Everything being billed under physician

[NeoTrion]

I just wanted to write and see if someone with more wisdom can answer some questions.  I and a peer work at a duel specialty that also practices allergy testing in Texas.  Currently a PA sees all the new and established allergy testing as well as clinical consults.  There were some issues with our scheduling software, and it was found out that these patient's were being scheduled and billed by the physician for 100% reimbursement.  This was being done when the physician was not on site (sometimes not in the state), and never laid eyes on the patient.  He was not co-signing the notes either.  After we found out about this, we did use the F word (fraud), which quickly got his attention.  We were called into his office and were informed that this was approved by the ABIM (American Board of Internal Medicine), and was completely legit.  He also said that since he follows up with the patient after that visit, that it is completely legit.  The thing is that he follows up with maybe 25% percent of the patient's that are initially seen by the PA.  He was very straightforward in saying that the reason why they do not bill under the NPI of the actual provider is because then they do not get 100% reimbursement.  We pointed out that the ABIM will not stand by you if the practice gets audited by the state or federal authorities.  He became very defensive and ask what we wanted to do.  We all stated we were educated that to bill us to see those patient's and for him to bill 100% under his NPI, he must have face to face contact with the patient or co-sign the visit note.  He said he would be willing to just pop in and say hi.  Well that lasted for about a week and half, and he decided to go home a couple of times because he was tired.  He then started co-signing some of the charts, but there is no further direction on what his plan is.  The primary physician did say that the other physician that is on site will have these visits charged under their NPI.  The other physician is unable to help because they do not know what is going on in that area of the clinic.  That physician is boarded in another specialty as well as internal medicine, which is well within their license to participate in allergy testing.  They were unaware that any of the allergy testing was being billed under their NPI when the lead physician was gone.  

So here is my question.  Is my understanding of the law correct that the patient has to have a brief face to face with the patient ("hi, my name is Dr. E), or cosign the chart in order to bill under their NPI?  I do not see how incident to billing could be utilized for new or consult patients without meeting these two criteria.  This is also considering that at times the led physician is not even in the state.  I am looking for the actual law or literature that states this is legal or not legal.  I was told that the clinic employs a part time billing auditor for these kind of situations.   Personally I would like to talk to this auditor with information either confirming my thoughts, or educating me on this type of billing they are utilizing.  I have already found issues with her insistence concerning the percent of chart audits.  That law was changed in Texas at the prior legislative session, so I know some of the information she has given is somewhat inaccurate.  It is also within her best interest.  If she has missed something, it does benefit her to tell me something to shut me up.  I think this goes along with the old adage, "If you can't impress them with brilliance, then baffle them with BS."    

We also work under the physician practicing another specialty in the clinic, and see our own patient's in our own POD.  I am unaware if he is billing this under our NPI or under his.  All new patient's do go through him, but follow up visits with these patient's are seen by the PAs or NPs.  This physician also does not co-sign the notes or do a face to face with the patient.  I have no idea how this is billed, but that would be the next logical question for me to ask should I find information affirming my suspicions noted above. 

 Any advice would be greatly appreciated.

[coloradopa]

Two different issues:

1. For Medicare/Medicaid the first encounter must be by the physician and must document the plan of care. The APP can then see the patient for the same problem under incident to as long as the physician is in the suite of offices. This is called incident to. If this does not happen then it should be billed under the APPs NPI at 85%. It doesn't matter if the chart is co signed. Any patient that the APP sees for the first encounter or sees without the physician present is billed under the APP NPI. 

2. For other insurance they are usually billed under the physician NPI at 100% unless the practice contract says different. 

With Medicare you are talking about fraud. I will also guarantee the ABIM does not say this is the way to bill. It seems you are working in a multispecialty center. I would talk to you practice manager or whomever is doing the billing let them know they may also be liable for fraud. 

