Wiki Legality of Signature of Non-present Provider

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TenaWright

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I have a provider who wants ALL visits in his hospital outpatient clinic registered under his name, regardless of who the patient actually sees. The visit documentation always has his signature appended, whether or not he actually physically attended the visit. Here is an example scenario:

Patient is registered under MD.
Patient arrives at visit and is actually seen by PA/NP.
Visit is documented solely by PA/NP.
Registration remains under MD.
Signature of PA/NP in addition to signature of MD is appended.
Claims processed under PA/NP.

Is this a problem and what are the ramifications with regard to insurance and compliance with the law?

Thank you for any information you can provide.
 
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It depends. There are billing/claims guidelines and rules but there could also be state rules and practice policy for co-signing everything by an NPP also. When you say registered under his name, what do you mean? Is he co-signing as the supervisor of the NPP as reviewing the note and plan, etc? Is the claim going out under the name of the NPP? It is not wrong for a supervising physician to review and co-sign NPP notes or for the patient to be "registered" (again not exactly sure what this means to you) under the physician. The claim billing has to follow correct practices for incident-to if outpatient and depending on the payer. Your practice or group compliance officer or committee should have a policy about co-signatures and NPPs. State practice rules also have rules about new NPPs and supervision.

There are a multitude of posts and published guidelines from CMS about incident-to billing, you can also search the forums here.
 
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amyjph said:
It depends. There are billing/claims guidelines and rules but there could also be state rules and practice policy for co-signing everything by an NPP also. When you say registered under his name, what do you mean? Is he co-signing as the supervisor of the NPP as reviewing the note and plan, etc? Is the claim going out under the name of the NPP? It is not wrong for a supervising physician to review and co-sign NPP notes or for the patient to be "registered" (again not exactly sure what this means to you) under the physician. The claim billing has to follow correct practices for incident-to if outpatient and depending on the payer. Your practice or group compliance officer or committee should have a policy about co-signatures and NPPs. State practice rules also have rules about new NPPs and supervision.

There are a multitude of posts and published guidelines from CMS about incident-to billing, you can also search the forums here.
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I very much appreciate your response. We are currently working with the provider to delineate his role regarding the "incident to" situation. I feel confident that we have the subject fully researched.

The portion where we lack understanding is when signatures from both the NPP and the MD are included on the document even when the NPP is clearly acting of their own accord, without an established plan of care or under supervision (as defined) of the MD. I have reviewed state guidelines, the Federal Register, CMS publications, AAPC published articles, local NCD/LCD, and now this forum. I have been unable to find any guidance preventing or disallowing the MD to sign the visit, indeed even the Federal Register is vague on this point seemingly indicating that HIPAA did not outline signature rules to that level of specificity. I will consult further with our Compliance officer.

For clarity, our facility is an RHC and the services are being provided in an outpatient clinic.

When speaking of the patient being "registered" to the MD as opposed to the NPP:
For this provider, ALL clinic visits are registered under his name whether or not he actually sees the patient. When a patient arrives at their appointment, believing they will be seen by the MD, they are instead informed the MD is not available and they will be seeing the NPP. The registered provider at the visit is not changed and it therefore appears in our EMR that the visit was attended by the MD instead of the NPP. The NPP will sign off on their documentation, then the MD will also sign - this is his only contribution to the visit documentation. There is no accompanying statement of his participation or review, simply his signature. In these situations, the claim is sent under the name of the NPP even though the MD signature has been added.

I am concerned this is not an appropriate representation of the visit and may not comply with Medicare Integrity guidelines, which indicates the signature on the document should represent the person who was primarily responsible for the care of the patient. Even though the NPP signature is there, the MD has claimed some responsibility for the visit just by adding his signature. I worry that it may appear the MD is attempting to get full reimbursement as opposed to the reduced reimbursement for the NPP.

We currently are processing the accounts in such a way that removes the signature of the MD; we may not need to do this if the signature isn't causing a problem just by existing on the document. I wanted to get another opinion from outside my organization and I again thank you for your response. I hope that you can also provide some further insight into the above.
 
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This sounds like an internal way for the doctor to get more credit than what they are actually doing. If the PA/NP saw the patient and the bill is being sent to insurance under the name of the PA/NP then why is the MD signing? Internal stats? Why would the doc want to sign a note for a patient that they did not see/treat?
 
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I agree, I think there is more going on here than we can really discuss on this forum. Do you have a compliance committee or officer? Is there some sort of internal RVU or pay for production method? I have seen practices where a NPP is directly paid by the supervisor and that supervisor did not want the NPP helping any other provider or any other provider's name associated. I don't know a whole lot about RHC so maybe there is some reason for it? Can incident-to even be done in a RHC?

Is it possible the provider is using this guidance? Whether or not they need to depending on your praticular practice? https://www.cms.gov/files/document/appendix-g-state-operations-manual
Interpretative Guidelines § 491.8(b)(3) & (c)(1)(ii) A physician must review periodically the RHC’s patient clinical records. In States where State law requires a collaborating physician to review medical records, co-sign medical records, or both for outpatients whose care is managed by a non-physician practitioner, an RHC physician must review and sign all such records.

As long as the biling and payment part is correct, I really don't think there's a problem if the record clearly shows who actually saw and examined the patient even if the NPP & MD both sign.

Forgot to add - may be more of a practice attorney/legal question.
 
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amyjph said:
I agree, I think there is more going on here than we can really discuss on this forum. Do you have a compliance committee or officer? Is there some sort of internal RVU or pay for production method? I have seen practices where a NPP is directly paid by the supervisor and that supervisor did not want the NPP helping any other provider or any other provider's name associated. I don't know a whole lot about RHC so maybe there is some reason for it? Can incident-to even be done in a RHC?

Is it possible the provider is using this guidance? Whether or not they need to depending on your praticular practice? https://www.cms.gov/files/document/appendix-g-state-operations-manual
Interpretative Guidelines § 491.8(b)(3) & (c)(1)(ii) A physician must review periodically the RHC’s patient clinical records. In States where State law requires a collaborating physician to review medical records, co-sign medical records, or both for outpatients whose care is managed by a non-physician practitioner, an RHC physician must review and sign all such records.

As long as the biling and payment part is correct, I really don't think there's a problem if the record clearly shows who actually saw and examined the patient even if the NPP & MD both sign.

Forgot to add - may be more of a practice attorney/legal question.
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Orthocoderpgu said:
This sounds like an internal way for the doctor to get more credit than what they are actually doing. If the PA/NP saw the patient and the bill is being sent to insurance under the name of the PA/NP then why is the MD signing? Internal stats? Why would the doc want to sign a note for a patient that they did not see/treat?
Click to expand...

Yes, there is MUCH more to this issue than can be fully described or solved here.

Incident-to can be performed in RHC per our MAC, but guidelines are SO strict I would not choose to bill this way if it were my practice!

At this point, I'm certainly headed for my Compliance officer to further discuss.
Thank you so very kindly for your input.
 
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