Wiki Provider Self Treating

Create Wiki
T

tbragg36

Networker
Messages
44
Location
Bonita Springs, FL
Best answers
0
Hi, I have a general question about a provider submitting claims under their NPI for treatment for themself. The MD works for our company. The Techs performs the EEG on the MD and the company has been submitting these DOS for treatment to the doctor into the insurance carrier with the doctor's NPI in box 24j on the CMS1500 as the rendering provider. Doesn't that suggest that the doctor is treating himself? Plus, isn't the doctor supposed to be supervising and be there in case of an emergency? What would happen if the emergency was him during treatment and he's the doctor on staff? I did find the AMA code of Ethics Opinion 1.2.1, but does anybody have any thoughts on this? Thank you, Teresa
 
Yes, if the physician is both the patient and the ordering or performing provider on the same claim, then it certainly does suggest that the physician is self-treating. If it's an isolated instance and nothing more than an EKG, it's unlikely to be a problem, but if this is occurring with any frequency it could very easily trigger red flags with the payer and it's something that I would absolutely bring it to a compliance officer's attention. If the physician needs a particular service that the practice is able to provide, it should be a simple matter to arrange, for example, to have another provider within the practice to offer this service and bill it under their credentials just to make sure there is no compliance issues created.
 
thomas7331 said:
Yes, if the physician is both the patient and the ordering or performing provider on the same claim, then it certainly does suggest that the physician is self-treating. If it's an isolated instance and nothing more than an EKG, it's unlikely to be a problem, but if this is occurring with any frequency it could very easily trigger red flags with the payer and it's something that I would absolutely bring it to a compliance officer's attention. If the physician needs a particular service that the practice is able to provide, it should be a simple matter to arrange, for example, to have another provider within the practice to offer this service and bill it under their credentials just to make sure there is no compliance issues created.
Click to expand...
Thank you, I wish I could find more literature on the topic. My company quoted the AMA 'for a short period of time for minor problems', and the company told me they have done this in the pass. I guess right now it boils down to; is EEG considered minor and what is considered a short period of time. I think if we have submitted claims in for his treatment since November to present, this would not be considered a short period of time.
 
tbragg36 said:
Thank you, I wish I could find more literature on the topic. My company quoted the AMA 'for a short period of time for minor problems', and the company told me they have done this in the pass. I guess right now it boils down to; is EEG considered minor and what is considered a short period of time. I think if we have submitted claims in for his treatment since November to present, this would not be considered a short period of time.
Click to expand...
I forgot to mention he's the only doctor on staff.
 
tbragg36 said:
I forgot to mention he's the only doctor on staff.
Click to expand...
He must have other physicians with whom he works for coverage who could do this for him though. I would let someone in management know he's putting himself at risk by submitting claims for himself to a payer. If it happens on an ongoing basis, this will eventually show up on a payer audit and the practice will have a problem on its hands and a lot of explaining to do. If you think it's a serious matter and don't have anyone in your company to speak to about it, you may want to put in a call to your state's medical licensing board and get their input.
 
State's Medical Licensing, interesting. This does happen on an ongoing basis. The doctor is employed by the company, so the company is submitting his claims for treatment. Management/owner of the company says the company has done this before. We all know how 'we've done this before' can work out. Just because the company has done this practice in the pass doesn't make it right and it can come back to hurt them. I need something in writing from a trusted website. I think it looks fraudulent billing the doctor's treatment under his NPI to the insurance carrier (Medicare), but that's my interpretation. The company's interpretation is we've done it before, it's ok.
 
I would also cover my butt by documenting that you've pointed out this might be an issue. That protects you in case there's a question, e.g. employer says "tbragg36 never told us!" and then it's on you to prove that you did or didn't.
 
I really appreciate everyone's input. This is a relative new remote job. A newly open clinic as of 2020. Yes, I have sent several emails concerning this along with the AMA code of Ethics Opinion 1.2.1 about self treating. This billing practice concerns me because this appears to be billing inappropriately and the payer is Medicare. I've looked for self treatment on CMS website and my local MAC, but was unable to find anything. @jkyles thank you for the BCBS link. I wish I could find something like that on the CMS website. When I have looked it refers me to the stark law. Our provider services are not among the list of designated health services prohibited for self referral on the stark law list. I've gone through a few Medicare manuals with the cltl + F keys, searching for key words about self treatment. Man, this really has been an eye opener. Jkyles I've asked the same question about the electroencepholgram as well. I've been told the company bills 95816 as part of brain training. Documentation is horrible. I use to freak out about how all of our notes have not been signed off on. I can only send so many emails and then I have to just let it go.
 
I've been told the company bills 95816 as part of brain training.
Click to expand...

OK, you can always submit a question to the MAC directly. However, I'm also wondering if the EEG would be covered by Medicare at all. What's brain training?
 
You must log in or register to reply here.
Top