Wiki Billing a Non-Credentialed Provider under a Credentialed Provider's NPI--HELP

[ashleytenee@gmail.com]

I am currently in the end stages of the interview process to become the lead medical biller at a smaller private practice. I have a friend who works there who mentioned last night I would need to be comfortable billing non-credentialed providers under the credentialed providers. She stated the credentialed providers will step into the office visit for a moment and that makes it legal to bill as listed above. I am HIGHLY unsure of the legality of this and do not want to start my career as a medical biller performing unethical practices that might be considered fraud. I understand each payer is different and it could depend on the individual contract. Can someone help make this more clear for me.

Thanks in advance!

 

[thomas7331]

You are correct to question the legality of this. Unless you are following 'incident to' rules or have written guidelines from a payer to do otherwise, a claim submitted under the credentials of a different provider than the one who provided services in order to obtain payment is a false claim and most likely a fraudulent practice. Having a credentialed provider "step into the office visit for a moment" is most certainly not sufficient to satisfy 'incident to' requirements.

 

[chelslk]

I've read that billing under the practice is allowed for a non-credentialed provider, so long as the insurance company allows billing under the clinic as a whole and the clinic is currently credentialed?

Is that correct? I'm in a very similar situation to the original poster, we have a new employee who is in the process of contracting and my provider is very adamant that she can "pop in the visit, assess his treatment plan" and sign off on the chart note. The doctors just put "This is chart note was reviewed and supervised by Dr. Blah Blah" and she says that's fine. We're now having a claim come back with requesting more information (chart notes) for one of the codes but since the claim was submitted under the supervising DRs name but the chart note is under the non-contracted provider's name, I'm concerned.

HELP.

 

[thomas7331]

You would really need to check with your specific insurance companies on this. This topic frequently comes up and I have heard it addressed by legal experts at a couple different conferences and their recommendation is always that this practice should be avoided completely if possible, but if your payer requires or allows it you should be extremely careful. What it boils down to is that if you are putting one provider's name on a claim for services that were performed by another provider, and you are not doing this in under the strict guidelines of the 'incident to' rules, then you are submitting incorrect information on the claim, i.e. a false claim. The only way you can cover yourself is in this scenario is to have something in writing from the payer stating that they agree to having you do this. You should obtain some kind of official payer policy, contract, letter, email or other communication that explicitly states that you can bill this way, and keep it on file to protect you in case anyone ever audits and asks why the claims were submitted this way; otherwise you are opening yourself up to a potential fraud liability. 'Signing off' on a note is quite simply not sufficient to make it legal or ethical for one provider to substitute their name on a claim for services that were performed by a different provider.

 

[karen@coastal-ent.com]

I am having the same issue, but with an audiologist. Can we bill the audiology services under our provider if they have never seen the patient. We have patients that are referred by their PCP for hearing evaluations but our commercial insurances will not contract with audiologist and say we have to bill under our physician.