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Thread: Billing All Mid-Level Providers Under the DOC

  1. #1

    Default Billing All Mid-Level Providers Under the DOC

    This may sound like a ridiculous question to some of you, but this has become a dilema with my organization and I need guidance, please.

    In terms of billing, I understand that there are some payers out there that will not credential or recongize a mid-level provider and in order to report those services we have to bill under the supervising physican and append the modifier SA so the payer will process the claim correctly and the carrier will reimburse at the correct level (usually 85%). Now the problem, my organization is asking if we can apply this methodology to all mid-level providers. Meaning can we bill all mid-level providers under the supervising physican and append the SA modifier across the board, or do would we open ourselves up to potential denials? Legalities? We do understand that Medicare does not accept the SA modifier. My understanding of the reimbursement process is that if the provider is credentialed with the payer and has his/her own number, you are to bill that provider under his/her own number.

    So, can anyone advise me on this issue, please? I think we can't do this across the board, but I am getting pushback. All thoughts appreciated.
    Last edited by dballard2004; 08-26-2011 at 02:33 PM.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2
    Join Date
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    Quote Originally Posted by dballard2004 View Post
    This may sound like a ridiculous question to some of you, but this has become a dilema with my organization and I need guidance, please.

    In terms of billing, I understand that there are some payers out there that will not credential or recongize a mid-level provider and in order to report those services we have to bill under the supervising physican and append the modifier SA so the payer will process the claim correctly and the carrier will reimburse at the correct level (usually 85%). Now the problem, my organization is asking if we can apply this methodology to all mid-level providers. Meaning can we bill all mid-level providers under the supervising physican and append the SA modifier across the board, or do would we open ourselves up to potential denials? Legalities? We do understand that Medicare does not accept the SA modifier. My understanding of the reimbursement process is that if the provider is credentialed with the payer and has his/her own number, you are to bill that provider under his/her own number.

    So, can anyone advise me on this issue, please? I think we can't do this across the board, but I am getting pushback. All thoughts appreciated.
    I believe that you can, because they are considered an employee of the physician. It's not considered pass-through billing, in that situation, but you should still check with your major payors individually to make sure they don't have any other criteria that has to be satisfied, or any restrictions. It's a better practice to bill them under their own info, though, when possible - if you're dependent on the SA modifier, what do you plan to do with patients who are double covered, with Medicare as a secondary payor? How about the ones who 'forget' to give you their COB information until after you've submitted a claim? Also, it does add a degree of liability to the supervising physician, since their name gets attached to everything that goes out the door. More claims means more chances for errors, and a higher probability of becoming the target of an audit. Even if you've got no reason to be concerned, why expose yourself to the hassle?

  3. #3
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    Default Billing All Mid-Level Providers Under the DOC

    Duble check with your reps and send out a few samples

  4. #4
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    You may want to check this out, too: http://www.physiciansnews.com/2010/0...iability-risk/

  5. #5

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    My thanks to both of you! This is very helpful!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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