Wiki Physician not Credentialed

[Licorice5]

We have a physician on staff (since Nov 2012) that is still not credentialed with any insurance. He signs his records and then the physician that is credentialed signs and billing is submitted under the credentialed physician. I recently found out the physician's license, that's not credentialed, is on probation until Oct. 2014. Someone said this is why he is not credentialed.

I am trying to find where in CMS I can find a statement or ruling regarding this practice. Incident to does not apply so I really believe this might be fraud.

Suggesting I ask the billing manager will not get me anywhere because I've asked several times about credentialling and other billing issues I have and all I get is the run around or very vague answers.

Thanks for any assistance.

 

[RebeccaWoodward*]

We have a physician on staff (since Nov 2012) that is still not credentialed with any insurance. He signs his records and then the physician that is credentialed signs and billing is submitted under the credentialed physician. I recently found out the physician's license, that's not credentialed, is on probation until Oct. 2014. Someone said this is why he is not credentialed.

I am trying to find where in CMS I can find a statement or ruling regarding this practice. Incident to does not apply so I really believe this might be fraud.

Suggesting I ask the billing manager will not get me anywhere because I've asked several times about credentialling and other billing issues I have and all I get is the run around or very vague answers.

Thanks for any assistance.

CMS does have guidance on this.

• Knowing misuse of provider identification numbers, which results in improper billing; 16

16 An example of this is when the practice bills for a service performed by Dr. B, who has not yet been issued a Medicare provider number, using Dr. A’s Medicare provider number. Physician practices need to bill using the correct Medicare provider number, even if that means delaying billing until the physician receives his/her provider number




This needs to reported to your executives and handled promptly!

http://oig.hhs.gov/authorities/docs/physician.pdf