PAs seeing Medicare patients

[Guest Krissy]

I am a derm PA in North Carolina. It was recently suggested to me by one of my nurses that I cannot see any Medicare patients under any circumstances unless my supervising physician was in the office. It was my understanding that I could see new and established new problem Medicare patients without SP present as long as it billed under my UPIN and Medicare number which would pay 85% of the physician charge. I understand that in order to bill 100% incident-to that the SP must indeed be in the office. Can anyone comment on this?

thanks!

[jer_sd]

You have it correct, now is the office only billing incident to to capture the higher reinbursement if so that could be where that idea came from. But more likley the nurse is just confused on the facts.

 

Jeremy

[Guest Krissy]

Well, our SP is trying to "get rid of" this nurse and another nurse because they are the highest paid in the office. The SP has been fabricating bogus charges against them and has even suspended them. It is a mess. I am thinking that she (the nurse) is trying to find something that she can use to report him and get him in trouble or close him down. Now as far as I know the billing is being done correctly and legally..........

But hypothetically.....would a PA be personally/legally responsible if his/her SP is billing incident-to/100% (without the PA's knowledge) when in fact they should have been billing under the PA/85% ??

Thanks in advance for everyone's advice!!

[ajnelson]

unfortunately we (and this includes both PAs and docs) are responsible for what our and how our billers charge, even if we are not involved in the billing process at all. So if the billing to medicare has been done wrong all along, both you and your SP and the biller will be responsible.

[Guest Krissy]

oh goodness....I was under the impression that fraud is the INTENTIONAL and DELIBERATE use of deception for personal gain. Anyone else have any opinions or knowledge on this topic? Fortunately, I think my SP has been billing correctly.

[bradtPA]

oh goodness....I was under the impression that fraud is the INTENTIONAL and DELIBERATE use of deception for personal gain. Anyone else have any opinions or knowledge on this topic? Fortunately, I think my SP has been billing correctly.

 

With medicare, you can also get into trouble for underbilling. There doesn't need to be fraud in that case, just bad billing.....

[ssiegelpa]

I was actually wondering the same thing, because I am not sure if my office is billing correctly. I think that everything that I bill for, is being sent out under my SP NPI number even though I have my own NPI. Where can I find out more information about billing for PAs? Thank you for letting me know, I will make sure to get the our billings director to ensure that they are doing the proper billing for me.

[jmj11]

I don't know if the nurse is smart enough to know this, but there is the Qui Tam law. This is the so called whistle-blowers law. If you report and testify regarding any overcharging of a government entity, then you can sue them on behalf of the government. You can personally collect three times the amount of the "fraud" or over billing. If billing "mistakes" have gone on long enough, this personal windfall can be in the millions.

[bradtPA]

Speaking of billing, I think the article in this link is a good read for those of us that get confused with coding....

http://www.medscape.com/viewarticle/463192_1

[Noreaster]

I am a derm PA in North Carolina. It was recently suggested to me by one of my nurses that I cannot see any Medicare patients under any circumstances unless my supervising physician was in the office. It was my understanding that I could see new and established new problem Medicare patients without SP present as long as it billed under my UPIN and Medicare number which would pay 85% of the physician charge. I understand that in order to bill 100% incident-to that the SP must indeed be in the office. Can anyone comment on this?

thanks!

 

I have gotten this same thing by excitable OMs in the past. As you guys have established, yes, you can see new Medicare patients but you should bill direct and not incident to.

 

A company I was working for was putting in for incident to and billing at 100%, even though I was checking off on the fee ticket direct. I found out about it and was frank with them and told them that I will not part-take in fraud and they were like, wahtta mean, fraud? When I held to my guns, they continued to be stubborn and didn't believe me, when I tried to tell them the rules. Finally, some imature person went to the CEO of the comany and asked him what to do. In his wisdom, he asked questions before giving an answer. After he found some things out, he give strict direction to bill correctly and to take the 85% and that it would be far less costly do do this than later run into huge fines.

 

I still have to advocate for doing the right thing. Greed is a funny thing; our nation is feeling the effects of greed right now...

[ssiegelpa]

Not sure if I am going off topic a little bit. But, I am still learning all this billing stuff.

