Question Fee-for-Time/Reciprocal Billing Question

Muncie, IN
Best answers
Hello, I have a difficult situation.

MD Anesthesiologist has been banned from Medicare enrollment but still has their license.
This group uses this provider as out of network for commercial carriers.
No enrollment needed to be done, so they submit commercial claims using this MD's information.
This MD occasionally will see Medicare cases due to the other Medicare-enrolled provider not being available.

A) Should this be allowed as fee-for-time billing (Q6 modifier) under the enrolled provider?
B) Since they are not credentialed as in network providers with other insurances, are they really considered to be working within the same group? Would the reciprocal billing modifier Q5 be more appropriate under the enrolled provider?
C) Or is this a situation that needs to simply not be done since the MD has no billing rights to Medicare and therefore cannot bill through other reciprocal methods? (I couldn't find anything supporting this in CMS Manuals, but if you can, please share.

Please site any sources that you may have to backup the answer so I can share with my providers.

Thank you for your feedback!
~Melissa, CPC
Best answers
Hi, please tell your providers to be very careful.

There are very strict rules about this - essentially you cannot bill Medicare for that doctor's services and reporting the services as a locum is not a workaround. In addition, may not be legal to pay them unless you can guarantee that none of the money is coming from Medicare, but that's something that an attorney would need to help you all sort out. Practices and other providers regularly pay steep fines because they accidentally employed someone who was excluded from Medicare.

Here is an excerpt from the HHS Office of Inspector General on Exclusion

The effects of an exclusion are outlined in the Updated Special Advisory Bulletin on the Effect of Exclusion From Participation in Federal Health Programs, but the primary effect is that no payment will be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity. This includes Medicare, Medicaid, and all other Federal plans and programs that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan).