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Documentation for billing under a provider?

  1. #1
    Default Documentation for billing under a provider?
    Medical Coding Books
    I have an issue here at my Physical Therapy office where we saw an HMO patient when we should not have because we did not participate. My Orthopaedic Surgeons did not see this patient as he was an outside physician referral. The previous staff billed this under my PT and the claims were denied as non authorized which was correct since we were not participating. They now want to put my doctors name on the claim and resubmit a corrected claim. Can anyone help me find documentation to show them that in billing this "corrected" claim, we are committing fraud? Since this patient was and is not under the care of our doctors, we can't knowingly bill this with their name on it, can we?? HELP!!!

  2. #2
    I think you might be going about this backwards.

    If the incident to requirements were not met, which it doesn't sound like they were, and the provider didn't see the patient....

    Exactly where are they coming from on this? I would make them provide documentation showing that they can bill it under the ortho in this situation.

    Otherwise it should stay as is and they will just have to take the loss in revenue.

    You can also find cases on the OIG website under enforcement actions where out of network providers billed under in network providers to get paid and got busted.

    Good luck,

    Laura, CPC

  3. #3
    Thanks for your help. I'm new to this particular practice and I'm just so confused by the way some things are done! I agree we'll have to take the loss but they want me to show documentation that they can't bill this way. I'll look again on the OIG website.
    Thanks again,
    AJ, CPC

  4. #4
    Here is a link to an OIG page

    but this is what I think is most pertinent for your situation.

    "Medicare allows physicians to submit claims for physical therapy that they do not perform personally, as long as the services are an “integral, although incidental, part of the physicians' personal professional services in the course of diagnosis or treatment of an injury or illness.”2

    Seeing as how your provider never treated this patient the care would not qualify based on this statement.

    Laura, CPC

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