 

When billing private insurance (BCBS, Aetna, United, etc...) do you have to bill out under the PA NPI for new patients and established patients with new problems, the same way you do with Medicare, or can they be billed out under the SP NPI? Also, if billed out under the PA NPI is the reimbursement 85% like it is with Medicare?

Thanks.

[coloradopa]

Not sure if I am going off topic a little bit. But, I am still learning all this billing stuff.

 

When billing private insurance (BCBS, Aetna, United, etc...) do you have to bill out under the PA NPI for new patients and established patients with new problems, the same way you do with Medicare, or can they be billed out under the SP NPI? Also, if billed out under the PA NPI is the reimbursement 85% like it is with Medicare?

Thanks.

It depends on the insurance company. Most insurance companies do not credential PAs. Therefore their direction is to bill under the physicians NPI. The few that do credential pay a variable percentage (65-100%) depending on the contract. Unlike Medicare the payment is negotiable. There is no incident-to billing for private insurance.

 

David Carpenter, PA-C

[BlocDoc]

Last I heard (and it has been at least 5 years) the OIG has oversight on issues regarding billing compliance- They charge at a rate of $7000 per proven fraudulent charge. Every office should have a compliance plan.

 

I am personally credentialed by a number of private insurers- For all, we bill under my NPI- I must have physician oversight for Workers Comp, Aetna, Medicaid and auto (Act 6), Champus, Humana and a few others- For the rest, we receive 85% of the rates that we negotiated.

 

Here is more on the subject-

 

http://www.wikihow.com/Implement-a-Medical-Billing-Compliance-Program

 

and here:

 

http://www.oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf

[BlocDoc]

Here is a summary- The fees are higher than I quoted!

 

 

I. Federal Laws

 

 

• False Claims Act (31 USC §§3729-3733)
  

The False Claims Act ("FCA") provides, in pertinent part, that: (a) Any person who (1) knowingly presents, or causes to be presented, to an officer or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval; (2) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government; (3) conspires to defraud the Government by getting a false or fraudulent claim paid or approved by the Government; or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government, is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person (b) For purposes of this section, the terms "knowing" and "knowingly" mean that a person, with respect to information (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required. 31 U.S.C. § 3729. While the False Claims Act imposes liability only when the claimant acts "knowingly," it does not require that the person submitting the claim have actual knowledge that the claim is false. A person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information, also can be found liable under the Act. 31 U.S.C. 3729(b).

In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false. An example may be a physician who submits a bill to Medicare for medical services she knows she has not provided. The False Claims Act also imposes liability on an individual who may knowingly submit a false record in order to obtain payment from the government. An example of this may include a government contractor who submits records that he knows (or should know) is false and that indicate compliance with certain contractual or regulatory requirements. The third area of liability includes those instances in which someone may obtain money from the federal government to which he may not be entitled, and then uses false statements or records in order to retain the money. An example of this so-called "reverse false claim" may include a hospital who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare program. In addition to its substantive provisions, the FCA provides that private parties may bring an action on behalf of the United States. 31 U.S.C. 3730 (b). These private parties, known as "qui tam relators," may share in a percentage of the proceeds from an FCA action or settlement. Section 3730(d)(1) of the FCA provides, with some exceptions, that a qui tam relator, when the Government has intervened in the lawsuit, shall receive at least 15 percent but not more than 25percent of the proceeds of the FCA action depending upon the extent to which the relator substantially contributed to the prosecution of the action. When the Government does not intervene, section 3730(d)(2) provides that the relator shall receive an amount that the court decides is reasonable and shall be not less than 25 percent and not more than 30 percent.

[akendall]

Ive been reading these links, and am realizing just how naive I've been as a relatively new graduate. I wish I was taught the ins and outs of this stuff in school. What would one recommend for myself, as someone that has been working in a urgent/internal med clinic for 1 year, and the billing department has been submitting under the physician's NPI number for medicare patients (when Im the only person having patient contact)? Do I need to worry, do I need to come clean with someone, should forget it and hope for the best, or do I need a lawyer? What would you say? The last thing I need is trouble. Im leaving this job in a matter of months anyways. Thoughts?