[NeoTrion]

Any chance you can give me a link to this law/rule?  So to be clear if I see a patient that is brand new to the clinic and make diagnosis-es, that has to be build under my NPI?  What if he personally introduces himself and says he agrees.  Then he goes back to his own schedule?  Does that satisfy the requirement? 

[coloradopa]

Here is a pretty good article. Look at question #3. 

http://www.medicaleconomics.com/modern-medicine-feature-articles/incident-billing-clearing-confusion

Here is another:

http://www.mdmag.com/physicians-money-digest/practice-management/non-adherence-to-incident-to-billing-can-prove-costly

Here is CMS guidance:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

 

[UCPA2018]

What if the NP/PA seeing the patient doesn't actually sign their own name in the EMR? The office I just started at has everyone log in to the EMR under the physician's username so the note is signed in his name. My name (the PA) goes on the fee slip and my initials get typed on the bottom of my chart under my plan but it's not 'my signature'. Usually the provider is not on-site or in-state. Is this allowed? Not really sure how it works...

[jmj11]

22 hours ago, PAS2student said:

What if the NP/PA seeing the patient doesn't actually sign their own name in the EMR? The office I just started at has everyone log in to the EMR under the physician's username so the note is signed in his name. My name (the PA) goes on the fee slip and my initials get typed on the bottom of my chart under my plan but it's not 'my signature'. Usually the provider is not on-site or in-state. Is this allowed? Not really sure how it works...

This makes no sense either. Your note is your note. Why do they do this if the billing is under your name? In a court of law, it looks like the physician would be held accountable for your note. I've seen people attempt this for the silly reason of saving money on the software. Some software has a monthly fee based on the number of provider subscribers in the practice. But I think that would be a poor excuse for create a note under a false signature. 

[EMEDPA]

23 hours ago, PAS2student said:

What if the NP/PA seeing the patient doesn't actually sign their own name in the EMR? The office I just started at has everyone log in to the EMR under the physician's username so the note is signed in his name. My name (the PA) goes on the fee slip and my initials get typed on the bottom of my chart under my plan but it's not 'my signature'. Usually the provider is not on-site or in-state. Is this allowed? Not really sure how it works...

the doc might also do this because they are lazy and this way the notes appear pre-signed by them, even though they never have seen the pt or the note...

[UCPA2018]

On 11/17/2018 at 11:17 AM, jmj11 said:

This makes no sense either. Your note is your note. Why do they do this if the billing is under your name? In a court of law, it looks like the physician would be held accountable for your note. I've seen people attempt this for the silly reason of saving money on the software. Some software has a monthly fee based on the number of provider subscribers in the practice. But I think that would be a poor excuse for create a note under a false signature. 

That's what I've been saying all along. I think EMEDPA is right when he says it's because he's lazy. I'm not sure who the visits are actually being billed under since my signature and credentials are on the fee slip but the EMR is signed by him. Hopefully it's being billed under my credentials but I guess I should find out..

[rpackelly]

Not being billed under your credentials, supervising doc not on site, equals illegal these days for Medicare at least

Problem is frequently this goes on without the provider knowing, except in your case even the note is fraudulent.  

 

Many PAs found this out only when CMS began allowing open access of provider data through Propublica, etc.     When Medicare has no record of your services yet you see patients over the age of 64  when the doc is not in the office it’s a big “tell”.  Literally before that there was really no way to discover this unless you can examine your own billing records (like if you are getting paid bonuses depending in reimbursements, etc.).   Some practices didn’t (don’t) know the law, some do but obfuscate.  You can tell the practice the rules, fill out the Medicare forms for your numbers, but if the practices hire out their billing and you are paid a salary there is really nothing to stop them from not telling the truth to you or the government.  In many ways if PAs were autonomous  and reimbursed personally rather than through the doc.  it would save the government from Medicare fraud.  If the 15% penalty for seeing a PA rather than a doc remained, it would save the government money and perhaps lower health care costs a bit as well, although I think the equivalence of PA services is a point worth fighting for under OTP.