Right to information

[NeoTrion]

Last year the APP staff became aware of some billing irregularities related to incident to billing and how things were showing up on our fee tickets.  After pulling up Medicare guidelines we found that our SP was not seeing Medicare patients for their initial visit.  This was brought to our office manager in an open meeting to which she stated "there is a loop hole for this."  I should note that our office manager / COO styles herself as a billing expert, and we were told that she has vast experience in billing and was certified as a coder and biller.  After two months it was finally decided that the SP would see these patient's for the first visit.  She was mum on how we were billing for exiting Medicare.  Further research in our state found that with Blue Cross Blue Shield that the do not pay incident to.  She refuted this in an open provider meeting and stated we only needed to use an SA code.  One week later she emailed us correspondence from a BCBS rep that confirmed a modifier code could be used when we saw the patient.  I emailed this rep and found out that the modifier code was to denote if an APP saw the patient and if it was billed under the SP.  In return we would only get 85% and that if we are already credentialed with them that it should not be billed under that modifier code but under our NPI.  The rep stated that if we were billing to the contrary we may be committing fraud.  You can only bill under the SP with that modifier code if you are not credentialed.  Our NP is credentialed with BCBS, but all of our billing slips had our SP as the rendering even if he was not on the grounds.  So naturally we sent multiple emails to our office manager / billing expert.  None were answered.  As a result myself and a nurse practitioner separately had a conversation with our only certified / licensed biller.  Based off of that conversation we had a conversation with our CEO/CMO about the billing.  A month later I find myself getting written up for asking the biller about if we were still billing incident to on Medicare and Private Insurance, and it undermined administration that I talked to her.  I pointed out that I emailed her multiple times for answers and that she never responded, and that we can be held responsible for anything billed that we see.  I made it clear to the biller at the time I did not want numbers or information that was considered privileged.    My question to the group is that is there any statute or law that gives us the right to ask how things are being billed, especially after making a formal request?  It should be noted that the NP did not get disciplined for talking to this biller over the phone as well.  The stories were exactly the same, and the main difference is that I talked to the biller in person in my office and the NP discussed it over the phone.   When I asked to COO/office manager for her billing and/or coding certification in front of the CEO she refused.  When I pressed her further she admitted she had let them "lapse" and could not remember when they had lapsed.

Edited April 21, 2021 by NeoTrion

[rev ronin]

So, given that bridges have likely been thoroughly burned, what you probably need to look into the implications of whistleblowing.  While it might suck to put your employer out of business (maybe) or immediately become persona non grata (pretty much guaranteed), it's about the only way to protect yourself, as I understand it.