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Need to report fraud, need some guidance

  1. Default
    Medical Coding Books
    I have some experience addressing some of the legal issues arising in situations such as the one you describe. Feel free to contact me (all communication kept strictly confidential) if you would like. Thanks--

    jmarkey@bm.net

  2. Default
    I am not sure what State your doctor is located or the type of patients, i.e., tranditional Medicaid, Medicare, or managed care, they serve. In NY, under Medicaid (not managed care Medicaid), the supervising physician needs not be in the same office or location and they can supervise up to three PA/NP and can bill under the supervising physician's name, however, the PAs/NPs must not be registered with Medicaid to bill under their own ID (waive the right to bill). By this account, you can see that different rule exists depending on the type of beneficiaries. So, check your local guidelines in addition to Medicare guidelines.

  3. #13
    Default
    Well put Michael. Cudos to you.

    Incident To services are on the OIG's work list this year. So it's not a matter of "if" they look. They "are" looking.
    My first job in this field was with a rather shady company. Luckily I got out unharmed. The owner is in jail, has been for the last couple of years now. I think he still has a few more to go.

    What does the overall operation where you work look like?
    Getting a lot of collection calls from vendors? Renting a lot of equipment?
    Running outdated software on old computers?
    Last edited by Peter Davidyock; 01-20-2012 at 05:12 PM. Reason: Correcting 5am mis-spellings

  4. #14
    Default
    This thread is very interesting. I'm reading Himgirl response stating that she spoke with the billing manager. The billing manager replies with the doc can get in trouble. I haven't heard a response to what she should do next?

    I noticed that some responses, justify that you can bill under doc regardless if they was present at time of visit for certain carriers. Really???

  5. #15
    Lightbulb
    In Texas, a PA can perform services without the presence of the supervising physician. PA is the "rendering" in box 24J of CMS-1500 and bills under the physician in box 31. The supervising physician could be providing services at another clinic (we have 5) on the other side of town, at same time/day as the PA.

    Texas Occupational Code and Texas Medical Board set the rules for physician/PA relationship and delegation of work to the PA. As long as the supervising physician is following those rules, it's perfectly legal.

    Don't know what state you're in but it stands to reason that you should also familiarize yourself with your state's guidelines before jumping to any conclusions.
    Susan M. Garrett, CPC, COC
    Past President El Paso Texas Chapter AAPC
    Past Member AAPCCA Board of Directors
    cell 915-204-8333

  6. #16
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Not to butt in here but.... When the Pa uses his NPI number in 24J then he is billing under himself and not the physician, and yes every state will allow the PA to do this and the physician must be reachable within a certain restriction which varies. What most on this post are referring to is using the physician NPI in 24 J as the rendering when the physician did not render nor was on site to supervise. This you cannot do.

    Debra A. Mitchell, MSPH, CPC-H

  7. #17
    Default
    Some commercial payers will allow it PA's to bill as their supervising MD, as long as the charges are appended with a modifier to indicate that the services were actually performed by an NPP (SA modifier). They won't allow you to get around the fee reduction for NPP's, though - one way or another, you have to let them know it wasn't the doctor. (Check your provider manuals for payer policies on NPP billing)

    Don't bill Medicare under the MD if the MD's not in the same building at the time, though - it doesn't meet incident-to requirements, and the issue is chronically on the OIG's hit list.

  8. #18
    Default
    Quote Originally Posted by mitchellde View Post
    Not to butt in here but.... When the Pa uses his NPI number in 24J then he is billing under himself and not the physician, and yes every state will allow the PA to do this and the physician must be reachable within a certain restriction which varies. What most on this post are referring to is using the physician NPI in 24 J as the rendering when the physician did not render nor was on site to supervise. This you cannot do.
    My mistake was box 31... should be box 33. 24 J is "rendering" provider but 24J doesn't make that provider the "billing" provider. The info in box 33 drives who's billing. In my case, the group name and NPI.
    Susan M. Garrett, CPC, COC
    Past President El Paso Texas Chapter AAPC
    Past Member AAPCCA Board of Directors
    cell 915-204-8333

  9. #19
    Location
    Columbia, MO
    Posts
    12,531
    Default
    box 24J which matches the signature on 31 is the NPI of the one rendering or supervising the service, 33 is the practice the provider is credentialed with. So when you use the physician NPI in 24J instead of the PA then you are "billing the claim under the physician" representing the physician as the provider/supervisor of the service.

    Debra A. Mitchell, MSPH, CPC-H

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