Dr employed by two different groups

tomtom2

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A Dr's salary is jointly paid by two different provider groups from two different hospitals. The Dr interprets lab tests at both hospitals. Can both groups bill for his services? Each group bills for services rendered at the their hospital. Or can only one group bill for the services?


Thanks,
 

btadlock1

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A Dr's salary is jointly paid by two different provider groups from two different hospitals. The Dr interprets lab tests at both hospitals. Can both groups bill for his services? Each group bills for services rendered at the their hospital. Or can only one group bill for the services?


Thanks,
That's an unusual arrangement (at least, I've never heard of anything like it...I guess it may not be that unusual)

Anyways, I'd say that both hospitals need to bill for their own services; otherwise, the doctor's services at one hospital might be misconstrued as a violation of the AKS or STARK.

This is probably an issue best discussed with your compliance department. The provider's billing/reimbursement arrangements with both groups should be specified in detail, in his contract with both hospitals. (If it's not, there might be a problem...) Hope that helps! :eek:

See: http://oig.hhs.gov/fraud/docs/complianceguidance/012705HospSupplementalGuidance.pdf (STARK starts on page 5, and AKS stuff on page 6 - the info below begins on page 9)

"b. Compensation Arrangements With Physicians
Hospitals enter into a variety of compensation arrangements with physicians whereby physicians provide items or services to, or on behalf of, the
hospital. Conversely, in some arrangements, hospitals provide items or services to physicians. Examples of these compensation arrangements include, without limitation, medical director agreements, personal or management services agreements, space or equipment leases, and agreements for the provision of billing, nursing, or other staff services. Although many compensation arrangements are legitimate business arrangements, compensation arrangements may violate the anti-kickback statute if one purpose of the arrangement is to compensate physicians for past or future referrals.

The general rule of thumb is that any remuneration flowing between hospitals
and physicians should be at fair market value for actual and necessary items furnished or services rendered based upon an arm's-length transaction and should not take into account, directly or indirectly, the value or volume of any
past or future referrals or other business generated between the parties.

Arrangements under which hospitals (i) provide physicians with items or
services for free or less than fair market value, (ii) relieve physicians of financial obligations they would otherwise incur, or (iii) inflate compensation paid to physicians for items or services pose significant risk. In such circumstances, an inference arises that the remuneration may be in exchange for generating business.

In particular, hospitals should review their physician compensation arrangements and carefully assess the risk of fraud and abuse using the
following factors, among others:
• Are the items and services obtained from a physician legitimate, commercially reasonable, and necessary to achieve a legitimate business purpose of the hospital (apart from obtaining referrals)? Assuming that the hospital needs the items and services, does the hospital have multiple arrangements with different physicians, so that in the aggregate the items or services provided by all physicians exceed the hospital's actual needs (apart from generating business)?
• Does the compensation represent fair market value in an arm's-length transaction for the items and services? Could the hospital obtain the services
from a non-referral source at a cheaper rate or under more favorable terms?
Does the remuneration take into account, directly or indirectly, the value
or volume of any past or future referrals or other business generated between the parties? Is the compensation tied, directly or indirectly, to Federal health care program reimbursement?
• Is the determination of fair market value based upon a reasonable
methodology that is uniformly applied and properly documented? If fair market
value is based on comparables, the hospital should ensure that the market
rate for the comparable services is not distorted (e.g., the market for ancillary
services may be distorted if all providers of the service are controlled by
physicians).
• Is the compensation commensurate with the fair market value of a physician
with the skill level and experience reasonably necessary to perform the contracted services?
• Were the physicians selected to participate in the arrangement in whole
or in part because of their past or anticipated referrals?
• Is the arrangement properly and fully documented in writing? Are the
physicians documenting the services they provide? Is the hospital monitoring
the services?
• In the case of physicians staffing hospital outpatient departments, are
safeguards in place to ensure that the physicians do not use hospital
outpatient space, equipment, or personnel to conduct their private
practices? In addition, physicians working in outpatient departments must
bill the appropriate site-of-service modifier..."
 

tomtom2

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Thank you Brandi,

Each hospital is billing for their own services (technical component). But both groups are independent and not employed by the hospital. They bill for their own services (professional component). I believe most of the rules posted are for the hospital and physician relationship; and a physician to physician relationship. Am I wrong?
 

