Practice Management Alert

There's only one exception to the rule -- do you know what it is?

One of your physicians wants you to bill under another physician in his same practice, under a different tax ID -- but should you do it?

Provider misidentification does happen -- sometimes intentionally and sometimes accidentally -- but either way, it shouldn't happen and can land you in a mess of trouble if it does. Let our experts point you in the right direction to ensure you bill physician services compliantly and don't end up fraudulent.

Turn to CMS Form for Guidance

The basics: The name and identification number (NPI/PIN) you enter on the CMS-1500 form must be the name and number of the provider who actually rendered the service to the patient. The only exception to this rule is incident-to billing. (See the article -Wondering if Your NPP Billing Is Up to Snuff? Test Yourself- in this issue for more on incident-to  billing.)

Warning: You cannot bill one physician incident-to another physician. Incident-to billing only applies to nonphysician practitioners.

Clearly stated: On the back of the CMS-1500 form, physicians are specifically certifying that they performed the services you-re billing for or that they were incident-to services.

The form states: -I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident-to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations.-

Caution: -Although most physician practices submit claims electronically, they really should not forget that the certification language on the paper CMS-1500 form still applies,- says Jean Acevedo, LHRM, CPC, CHC, senior consultant with Acevedo Consulting Inc. in Delray Beach, Fla.

The penalty: Billing for services not provided by the provider indicated on the CMS-1500 is a direct violation of compliant practice operations. If you or your providers falsify a claim by billing services under another physician's name and ID numbers, you could both face fines or even imprisonment.

At the back of the CMS-1500 claim form you use, you-ll see the wording: -Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties.-

-The fact that this statement is printed in bold face type underscores the importance of this,- Acevedo says. -One only has to look at the federal and states- False Claims Acts to realize that submission of -false- information could lead to severe financial penalties of treble damages plus $5,000 to $11,000 per claim.-

Third-Party Billers: You-re Not off the Hook

Third-party billing companies can also end up in hot water for knowingly billing services for a physician under another physician's name, says Katherine Abel, CPC, billing administrator with Stat Solutions in Nashville, Tenn., and senior instructor for e-learning for the American Academy of Professional Coders.

-Regardless of who does the billing, the same rules apply,- Acevedo says.

What to do: The OIG Compliance Program Model Guidance for Third-Party Medical Billing Companies offers directions on what you should do if you-re asked to bill fraudulently in this manner, Abel says. The OIG model guidance states: -If the billing company finds evidence of misconduct on the part of the provider that they service, the billing company should refrain from the submission of questionable claims and notify the provider in writing within (30) days of such determination ...-

Best bet: First, -gently remind- the physician that you cannot submit the claim under another physician's name and ID because it does not meet the criteria for incident-to billing, Acevedo says. If the physician insists on billing in this manner, turn to your supervisor, office manager or compliance officer for assistance.

Final say: -Under no circumstances, however, does a biller want to be complicit in submitting a -false claim,- - Acevedo says. Don't submit the claim unless the physician allows you to do so under the proper identification number. If the provider insists on billing with misleading information, terminate your work with him, as painful as that may be.