Welcome to this series on billing errors. Over the next few weeks, we will bring you common issues we continue to see when working with medical practices large and small. The first “no-no” to explore is the uncredentialed provider. We use this term to mean any clinician (physician or non-physician practitioner [NPP] such as a nurse practitioner or physician’s assistant) who has not had his/her credentials verified and approved by a payor and is essentially, not a ‘participating provider.’ All payors require a credentialing and approval process, from Medicare and Medicaid to managed care plans; because these entities are heavily regulated, paying a non-credentialed provider for services can be problematic.
Why do uncredentialed providers get themselves in hot water? The first reason is they just don’t understand the rules. Many clinicians rely on the grapevine for their information instead of going to the source and embrace the adage, if everyone’s doing it, it must be right. Sometimes, though, the medical practice goes through creative gyrations to shoehorn the uncredentialed practitioner’s work into a reimbursable service – intentionally.
Let’s start with the understanding that every payor requires a practice to submit a medical claim/encounter that reflects the provider who actually rendered the service. Just like taking an exam for a friend is unethical, billing a claim under the name of Provider B when Provider A saw the patient is fraudulent. This can occur when a practice hires a clinician whose credentialing is still being processed, when the provider cannot be credentialed by a payor (for whatever reason), or when there is a financial advantage.
Medicare, for example, pays a lower rate when an NPP renders a service as compared to a physician. We’ve seen practices routinely bill NPP visits under the name of a physician, even having the physician co-sign the note to make it look legit. The only instance when this would be acceptable is when the physician collaborated with the NPP in seeing the patient, performed some part of the visit and otherwise actively supervised the encounter. This has nothing to do with the fact that most NPPs need a supervising physician; in that respect, the supervising physician has delineated a scope of practice for the NPP and is available for questions or issues. But if there was no physician involvement in the encounter, the practice cannot bill the NPP’s visit under the name of the physician.
Remember that especially with electronic medical records, every keystroke is tagged to a user and date/time-stamped. So, if indeed a physician collaborated on the encounter, he or she should document on the note exactly what was done and authenticate the entry.
The one exception to the above is “incident to” billing for Medicare beneficiaries where CMS will pay at 100% of the physician fee schedule even if an NPP sees the patient. An incident-to scenario is one where the physician has personally treated the patient for the particular medical problem and has established the diagnosis and treatment plan; in this case, the NPP is carrying out an order from the MD/DO while a physician (not necessarily the one who gave the order) is on the premises during the service. In addition, the physician who gave the order must still be involved in the patient’s medical care, as evidenced by medical record entries. In this case, the practice would bill under the physician’s NPI and receive 100% payment.
Read the next installment in our Billing No-Nos series: Careless eligibility checks.