Question Can you bill the secondary ins with a different Tax ID # than the primary claim

MZorovic

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Can you bill the primary ins under one tax ID and then bill the secondary under a different tax id. We have a hospital who send out the primary claims for 2 different insurance under their tax id, but changes and sends the claim to the secondary under our tax id number. This doesn't sound right to me. Is there any documentation on this
 

thomas7331

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I've never heard of this and it does seem odd that a provider would report income from a single service as being paid to separate entities , but it may have something to do with the corporate structure of your hospital. This is really a question for a tax attorney or accountant, not a coder. There may or may not be a legitimate reason for this, but a coding forum isn't the right place to get definitive tax or legal advice. I would suggest perhaps you may want to bring it to the attention of someone in your hospital's finance or compliance department who might be able to look into it further or give you an explanation as to why they are doing this.
 

SharonCollachi

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We have a hospital who send out the primary claims for 2 different insurance under their tax id,
So we can safely assume they are a hospital and are billing on a UB4... or are they billing for something on a HCFA?

but changes and sends the claim to the secondary under our tax id number. This doesn't sound right to me. Is there any documentation on this
And what type of institution are you?
 

MZorovic

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So we can safely assume they are a hospital and are billing on a UB4... or are they billing for something on a HCFA?



And what type of institution are you?
We are a private community practice and our local hospital bills out on HCFA 1500 our charges for 2 insurances thru a clinically integrated network. When a patient has a secondary, they have been changing the tax id on the claim and sending it to the patients secondary ins under our tax id. I think they should run the entire claim thru their system, and one of my billers/payment posters thinks this is fraud and we are trying to figure out which is accurate.
 

csperoni

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I agree with Thomas that this is not really a coding question, but rather a legal or finance question.
I imagine this is being done if the provider is credentialed differently with the primary and secondary insurance. For example, credentialed under Medicare as a group, but individual credentialing for United HealthCare. I don't believe it would be potential fraud unless they are billing the same service to the same insurance under multiple bills. The intention is to seek the balance after primary insurance, not to receive a duplicate payment.
I have seen similar situations, and I assumed the legal department, compliance department, or others with expertise in the area had reviewed this before instructing dozens of their practices to do so.
I will note there were some 2ndary carriers who had an issue with the primary EOB TID not matching what we submitted to them, and then had to appeal.
 

SharonCollachi

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I have seen similar situations, and I assumed the legal department, compliance department, or others with expertise in the area had reviewed this before instructing dozens of their practices to do so.
I am naturally a cynical person. I do not, for one moment, assume that anyone with expertise would have reviewed this situation before someone decided "this is what we should do." Sometimes my doctor wants to do something and he loves to say, "well, all the doctors at (large institution) are doing it, so it must be okay", and then I'm forced to dig up a recent article on large institutions doing things they shouldn't do.
 

SharonCollachi

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We are a private community practice and our local hospital bills out on HCFA 1500 our charges for 2 insurances thru a clinically integrated network. When a patient has a secondary, they have been changing the tax id on the claim and sending it to the patients secondary ins under our tax id. I think they should run the entire claim thru their system, and one of my billers/payment posters thinks this is fraud and we are trying to figure out which is accurate.
I wouldn't call it fraud necessarily, but it would make me uncomfortable. I am always uncomfortable when someone else wants to bill for us, because we have no control over what they do yet our name is on it.
 

MZorovic

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I wouldn't call it fraud necessarily, but it would make me uncomfortable. I am always uncomfortable when someone else wants to bill for us, because we have no control over what they do yet our name is on it.
I know if kind of falls in the false claims act, but it is a fine line. Box 33 is the only thing changing on the claim, but it has been modified from the original claim. Location and provider are all still the same.
 

thomas7331

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I know if kind of falls in the false claims act, but it is a fine line. Box 33 is the only thing changing on the claim, but it has been modified from the original claim. Location and provider are all still the same.
It is not a false claim if both tax IDs are owned by the same organization. The function of the tax ID is only to identify for the payer how the revenue is to be reported to the federal government. This is done for tax purposes, so if there is any potential fraud involved, it would be tax fraud. As long as the rest of the information on the claim is accurate - the procedure, diagnoses, NPI numbers, etc. - and correctly describes the services rendered, then it is not going to be a false claim. But it could even simply be an error in the billing software setup that needs to be corrected and not something fraudulent at all.

I think your concern is a legitimate one and you are right to question this - it's important that claims be filed correctly to avoid creating a potentially costly mess down the road. But again, this is something that needs to be reviewed by your compliance officer or someone on site who can do a proper review, get an understanding of what is going on, and make changes in the process if needed, and if I were in your place I would be raising the question with the responsible persons. An internet discussion forum is not the place to litigate legal issues or try to reach a verdict on whether or not your provider is breaking the law. We simply don't have the information here to be able to make an informed judgment.
 
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