Wiki Midlevel Billing and Commercial Reimbursement Policies

[clarkmegan]

Can someone provide me with links to Cigna or Humana regarding the billing of Midlevel providers? I cannot find clear polices on their websites stating whether or not they want services billed under the physician or midlevel. Do they follow CMS incident-to guidelines? Thanks!

 

[mitchellde]

A few years back the OIG stated that you should assume all payers follow Medicare on this as they are the "Gold Standard". If you find a payer that states they do not followMedicare or says "just bill under the provider". It is your responsibility to obtain this policy in writing making sure it is clear in this policy that the provider has not evaluated the patient for a this specific problem and the provider may not be in the office at the time of the encounter, and they are still instructing you to bill using the MD's NPI.
Until you have this as a written policy, should assume that the payer does follow Medicare. If the payer does not wish to credential your midlevel then that midlevel will be restricted from seeing new patients, new problems, or patients when the provider is not in the office who are covered by that payer.

 

[chimilej]

A few years back the OIG stated that you should assume all payers follow Medicare on this as they are the "Gold Standard". If you find a payer that states they do not followMedicare or says "just bill under the provider". It is your responsibility to obtain this policy in writing making sure it is clear in this policy that the provider has not evaluated the patient for a this specific problem and the provider may not be in the office at the time of the encounter, and they are still instructing you to bill using the MD's NPI.
Until you have this as a written policy, should assume that the payer does follow Medicare. If the payer does not wish to credential your midlevel then that midlevel will be restricted from seeing new patients, new problems, or patients when the provider is not in the office who are covered by that payer.

Do you by chance have a link to where the OIG states this? We are struggling to find split/ shared visit policies for the commercial payors, so we are allowing the doctors and midlevels to share their critical care.