Wiki Is this legal?? Need advice please!

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srouleau

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First, my expertise lies in coding, not billing and contracts, etc.
I just took a job at an outpatient imaging center and have some concerns regarding the billing. I have been told that if the insurance does not pay for certain procedures (mostly pain management supplies) in-network then, if the patient has out of network benefits, they bill that way and sometimes get paid. I'm concerned that this is not legal. Any advice/thoughts? Also, I need written proof to back up my statement if this is illegal so if I could also get a website where this info can be found that would be greatly appreciated. Thanks!
 
I dont really understand how you can bill in versus out of network, you bill the appropriate code and if you are participating they pay at an in network level of benefits, if you are not participating they pay out of network benefits. You wouldn't bill twice in two different ways. As far as finding this in writing, it states in a standard insurance contract that you can not bill the patient other than for copay, coinsurance or deductible so I would check in your provider contracts or on the insurance company's website, most companies have their provider manuals on line.
 
srouleau said:
First, my expertise lies in coding, not billing and contracts, etc.
I just took a job at an outpatient imaging center and have some concerns regarding the billing. I have been told that if the insurance does not pay for certain procedures (mostly pain management supplies) in-network then, if the patient has out of network benefits, they bill that way and sometimes get paid. I'm concerned that this is not legal. Any advice/thoughts? Also, I need written proof to back up my statement if this is illegal so if I could also get a website where this info can be found that would be greatly appreciated. Thanks!
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If you're contracted, the insurance company should be able to recognize that by your Tax ID or NPI (depending on the payer). You can't bill non-PAR when you're participating, because they check that. The legal issues behind it would only come into play, if you're somehow altering the claim information to deceive the payer, by making them think you're billing under someone other than yourself (changing a name, address, TIN, NPI, etc., or otherwise submitting information that you know to be 'false').

If your clinic's found a way to get around their own contracts and bill out of network without changing the claim to conceal their PAR-status, then they're still risking violating the terms of participation with the payers they bill - depending on the payer and the fine print in the contract, the consequences for doing things like that could range from losing your ability to contract with the network, to a lawsuit for breech of contract, claim recoupments. If they are altering the claim info, I would advise you distance yourself from that practice - chances are, what they're doing could land them in big trouble, if they're caught.
 
Here's a little more to the story that I did not have when I initially posted my question. If the supplies are not paid for when billing the in-network benefits then they bill under the doc's other tax id which is out of network. He has two legit businesses with two separate tax id's. Now, with this being the case, is this illegal?
 
srouleau said:
Here's a little more to the story that I did not have when I initially posted my question. If the supplies are not paid for when billing the in-network benefits then they bill under the doc's other tax id which is out of network. He has two legit businesses with two separate tax id's. Now, with this being the case, is this illegal?
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No that's shady...I'd find somewhere else to work.
 
I would not only find another place to work, after I found another job, I would report your employer to the insurance companies involved, this is extremely shady and unfair to the patients and the insurance company.
 
If services were provided under one Tax ID# and a determination was made by the insurance, then the claim was resubmitted under a different Tax ID# looking for a different answer or additional reimbursement....this is fraudulant. The services were provided under ONE TAX ID#. Pick one and stick with it. I realize you came into this situation and are just figuring this all out, but I totally agree with the previous posters...this puts you in a very precarious position of being party to these actions. I know jobs are not easy to find right now, but you seriously need to consider leaving. So sorry!
Jenna
 
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