Wiki LPN and RN Billing to Third-Party Payers

[Rperry]

Good Evening Fellow Subject Matter Experts,

Can someone provide me with feedback regarding the following statement:

If your practice provides medical services to patients (regardless of the location), and no supervising physician or non-physician provider (PA or NP) is present, those services can not (I repeat, can not) be billed to any insurance carrier. This is considered a false claim and has serious ramifications under the Federal False Claims Act.

 

[Pam Warren]

This statement is describing the legality surrounding 'incident-to services', which can be provided by a medical assistant, RN, LPN, etc., under the direct supervision of a physician or otherwise credentialled non-physician practitioner: i.e. someone who is credentialled to bill independently. 'Direct supervision' means that this provider must be in the same suite at the time, but doesn't necessarily have to be in the exam room. To bill without physician supervision is fraudulent except for one example within a physician practice that I am aware of. Our Medicare contractor, NHIC allows us to bill flu shots at a flu clinic without direct physician supervision. Lab drawing sites are also able to bill without direct physician supervision, but that's not my area of expertise. Maybe someone else can comment.

Aside from the obvious billing concerns, I would question the safety of providing any kind of medical service without the presence of a licensed practitioner.

 

[MMAYCOCK]

Billing

Good Evening Fellow Subject Matter Experts,

Can someone provide me with feedback regarding the following statement:

If your practice provides medical services to patients (regardless of the location), and no supervising physician or non-physician provider (PA or NP) is present, those services can not (I repeat, can not) be billed to any insurance carrier. This is considered a false claim and has serious ramifications under the Federal False Claims Act.

It is important to check your state regulations.
1. Licensed Health care professionals are allowed to operate within their scope of care which will be outlined as part of their licensure in that state.

If they are operating within their scope of care and you are billing their services not under the provider ID of a physician or NPP, it is not fraud. The fraud would be if you billed it as a service provided under a doctor's supervision when it wasn't.

But to directly answer your question. That statement is false.