Wiki Independent Contractor Physician surgery question

[aimes]

Our practice just hired an independent contractor to see patients at our office part time. He has an NPI under our practice and also an NPI under his own practice. We are HemOnc and he is a Pulmonologist. He will be seeing patients at both places. Ours being part time.
Here's my question and need clarity:
He saw a patient at his Pulmonary practice and that office(completely separate from our office) set up a surgery for that patient however the surgery is related to Hematology (which is our practice and also a mutual patient). The Dr has given us a list of patients that he has done Oncology related surgeries on and Our practice is wanting to bill for these surgeries (EBUS as an example) however, prior authorization was obtained by his pulmonary practice but not through ours. Can we still use that authorization for that procedure or do they still need to be seen through our practice?

Shouldn't the patients he see's for us be completely separate if he intends on doing surgery on patients seen in our practice? I need some kind of guidance on the guidelines of the correct billing for an independent contractor.

Also, any follow up visits for post op needs to be at our clinic, correct?

 

[CBLENNIE]

I work in insurance and for us our prior authorizations are specific to the provider ID # we assign to the providers and if they are practicing as part of multiple provider groups, their ID # is different for each provider group. So, for us, in this scenario where the PA was approved for the provider's pulmonary practice the system would not recognize that the PA was associated with the provider if the claim were submitted under his provider ID # setup for your HemOnc provider group. So, if the PA is not updated prior to the procedure and claims being submitted the claim is going to process through w/out being connected to the PA and whatever penalty/denial would apply to the claim when processed.

For us the prior to the procedure the PA needs to be withdrawn from under the provider ID # for the pulmonary practice and transferred to the provider ID # for the HemOnc practice.

I don't know how this might work for other insurance companies, so you'll need to check for each patient that has an existing PA under the pulmonary practice to find out whether it will follow the provider automatically and attach/link to the claim received. Or if it needs to be handled in a manner similar to our process so that the PA properly attaches to the provider under the HemOnc practice when the claim is received.

I don't know how many existing PAs this provider might have that need to be investigated, but it is probably worth verifying with the various insurance companies so that you don't have issues with claims processing without the PA attached to the claim and then having to fix it after the fact.

As for billing for his services for procedures performed for your practice they should be billed under your practice; however, don't forget that these will not be new patients to him for any E&Ms billed out under your practice since he will have seen them in the past 3 years considering that he has a PA on file for a scheduled surgery. Also, these patients who have already had visits for pre-op services and the decision for surgery was made under his pulmonary practice should not be billed for a pre-op visit separately under either practice as his services are still going to be billed globally under your HemOnc practice.

 

[aimes]

Thank you so much, this answered my question