Rampant billing fraud with PAs and NPs

[Gordon, PA-C]

I encourage everyone to study your billing arrangements carefully.

It is a fact that many/most clinics in this country that have PAs or NPs working under a physician are committing fraud.

Medicare pays 85% of the physician fee schedule to PAs or NPs who are billing under their own NPI.  So many clinics will have the NPs or PAs bill under the physician's NPI to get 100% reimbursement.

That is totally fine, ASSUMING you follow the "incident-to" billing rules:

1.  Must be in a non-hospital setting

2.  Can't bill for the first visit.

3.  Can't bill for a visit with a new problem.

4.  Physician must be immediately available in the same clinic during the visit.

I would bet that there are thousands and thousands of clinics out there who are not following the rules and are billing under the physician NPI even though the PA was the only person to see the patient or do any kind of workup/treatment.

You guys need to check with your billing departments, because there's a reckoning coming.  CMS is starting to flag diagnosis codes and send out the feds to clinic sites.  For example, if the patient has a total of 3 visits and all the charts are signed by the PA with no MD signature (assuming all visits are billed under physician NPI), they are going to get audited and lose many thousands of dollars.

[mgriffiths]

My collaborating physician signs 100% of my charts, simply for billing purposes.  It was our understanding that reviewing/signing chart could help in recouping that "lost" 15%.  Supposedly there is a threshold that has to be met to get full 100% billing, but he just signs all as it's easier than calculating the number of charts to co-sign and then counting.

[waky02]

Hmm you mean he is signing charts on pt's that he has never seen?

failure to follow "incidence to" to the letter can bite them very hard "clawbacks and all", might even have whistleblower properties 

 

[katieo]

I saw this when I was shadowing and I wondered about the ethics. It seemed a little questionable but the PA was so confident and open about it.

[wdtpac]

For incident to services, the physician MUST also see the patient physically AND have a meaningful contribution to the direction of care. 

[ventana]

more reasons why we need to not be "dependent" employees

 

also why we should be able to direct bill

 

 

 

Incident to needs to go away!!

 

[SedRate]

On 4/30/2018 at 4:42 PM, mgriffiths said:

My collaborating physician signs 100% of my charts, simply for billing purposes.  It was our understanding that reviewing/signing chart could help in recouping that "lost" 15%.  Supposedly there is a threshold that has to be met to get full 100% billing, but he just signs all as it's easier than calculating the number of charts to co-sign and then counting.

You need to discuss this with your SP and billing department. It doesn't sound like you are meeting all of the criteria and therefore billing fraudulently. 

[sas5814]

and let me add the billing is being done in your name or on your work you can't shrug and say "I didn't know" even if you didn't. You have responsibility for what is being billed for your work. 

I had this discussion here in my giant corporation when we, in the UC, were told that they expected 75% of our visits to be level 4. I pointed out they couldn't set targets like that as we take whatever walks in the door  and have no control over complexity and only the provider can assign the visit level for a reason. When they continued to push I asked for someone in admin to write that down and sign their name to it and distribute it throughout the system. *crickets chirping*

[True Anomaly]

3 hours ago, ventana said:

more reasons why we need to not be "dependent" employees

 

also why we should be able to direct bill

 

 

 

Incident to needs to go away!!

 

Agreed- another reason to support HR 5506 that will finally allow us to be directly reimbursed for our services

[Cideous]

Not going to put us all in jail.  We have so much stuff to worry about, how your company is billing for your services seems like a bridge to far.  Not to mention immediately being labeled a “trouble maker” and being let go.  I’ve seen it happen, specifically in a large UC chain.

I’m not discounting what your saying, just that I don’t see many following up with it.

[sas5814]

7 minutes ago, Cideous said:

Not going to put us all in jail.  We have so much stuff to worry about, how your company is billing for your services seems like a bridge to far.  Not to mention immediately being labeled a “trouble maker” and being let go.  I’ve seen it happen, specifically in a large UC chain.

I’m not discounting what your saying, just that I don’t see many following up with it.

Oh yea...don't think I haven't been marked by the organization but my soul isn't for sale. This organization yammers about being ethical alllllll the time so the hypocrisy couldn't be escaped . There is a difference between some passive semi-unaware participation and active participation in what could, by the wrong people, be construed as a conspiracy to over bill. Never say never. I worked for a hospital district that wasn't all that big that got a 12 million dollar fine for similar practices.

[aimhye]

I've been trying to research this very topic for some time because it came up at contract renewal when they said they couldn't (or wouldn't) provide my RVUs or any production numbers--although they thought that was a good idea and they were trying to come up with some way to capture that. :-).....(don't hold your breath). They said performance could be indirectly measured by overall profits of the clinic but salary was based on overall financial health of the company. I work for a multi facility non-profit and while clinics are separated by specialty they fall under one organization. While Medicare does have hefty fines for billing fraud, even if the billing was a mistake or done "unintentionally" by some unaware coder/biller, I agree with Cideous, they are not going to put "us" in jail, or hit "us" with a hefty fine because IF you are an employee of a large organization or hospital system your services are likely being billed under the umbrella NPI of that System (not your own or your SP) and payment is made using the organization's TIN. I still don't have a clear answer if that is the 100% correct method, but that is what my clinic manager keeps telling me, and apparently the manager's of the other 100+ PAs in the system. That is likely why, in your case SAS5814, the hospital district was fined 12 million dollars and not you personally. Although, if you know fraud exists then you have three choices, turn a blind eye, report it, or leave. If it's your NPI they are misusing, I'd say the latter two choices make the most sense--ASAP.

