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Help, I think my company is committing billing fraud

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#1 cmkrmc



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Posted 17 February 2017 - 03:21 PM

So for starts, I am an NP not a PA  but the details I think would be the same.


Background: I work at a clinic with no onsite physician, ever.  The second clinic has an MD on site, and is about 15 minutes away.



Situation:  We use ECW, everything is set so that the Pay to, Rendering and Supervising is set to one of the MDs, with the incident-to box not checked.  Now I don't know how to see what is sent electronically, but when I view the 1500 form, they all have the MD as the referring physician, and IF NPI numbers are on the form, it is only his in the rendering field (24J).  Sometimes the only NPI number is the Business NPI in boxes 32a and 33a.  Sometimes, no NPI number is on the form at all.


Now, I have no billing training at all, but it looks to me as if they are billing these as if he is seeing the patients or somehow the business is seeing the patients.  I can't believe if I am the sole provider in the clinic, my NPI number shouldn't be on the forms somewhere.  It also does not look like their is a 15% reduction in fees, which would show if they were billing me as the primary.


This has me freaked out, so any help, suggestions etc. are welcomed.  If it is fraud, I am reporting it immediately, as I do not want to lose my right to practice over their illegal activity.

#2 BruceBanner



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Posted 17 February 2017 - 04:24 PM

I'm not a billing expert either, but that does sound suspect to me. Very suspect.


I would just make certain there is fraud happening before reporting it....and even then think very carefully about opening that can of worms.


#3 ventana


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Posted 17 February 2017 - 09:25 PM

If you have been there for a few years and you treat Medicare patients, go look up your billing data on the medicare web site.

If the doc is not on site and immediately available it MUST be billed under you for any new problems - if it is truly incident to then you might be able to bill under the doc....

If you are not even listed on the medicare site as having gotten paid by medicare then that is your answer

If you report them then you will be a federal whistleblower and afforded some protections and might get some money out of it - But you will loose you job and likely be blackballed.....

The Fine Print - you didn't pay for my advice so please consider this when reading it. I don't care about typos so don't tell me I can't type.:eek:

I vote for a  Full Practice Authority and staged independent practice.




#4 knitpurl



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Posted 05 March 2017 - 02:04 AM

See my post on this exact topic...

http://www.physician...+billing +fraud

It's fairly easy to self-train on incident-to guidelines. And don't worry because I think no one at all from my PA class got any training on this topic whatsoever. Just Google "Medicare incident-to".

The first and foremost requirement for incident-to billing is that your physician is physically in the office suite (not even in a different room of the same building) to qualify to bill it under their name. It sounds to me like NONE of your encounters should qualify for incident-to.

Each private insurance has their own incident-to billing requirements. An office manager should be a resource in helping you sort that out (mine was). Some of them do not allow incident-to billing at all, therefore everything goes under your NPI.

I would approach your manager and ask for clarification on whose NPI your encounters are billed under and then be prepared to show them a copy of the incident-to criteria for Medicare, and other insurances if you can find that information. But be warned, I got fired over this. But then again, my doctor was a controlling a******.

#5 CJAdmission



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Posted 05 March 2017 - 08:53 PM

But be warned, I got fired over this. But then again, my doctor was a controlling a******.

Being fired is sometimes a great blessing.

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