Page 1 of 2 12 LastLast
Results 1 to 10 of 11

Legal question

  1. #1
    Post Legal question
    Medical Coding Books
    Hello I am looking for some advise...I have a new doctor that is a surgeon and has told me that the NCCI edits do not apply to him because he is Not contracted with any insurance company at the moment. I have stressed the need and value to having the edits available in his billing program. He is having me work on claims and submit how he wants them submitted, with like 15 codes for everything Done during surgery..unbundling several procedure codes. I have documented my conversations with him..I own my own billing company and recently became certified. Is there something else I can do to protect myself if and when he does get audited and he is requested to refund monies that he already paid me for the work that I did? (My percentage agreement)?
    Any legal advise would be very helpful. Thank you!

  2. #2
    Default
    From the American College of Emergency Physicians (ACEP) FAQ page:

    "Private payers use a combination of NCCI/CCI edits and proprietary edits to determine ?covered services? in accordance with payer benefit plans. Payer payment policies frequently draw from CPT, NCCI/CCI and Medicare as well as applying payer-specific proprietary edits. Thus, NCCI/CCI may be used by private payers in some form, but often NCCI/CCI is only one of a number of tools utilized by private payers to determine separately covered services."

    http://www.acep.org/content.aspx?id=48111

  3. Smile Legal question
    Although he is not a contracted physician, he might still be subject to the false claims act if he submits a claim for a Medicare patient. Unbundling procedures for payment comes under the False Claims Act. To protect your company, you might want to contact the OIG or a medical attorney. You want to be sure that every claim your company files is both accurate and in compliance.

  4. #4
    Location
    Austin, Texas
    Posts
    467
    Default
    Just because he is not contracted does not mean the carriers won't process like they always do, and they will deny claims that are unbundled just like a contracted provider. They will also looks at his claims with them if he does want to become contracted and may not contract with him due to excessive charges/codes.
    Marcus Murphy, CPPM

  5. #5
    Default
    Thank you!

  6. #6
    Default
    Quote Originally Posted by Bready View Post
    Although he is not a contracted physician, he might still be subject to the false claims act if he submits a claim for a Medicare patient. Unbundling procedures for payment comes under the False Claims Act. To protect your company, you might want to contact the OIG or a medical attorney. You want to be sure that every claim your company files is both accurate and in compliance.
    is there a specific link to OIG? it seems the doctor is willing to put something in writing, stating he was given information on how claims should be filed, using ncci edits, and that he is making the final decision on how claims should be filed..but, does this still make me liable? knowingly billing out claims that have cpt codes that are 'unbundled'?

  7. #7
    Location
    Columbia, MO
    Posts
    12,913
    Default
    Yes it does! To do something you know is incorrect just because you were directed to do it is still wrong and you are still liable. You cannot sign away liability and no one can take it for you.

    Debra A. Mitchell, MSPH, CPC-H

  8. Exclamation Legal Question
    Debra is correct. There is always the possibility that you could be held responsible for filing claims that you knew to be incorrect regardless of anything you have in writing from him.

    Marcus is correct in that the insurance companies (who employ coders)will process the claims for payment according to the correct guidelines regardless if the provider is contracted or not. Once in awhile the provider may be paid for a procedure that was unbundled, but during an audit this will be found and refund requested from the provider.

    OIG can be found at www.oig.hhs.gov

    All the best.
    see it own it solve it do it

  9. #9
    Default
    Contracted or not the guidelines are still the guidelines.

  10. #10
    Default
    Quote Originally Posted by mitchellde View Post
    Yes it does! To do something you know is incorrect just because you were directed to do it is still wrong and you are still liable. You cannot sign away liability and no one can take it for you.
    I truly appreciate the information. I will be having a conversation with this doctor and I likely doubt he will want to keep me signed on to his practice.
    Thank you all.

Page 1 of 2 12 LastLast

Similar Threads

  1. Legal\Ethical Question re: Urine Toxicology Testing
    By Despe in forum Compliance General Discussion
    Replies: 1
    Last Post: 09-26-2015, 07:28 AM
  2. Ethical\Legal Question re: Toxicology Billing
    By Despe in forum Billing/Reimbursement
    Replies: 0
    Last Post: 09-23-2015, 11:03 AM
  3. Legal Question
    By klp010102 in forum Auditing General Discussion
    Replies: 14
    Last Post: 05-22-2014, 11:56 AM
  4. Legal question
    By kparkhurst in forum Auditing General Discussion
    Replies: 2
    Last Post: 04-29-2010, 10:51 AM
  5. Legal Question
    By medcode12 in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 10-09-2008, 09:33 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.