Wiki Referring provider

[NMURPHY8366]

Hello. I work for a pain management company and they are using the owner which is a dr as the referring physician on 90% of the claims. Is this legal?

 

[thomas7331]

This is not illegal in and of itself, it really depends on what is being ordered, by whom, and what the financial implications are. If you have concerns, I'd recommend doing a web search on physician self-referral laws - the rules are complex but there are a lot of good articles out there to guide you. If you think those situations might apply to this practice as potential violations, then discuss it in more detail with your manager or a compliance or legal specialist.

 

[NMURPHY8366]

he's actually not the referring physician, I believe they use his name because either they do not have the actual referring physician information or someone else referred them and/or that field has to be filled in, in order to process the claim.

 

[wbrodsky]

he's actually not the referring physician, I believe they use his name because either they do not have the actual referring physician information or someone else referred them and/or that field has to be filled in, in order to process the claim.

First off, for Consults you must have a referring physician's name, as you know. This physician cannot be from the same practice. If there is not a referring physician name on the note, then the visit is considered a New Patient visit and should be coded as such. I would advise the staff to stop putting his name as the referring physician for patients that are being seen in your practice, immediately as you could get in a lot of trouble with that. Have them change the Consult codes to New Patient codes, instead. The RVUs are not that different anyway. On the other hand, being that he is a physician, he is able to refer patients OUT to another provider/practice/specialist.

Second, if it's Medicare, it wouldn't matter anyway as they do not accept Consult codes.

I hope this helps!