Question Doctors Rules

ShauntaEskridge

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I have some concerns about the way the doctor I currently work for is asking me to bill. I bill both professional and Facility claims for him. I need to know if I am within the coding guidelines when billing. We are out of network the provider and the facility. For facility he wants me to bill both 0490 and 0360 together, I’ve explained that we are not affiliated with a hospital so we shouldn’t bill those codes together. He insist and says he get the blow back if it should come back to haunt us not me. 🤔🙄We are not certified with Medicare as a facility but we perform surgeries on Medicare patients in this facility. I bill the professional component but not the facility for these patients. I also bill for screws and implants on the professional claim for Medicare patients when they should be billed on facility claims, screws and implants are never paid by Medicare professionally but now I have to “figure” why and when I tell them they say that’s not good enough. We never collect coinsurance for facility. This office is starting to give me red flags and I’m not sure if I should stay here or not. Is it just me or are my suspicions warranted?
 

Orthocoderpgu

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I don't do any facility coding/billing, professional only. You should have a compliance department to bring this up with. You cannot be billing facility charges on the professional side. That's a red flag to me. I would enter a note in the computer that you do not agree with the billing of screws and implants but are being told to by the provider. If you don't have a compliance department/person that can help you out and the doctor/s will not listen, I would seeking other employment.
 

ShauntaEskridge

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AppleValley, CA
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I don't do any facility coding/billing, professional only. You should have a compliance department to bring this up with. You cannot be billing facility charges on the professional side. That's a red flag to me. I would enter a note in the computer that you do not agree with the billing of screws and implants but are being told to by the provider. If you don't have a compliance department/person that can help you out and the doctor/s will not listen, I would seeking other employment.
We do not have a compliance department. I appreciate your feedback.
 

csperoni

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Agree with Orthocoderpgu. If you're not a facility, you should not be billing as though you are. Many years ago, we had a AAAASF surgical suite in the office. Some shady and slick consultants stated they could get us extra money by billing as an out of network facility. I did a little research, and found a lot of legal issues unless you are credentialed as Article 28 (at least in NY). After the consultants were questioned about this, we decided to terminate their agreement. California could be different, but this definitely seems suspicious at best.
Most concerning issues for me:
1) You state you're not certified with Medicare as a facility, but do procedures on Medicare patients. What do you use as your POS? I don't think you can change your POS depending on the insurance.
2) You state you are not collecting the facility co-insurance. That is another huge red flag for me. You are required to bill patients their financial portion and at least make an attempt to collect it.
 

ShauntaEskridge

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AppleValley, CA
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Agree with Orthocoderpgu. If you're not a facility, you should not be billing as though you are. Many years ago, we had a AAAASF surgical suite in the office. Some shady and slick consultants stated they could get us extra money by billing as an out of network facility. I did a little research, and found a lot of legal issues unless you are credentialed as Article 28 (at least in NY). After the consultants were questioned about this, we decided to terminate their agreement. California could be different, but this definitely seems suspicious at best.
Most concerning issues for me:
1) You state you're not certified with Medicare as a facility, but do procedures on Medicare patients. What do you use as your POS? I don't think you can change your POS depending on the insurance.
2) You state you are not collecting the facility co-insurance. That is another huge red flag for me. You are required to bill patients their financial portion and at least make an attempt to collect it.
Medicare is still billed on POS 24.
 

csperoni

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So for Medicare patients, you are billing the professional fee as a facility POS. Let's take out for a second that the facility is not credentialed with Medicare and whether or not you should be billing as a facility for any insurance. The facility is required to provide the supplies/screws/implants/etc. The physician will not be paid for them and should not be billing for them.
On these Medicare patients, you are not getting a site of service differential or a facility fee. You are paid exactly the same as if you did the procedure in an ASC or hospital. You are providing all the additional expenses - recovery room, supplies, staff, etc. I have to wonder why anyone would do that. It does not seem like sound financial advice.

Now let's address about whether or not you are actually a facility. I know in NY, if you can't get Medicare facility approval by being Article 28, you can't get it for any other insurance and are not a facility, but rather providing OBS services (office based surgery) and bill POS 11 since it is an OFFICE based surgery suite. You should not bill any facility fees since you are not legally a facility. You will get the site of service differential for performing the procedure in a non-facility setting.
I have heard of other states that are more "flexible" on the whole facility issue where there is a separate TID, separate address, separate business (or whatever requirements your state has) doing procedures for commercial insurance, but not for Medicare. I don't have any experience in that, but that also does raise an eyebrow, unless you have a regulation for your state clarifying this issue.
Aetna specifically prohibits facility billing unless you are a freestanding licensed ASC. There was a big legal issue where they attempted to recoup years of payments. Faced with lawsuits, Aetna decided to drop the recoupment, but not pay going forward. Many other commercial carriers followed suit. https://www.beckersasc.com/asc-codi...based-surgery.html?oly_enc_id=0517H4521189B0O

If you don't have a compliance department, I imagine you don't have a legal department either. To me, some of these are legal/compliance questions. If you don't have someone above you to bring this to, and the physicians are not listening to you nor willing to obtain legal advice, I would look for a new job.
 

thomas7331

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It sounds like there are multiple different problems going on here - this is more than can be addressed properly on a forum like this. Just guessing from what you've described I would think that the provider is probably losing a lot of more money by doing things this way than they are gaining form improper overpayments, so I think it's unlikely that you would be accused of fraud - it sounds more like just plain incompetence. To get this fixed, you really need someone with experience in the credentialing and billing for a freestanding facility in your state - if there's no one on site who has that experience, then you probably need to get a consultant to help you sort it out. Unfortunately, if your provider or manager is insisting that they are already doing it correctly and is unable to answer your questions and not willing to get you outside resources to make sure you know that you're doing your job properly, then - and I know it's harsh to say this - if I were in your place I would likely be seeking employment elsewhere.
 
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