[sas5814]

Yea it is clear as mud. The provider is the only one who can set the visit level but the billing is done under an umbrella NPI or TIN. I'm all about  making the best buck possible but I'd be more comfortable with a conversation about improving documentation so we could capture every penny we are due than setting a hard target on visit levels.

 

Life is hard....

[Joelseff]

I work for a hospital based system and bill on my own NPI but have seen this at other clinics before. I always thought it was a little iffy

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[mgriffiths]

2 hours ago, waky02 said:

Hmm you mean he is signing charts on pt's that he has never seen?

failure to follow "incidence to" to the letter can bite them very hard "clawbacks and all", might even have whistleblower properties 

 

He cosigns the charts stating that he has reviewed them and agrees with the plan.  Nowhere is he stating that he physically saw the patient.  All billing is done under my NPI, or whatever ID they use for billing, but the last 15% is recouped by him reviewing over a certain percentage of my charts.  This is how it is done for every single "APP" in our practice and I am one of 21 "APPs."

[mgriffiths]

23 hours ago, wdtpac said:

For incident to services, the physician MUST also see the patient physically AND have a meaningful contribution to the direction of care. 

From what I have read this is not true.  The below was copied and pasted from "incident to" criteria:

"This does not mean that on each occasion of an incidental service performed by an NPP, that the patient must also see the physician."

The below is from an article published trying to clarify the mud:

"You do not have to be physically present in the treatment room while the service is being provided, but you must be present in the immediate office suite to render assistance if needed. If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise."

So I am confused why we think the physician must also physically see the patient?

You are correct thought that the physician must see the patient for the first visit.

[SedRate]

This website outlines the Medicare rules for incident to billing and reporting: http://www.physicianspractice.com/coding/medical-practices-guide-incident-billing

[Marinejiujitsu]

This is why as a MD I would hire an NP. So many reasons, billing, no signing of charts, less liability. Of course, NPs are jacking us up getting a lot of jobs.

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[Gordon, PA-C]

14 minutes ago, Marinejiujitsu said:

This is why as a MD I would hire an NP. So many reasons, billing, no signing of charts, less liability. Of course, NPs are jacking us up getting a lot of jobs.

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Hiring an NP doesn't fix this issue.  NPs only get 85% of Medicare fee schedule if they bill under their own NPI.  So far the nursing lobby has been unsuccessful in getting "pay parity" for Medicare.

PAs and NPs are in the same boat when dealing with "incident-to" billing issues.

[jmj11]

On 4/30/2018 at 4:25 PM, Gordon, PA-C said:

I encourage everyone to study your billing arrangements carefully.

It is a fact that many/most clinics in this country that have PAs or NPs working under a physician are committing fraud.

Medicare pays 85% of the physician fee schedule to PAs or NPs who are billing under their own NPI.  So many clinics will have the NPs or PAs bill under the physician's NPI to get 100% reimbursement.

That is totally fine, ASSUMING you follow the "incident-to" billing rules:

1.  Must be in a non-hospital setting

2.  Can't bill for the first visit.

3.  Can't bill for a visit with a new problem.

4.  Physician must be immediately available in the same clinic during the visit.

I would bet that there are thousands and thousands of clinics out there who are not following the rules and are billing under the physician NPI even though the PA was the only person to see the patient or do any kind of workup/treatment.

You guys need to check with your billing departments, because there's a reckoning coming.  CMS is starting to flag diagnosis codes and send out the feds to clinic sites.  For example, if the patient has a total of 3 visits and all the charts are signed by the PA with no MD signature (assuming all visits are billed under physician NPI), they are going to get audited and lose many thousands of dollars.

This is somewhat billing 101. Surely most clinics are not doing this. When I owned my own clinic, I followed the rules to the letter (usually billing at the 85%, rarely meeting the 100% requirement).

[lkth487]

On 5/2/2018 at 11:53 AM, sas5814 said:

and let me add the billing is being done in your name or on your work you can't shrug and say "I didn't know" even if you didn't. You have responsibility for what is being billed for your work. 

I had this discussion here in my giant corporation when we, in the UC, were told that they expected 75% of our visits to be level 4. I pointed out they couldn't set targets like that as we take whatever walks in the door  and have no control over complexity and only the provider can assign the visit level for a reason. When they continued to push I asked for someone in admin to write that down and sign their name to it and distribute it throughout the system. *crickets chirping*

Nice job asking them that in writing! 

[lkth487]

23 hours ago, Marinejiujitsu said:

This is why as a MD I would hire an NP. So many reasons, billing, no signing of charts, less liability. Of course, NPs are jacking us up getting a lot of jobs.

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Interestingly on the NP forums, a hot topic of discussion is always that they feel PAs get hired preferentially.

[EMEDPA]

2 hours ago, lkth487 said:

Interestingly on the NP forums, a hot topic of discussion is always that they feel PAs get hired preferentially.

I think this is true with regards to EM and surgery where we have a lot more training.

Peds, women's health,  psych, and primary care belong to the NPs in many settings. 

[Marinejiujitsu]

I think this is true with regards to EM and surgery where we have a lot more training.
Peds, women's health,  psych, and primary care belong to the NPs in many settings. 

I'm wondering if surgery because surgeons can control us more. NPs would have to scrub out after 2 hrs for a break. Lol.

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[EMEDPA]

30 minutes ago, Marinejiujitsu said:

I'm wondering if surgery because surgeons can control us more. NPs would have to scrub out after 2 hrs for a break. Lol.

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The vast majority of NP programs do not provide surgical training or rotations. Some do not have students rotate through inpatient services at all.