Concerns About Billing Under Another Provider (PRIVATE Insurance)

[atltree]

Good Evening,

I have a sit down meeting with my supervisor and I need to come up with as much source material as possible to address the following:

Why billing a non credentialed provider's services under a credentialed provider (as rendering) is not a good idea for PRIVATE insurance. The information is abundant on why it's a bad idea for Medicare, but I need to give facts to support the need to stop doing this on private insurance carriers.

So far all I've found is from the United Healthcare contract, "...you will assure that a member of your professional staff who has not been approved or is not in good standing under our credentialing program will not provide covered services to our customers. In the event that professional does provide covered services, you will not bill us, our customer, or anyone acting on our customer's behalf for the service, and you will assure that the professional also does bill for the service..."

I would also greatly appreciate some examples of worst-case scenarios of doing this (I.E. audit, terminated contracts, or other penalties). Thank you all so very much for any assistance you are will to give.

Sincerely Yours,

A Concerned Medical Biller

[coloradopa]

21 hours ago, atltree said:

Good Evening,

I have a sit down meeting with my supervisor and I need to come up with as much source material as possible to address the following:

Why billing a non credentialed provider's services under a credentialed provider (as rendering) is not a good idea for PRIVATE insurance. The information is abundant on why it's a bad idea for Medicare, but I need to give facts to support the need to stop doing this on private insurance carriers.

So far all I've found is from the United Healthcare contract, "...you will assure that a member of your professional staff who has not been approved or is not in good standing under our credentialing program will not provide covered services to our customers. In the event that professional does provide covered services, you will not bill us, our customer, or anyone acting on our customer's behalf for the service, and you will assure that the professional also does bill for the service..."

I would also greatly appreciate some examples of worst-case scenarios of doing this (I.E. audit, terminated contracts, or other penalties). Thank you all so very much for any assistance you are will to give.

 Sincerely Yours,

 A Concerned Medical Biller

Its actually pretty normal for private insurance. PAs and NPs are generally not credentialed by most private insurance companies. This is slowly changing in some parts of the country. Generally the instruction from the insurance company is to bill under the supervising/collaborating physician. 

If you want to be sure, call the insurance company and ask; how do I bill for PA services? The answer will almost certainly be to bill under the supervising/collaborating physician. 

[atltree]

Thank you for your reply. I should clarify, however, that these are MD Physicians rendering the services. I know this is probably isn't the best place given the name of the forum, but I couldn't really find any other websites. AAPC requires me to become a member to post on their forum.

[jmj11]

I'm not sure if I fully understand the question, but if it is un-credentialed physicians billing under the credentialed physicians name, who didn't render the service, then this article may be helpful:

 

 

[atltree]

Thank you also, JMJ11, for your reply. You are exactly right; we are billing un credentialed providers (MDs) under a credentialed provider's name. That's a great article but I was hoping for some information for commercial carriers. I think in the industry it's very well known not to fool around when it comes to Medicare, but my boss has this attitude that it's more grey when it comes to private sector insurance. He's made vague references to phone calls with insurance reps telling him it's ok, or said something along the lines of "if the supervising physician is within a 60 minute drive they may be billed under". I want to set him straight here.