Billing under one provider for the group

[midwifebiller]

I've seen this twice now, and need to ask.

A physician's group of seven doctors, but everything is billed under the Director's name as the rendering provider.

A midwifery practice of three midwives, but everything is billed under the senior midwife's name as the rendering provider.

Both groups are out-of-network with all insurance companies.  Are there any negative repercussions to submitting group claims under one provider?

Thank you.

[Michele]

I believe this law is effective in all states, but it is best to check your state.  I understand that it is illegal for any doctor to bill for services provided by another doctor.  The rendering provider must be indicated.  If they want payment to go to one doctor for all doctor's services then they need to set up with insurance companies that way. 

As for the mid-wife's, I do not know if that law applies to them.  If they are the same 'level' or 'degree' then I would think it would apply to them as well.  If they are being supervised by the one midwife because they are not yet able to work on their own, then possibly.  But usually the billing is done under the one name because they didn't get things set up correctly with the insurance carriers.

Michele

[midwifebiller]

Michele,

Thank you for your reply.  Since these providers are out-of-network, I'm not sure what you mean by "set up with the insurance companies".  Usually, all we have to do to be loaded into their system is send a W-9, if even that.  We do not bill for the physician group, but we do bill for the midwife group.   It gets tricky, since the client/patient sees all three midwives during her pregnancy and any two of the three midwives will attend her delivery.  Which midwife would be the rendering provider...?  For simplicity, they thought billing everything under the senior midwife would be a good idea, and I'm not quite sure how to respond. Should I call Provider Relations at each insurance company and explain the situation?

Thank you.
PS: Midwives are considered the primary caregiver during pregnancy and six weeks postpartum.  Sadly, not all insurance companies recognise this, though.

[PMRNC]

it is illegal for any doctor to bill for services provided by another doctor.  The rendering provider must be indicated.  If they want payment to go to one doctor for all doctor's services then they need to set up with insurance companies that way. 

I'm agreeing with this. Each service rendering provider must be indicated as such on the claim form.  Each carrier will require that each service rendering provider be in their system as per their credentialing rules.

[Michele]

Doesn't the midwife group have a group name, group NPI and EIN/tax ID number?  If that is the case then each time a service is billed, the individual npi of the midwife that saw the patient would be in box 24, their name would be in 31, and the group info would be in 33.  If they are non par, then there should be no reason to bill it this way.  If they see all 3 during the pregnancy and you are billing for the delivery then I would think it would go under whichever one actually did the delivery.  Calling provider relations is a good idea to make sure.

Michele
 

[midwifebiller]

Thank you for your responses.  Since these midwives deliver babies at home (and don't have staff, shifts, or on-call docs to relieve them), there are always two midwives in attendance.  All of our midwives have NPIs, EINs, and group numbers where appropriate, but are OON.  I will take your advice and call the three or four insurance companies that we deal with the most to see what their policies are.  I'll post again after I call, for anyone who is interested.

[midwifebiller]

What a hassle!  I've been transferred from the Provider Relations Dept to Contracting, then Authorizations, back to Prov Relations, and on hold forever while they try and find someone who can answer my question.  We're out-of-network, so we don't have a provider rep, but maybe they can find a consultant who would know.  So far I left messages at three insurance companies.  Now we wait.

[Michele]

One more piece of advice, don't hold your breath while waiting.  It could be hazardous to your health.  JK

Sorry, I couldn't resist.

[midwifebiller]

Thanks, Michele--I needed a good laugh at the end of the day today.  It's been one.of.those.days.

I love my job, I love my job, I love my job......