Wiki Contracting a new provider Owner wants to do crazy stuff?? HELP!!!

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MarilynS

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We have a new doctor joining us (Dr A). She is only contracted with 3 insurances so far. The Head doctor (Dr B) wants her to see more patients than what she is contracted with. DR B came to me today and said that for the insurances that the Dr A is not yet contracted with she wants her to bill under Dr B's information until the contracting goes through. I told her that is NOT going to happen. She is insisting that other doctors are doing so she is too. I can't find the correct article or rule that forbids her from doing this. PLEASE help me find something that I can show her so she won't do this. Thanks!!
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Dr. A needs to only see patients with the plans she is contracted with.
You would have to check all the contracts for each payer to confirm their billing rules on this, but most do not allow it. If they did, why would they credential anyone?
There are different rules for NPPs and teaching physician scenarios. There are also some scenarios where the payer might allow backdating of credentialing but this is a sticky situation. The best practice is they do not see patients until credentialing is complete unless it is 100% confirmed the payer allows it.

Search this topic in the forums here and you will find much info, or google it.
Search incident-to, reciprocal, locum tenens for info (not your scenario but helpful info): https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c01.pdf

(some of below links may be outdated with regard to incident-to for NPP)
(Dental but same concept) https://www.lilesparker.com/2019/08...s-of-a-non-credentialed-dentist-overpayments/
 
MarilynS said:
We have a new doctor joining us (Dr A). She is only contracted with 3 insurances so far. The Head doctor (Dr B) wants her to see more patients than what she is contracted with. DR B came to me today and said that for the insurances that the Dr A is not yet contracted with she wants her to bill under Dr B's information until the contracting goes through. I told her that is NOT going to happen. She is insisting that other doctors are doing so she is too. I can't find the correct article or rule that forbids her from doing this. PLEASE help me find something that I can show her so she won't do this. Thanks!!
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Click to expand...

Amy provided some good links above. I just wanted to add that this would be deliberately misrepresenting information on a claim to get reimbursement that the provider wouldn't otherwise receive. It would be hard to defend from a fraud, waste, and abuse perspective, and also most payer contracts will stipulate that the physician who actually provided the service needs to be the one who is billed.

Of course, I understand why it is frustrating to have a new physician who is limited in what they can help cover. There are some strategies that could possibly be used while still remaining in compliance with your payer agreements.

If not prohibited by your payer agreement, the new physician could cover non-billable visits (like follow ups within a global period).
I've also seen where a current provider's schedule was so busy that a business decision was made to have the new physician cover some visits and just not bill for them.
If you have any self-pay visits, assign those to the new physician.
If the patient has out of network benefits and the payer permits, the new physician could see the patient out of network and only hold the patient responsible for what the in-network rate would have been.

(Disclaimer: know your payers and your payer agreements before using any of these strategies.)
 
@amyjph and @sls314 hit the nail on the head. I realized I had typed up my response prior, but never posted it, so here it is - giving basically the same advice above.
Basically, you may never bill the services of one provider under another provider, unless there is a specific guidance to do so (like incident-to or Locum Tenens or reciprocal billing.) It may be true that other practices are doing this. It is also true that those practices are doing something very, very wrong. I don't like to use the "F" word (fraud), but fraud is intentionally submitting a claim you know is incorrect for the purposes of getting payment. It is always a struggle when having a new doctor join to keep them busy during that lag from start date to insurance credentialed date. Other than intentionally submitting incorrect claims, here are some suggestions to keep this provider at least somewhat productive.
1) All patients with the 3 insurances she is credentialed with or self pay get funneled to her.
2) If any of your carriers will make a retro-active participation date, she may see those patients as well. Some will. Some won't. Those claims should be held until that retroactive par date is updated.
3) Provide services that would not be billable anyway. Prescription renewal calls. Test results. Postop global care. Peer-to-peer authorization reviews. My group does hospital rounds both AM and PM. The non-credentialed provider could do one of those rounds, and the visit would be billed under the other provider who also saw the patient that day.
4) You could offer patients the option of seeing the new out of network provider if they want to be seen sooner than waiting for the fully booked other provider. If that is being done, you would need to provide patients with good faith estimates and make them aware this is out of network.
5) Make a business decision for the new provider to see patients and not charge for it.
Also, use this as a learning experience to start credentialing a new provider BEFORE they start. I recommend as soon as contracts are signed.
 
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