btadlock1

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Thank you Brandi,

Each hospital is billing for their own services (technical component). But both groups are independent and not employed by the hospital. They bill for their own services (professional component). I believe most of the rules posted are for the hospital and physician relationship; and a physician to physician relationship. Am I wrong?
I'm not sure I understand your question, then - how does your doctor fit into all of this? It sounds as though the groups (which I understood to be from different hospitals), both perform their own labs, and your physician performs the interpretation for both groups. If that's correct, then your physician should be billing for the professional component for the services, because that's what he's rendering. How he bills the services, depends on a couple of factors:
1. Is he billing as an independent physician, with his own tax ID and billing NPI, or is he affiliated with the groups (eg, shares their tax ID & billing NPI)? If he's his own entity, then he would report services under his own info. If he's affiliated with the groups, you'd use the billing info corresponding with the group who he is working for, with each encounter. So, if he's interpreting charges for Group A, use Group A's TIN & billing NPI; if it's Group B's patient, then use Group B's info...unless he's not associated with either group, and is considered an individual practitioner - in which case you will always use his TIN and billing NPI, regardless of which group he's performing services for)

2. Are the groups billing for the whole procedure (both Technical and professional components), and reimbursing the provider for his services? (Also known as: "Pass-through billing")? If that's the case, then you shouldn't bill payers at all; you'd requisition the groups, for payment. (*Also worth noting: many payers explicitly prohibit the practice of pass-through billing, and require all providers to be individually contracted with their network; it's very likely that the hospital groups are violating their payer contracts, if they bill this way.)

The info I provided earlier, pertains to the provider's relationship with the hospital(s)/groups. It may or may not be relevant to your situation, but it's worth considering, anyways (particularly if your physician's practice is located within a facility owned by one of the hospitals) - I only brought it up because, unless the arrangement between the 2 hospitals, to split your physician's salary, fits into a STARK exception and/or AKS safe harbor, they may be at risk of violating one (or both) of those laws (which both carry steep penalties).

It's probably not your job to assess the legality of your physician's relationship with the 2 groups - that's normally a compliance/legal department function...but, the way that you bill services on behalf of your provider, should be spelled out in his contracts, so you'll have to address this question with that department, anyways.

If you discover along the way, that there is no written contract with the groups, you'd be doing your doctor a favor to pass that info along - it's better to be safe than sorry. Hope that helps!
 

tomtom2

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Thank you again Brandi,

I believe you best explained it with " If he's affiliated with the groups, you'd use the billing info corresponding with the group who he is working for, with each encounter.So, if he's interpreting charges for Group A, use Group A's TIN & billing NPI; if it's Group B's patient, then use Group B's info". I guess my real question should have been if a provider can be affiliated with two different groups and the two different groups bill for the provider's services?
 

btadlock1

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Thank you again Brandi,

I believe you best explained it with " If he's affiliated with the groups, you'd use the billing info corresponding with the group who he is working for, with each encounter.So, if he's interpreting charges for Group A, use Group A's TIN & billing NPI; if it's Group B's patient, then use Group B's info". I guess my real question should have been if a provider can be affiliated with two different groups and the two different groups bill for the provider's services?
And therein lies your potential compliance issue. :)

You really should ask someone from the compliance/legal department (or a supervisor who can ask them for you, if necessary), how to bill this, and (tactfully), if it's legal for a provider to be affiliated with 2 different groups, in the manner that your provider is.

Under some circumstances (namely, in a 'medical directorship' situation), it is acceptable for a provider to be contracted under (or, 'affiliated with') more than one entity. Usually, this is limited to providers who specialize in a unique area, where there may only be a few providers with their expertise available in an area (a good example is a Sleep medicine doctor).

If your provider is interpreting routine labs, it's still possible that he may be operating under a locum tenens-type arrangement, where he's considered 'temporary' help, and not a permanent part of either group - if billed correctly, this is also acceptable (but would require a totally different method of billing than I've given you, so far). There are a lot of rules associated with locum tenens & reciprocal billing arrangements, so if you find out that one of those applies, you should make sure your provider is meeting the requirements.

Aside from those situations, I'd approach an arrangement, where a provider is working for 2 different groups, with extreme caution; especially if one of those groups is in a position to refer patients to the other (like, a hospitalist group, and a specialty group, for example). That type of arrangement is straying into seriously dangerous territory, as far as the OIG is concerned. Hope that helps! ;)
 

tomtom2

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The provider is for now temporary and is providing interpretations in the very specialized molecular diagnostic tests. As of now; only Group A is doing billing for his services with Group B not receiving any payment for services provided on the jointly employed provider. This will probably end soon, in the mean time I'm only to research "locum tenens & reciprocal billing arrangements".

Thanks for all of your help Brandi.
 

btadlock1

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The provider is for now temporary and is providing interpretations in the very specialized molecular diagnostic tests. As of now; only Group A is doing billing for his services with Group B not receiving any payment for services provided on the jointly employed provider. This will probably end soon, in the mean time I'm only to research "locum tenens & reciprocal billing arrangements".

Thanks for all of your help Brandi.
No problem! Here's a good place to start your research: http://www.trailblazerhealth.com/Publications/Training Manual/Locum Tenens.pdf ;)
 
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