In a group practice situation where a provider is not credentialed by an insurance company and does not wish to bill as an "out of network" provider, is it acceptable for another provider to "supervise" the non-credentialed provider and to bill under the supervising provider's id number?
There are multiple components to this question, but our answer is limited to the Billing and Legal Perspective, which follow:
Billing Perspective - Bert Lurch, President of E Central Medical Management explains that from the billing standpoint each insurer has different policies, and therefore in some instances, a practice may get paid if a “supervising” provider bills for the service. More specifically, some plans will process a claim without the rendering provider’s information on the claim; such a claim could be billed and paid with only the billing provider information. Other plans will pay claims with the group NPI information as the rendering provider. Conversely, a plan may process a claim in-network if the plan’s systems are capable of cross-walking the participating billing provider’s NPI to the non-participating rendering provider. In other instances, if a non-participating rendering provider is listed on the claim anywhere, the claim will be paid out of network as these plans do not recognize groups as participating providers. http://www.ecmmgt.com. To contact Bert with any billing or credentialing questions call (718) 525-8567 or email Bertl@ecmmgt.com.
Legal Perspective - While the above described claims may be paid, you may be committing insurance fraud by knowingly or intentionally submitting false or misleading claims.
The first cause for concern as to why the claims may be false or misleading is that a participating provider’s billing practices are governed by contract. If you have agreed to participate with an insurer, then you have likely entered into a written contract with the insurer that establishes requirements for, amongst other things, how you should bill and what your reimbursement will be for rendering services to the insurer’s insureds. Theoretically, in exchange, your practice will benefit from referrals from the insurer. The above question contemplates involving an additional practitioner in treatment for “supervisory” purposes, presumably, only to manipulate billing. Such activity, while seemingly harmless, is tantamount to insurance fraud. Only practitioners actually involved in treatment should be reflected on medical or billing documentation.
Additionally, licensure exposure may lie with the treating and the “supervising” physician for representing “services” performed, when in fact no services were rendered. Also, to add another log on the fire, if such activity were interpreted as tantamount to fraud, or viewed as intentional, you may be in breach of your participating provider contract, and also, viewed as tortiously interfering with the insured’s contract with the insurer – both actionable. Let’s also not forget our favorite risk: Audits! Remember: You are the captain of your own ship, which means, you are responsible for all services you provide and you or your practice bill on your behalf.