(4) Charging the patient for a non-reimbursed medical procedure performed;

(5) Submitting a bill for the reimbursed medical procedure performed or service provided on the designated Departmental form within 12 months of the date of service as follows:

(a) If an eligible patient is uninsured or is insured, but the insurance does not provide coverage for the reimbursed medical procedure or service, the participating physician shall send to the Department the bill for the procedure or service, with a denial from the applicable insurance carrier, on the form designated by the Department;

(b) If an eligible patient is covered by Medicare or other insurance, the participating physician shall bill:

(i) Medicare or the other insurance for the procedure or service in accordance with Medicare or the other insurance billing specifications; and

(ii) The Department for the outstanding deductible and patient contribution amount.

(6) Maintaining reports of the results of the following diagnostic tests and sending to the Department upon request:

(a) Sonogram or other breast cancer test which identifies an area as suspicious;

(b) Breast biopsy in which cancer is present; and

(c) Cervical biopsy which identifies a change associated with:

(i) Cervical carcinoma in situ;

(ii) Cervical intraepithelial neoplasia;

(iii) Invasive cervical cancer; or

(iv) The human papilloma virus;

(7) Maintaining reports of the results of the following diagnostic tests and sending to the Department upon request:

(a) Sonogram or other breast cancer test that is negative or shows a benign finding;

(b) Breast biopsy in which cancer is not present; and

(c) Cervical biopsy which is negative or shows a benign finding;

(8) Maintaining and sending to the Department upon request, reports pertaining to the staging of the cancer; and

(9) Maintaining and sending to the Department, upon request, the result of a treatment procedure.

F. The participating physician may not bill the Department under this Program for:

(1) Completion of a form;

(2) A broken or missed appointment;

(3) A professional service rendered by mail or telephone; or

(4) A professional service provided to a patient enrolled in a Medical Assistance program other than those listed in Regulation .03C(4) of this chapter.

G. The Program shall reimburse for claims submitted pursuant to this regulation as set forth in Regulation .21 of this chapter.