Pediatric Coding Alert

Answer: No, it doesn’t sound like this scenario illustrates an instance where one provider should bill under another provider’s credentials. The Office of Inspector General (OIG), which audits organizations for fraud, emphasizes that most stakeholders in the U.S. healthcare system rely on physician honesty for both quality of patient care and integrity of documentation and reporting of that care.

The OIG explains: “Because the Government invests so much trust in physicians on the front end, Congress provided powerful criminal, civil, and administrative enforcement tools for instances when unscrupulous providers abuse that trust. The Government has broad capabilities to audit claims and investigate providers when it has a reason to suspect fraud. Suspicion of fraud and abuse may be raised by irregular billing patterns or reports from others, including your staff, competitors, and patients.”

Here are a few ways to help keep things moving during the credentialing lag time:

• Funnel self-pay patients and patients who have the creden­tialed insurance to the new provider.
• Check the retroactive participation date for respective payers.
• Assign the new provider services that aren’t billable, such as post-op care that falls under global care, peer-to-peer authori­zation reviews, and fielding prescription renewal calls.
• Describe the new provider as out-of-network, and let patients decide whether to see them.

Remember: There are some situations where providers can bill their services under another physician’s information. For example, Medicare may reimburse an organization when

an encounter involves incident-to services, Locum Tenens agreements, or reciprocal billing. Providers may be legally allowed to bill the services they provide under a different physician’s information, but only when very specific criteria are met. In some of these situations, like incident-to services, the reimbursement rate may be different for nonphysician practitioners (NPPs) than physicians. Many commercial carriers follow the lead of the Centers for Medicare & Medicaid Services (CMS) when determining when organizations can legally bill services in this manner.