Author Topic: Concerns About Billing Under Another Provider (PRIVATE insurance)  (Read 986 times)

atltree

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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

PMRNC

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Re: Concerns About Billing Under Another Provider (PRIVATE insurance)
« Reply #1 on: September 01, 2019, 01:31:08 PM »
I think it's probably better to consult the practice attorney and let them do this work for you, I don't mean to sound crass but you said it's clear with Medicare and well Medicare is pretty much top dog as an entity of the federal gov.  And as for examples of worst case scenario's they would be remiss...could be loss of medical license, kicked out of a network, barred from Medicare or handcuffs, orange jumpsuit and 9X9 cell.

Quote
but I need to give facts to support the need to stop doing this on private insurance carriers.

According to the law on fraud and abuse you don't need facts but the  practice should have been stopped the moment it was known about, facts or not. Billers are held to the same level of liability as they can "knowingly" submit fraudulant claims this way. Once you knew.. even suspected really, the practice of doing it should have been stopped.   It's no different than the everyday question this forum and others get when someone comes on and asks "Can someone give me proof that it's illegal to waive patient's out of pocket." 

I do understand when a higher up is wanting you to find the info, most times I'll find something and give to my clients but not when it's something they DO know and are just looking for any justification to do it anyway. That's when I say, I won't do it. It's my neck on the line. If you are being made to find this info, simply explain the obvious and advise them to speak with their attorney.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

atltree

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Re: Concerns About Billing Under Another Provider (PRIVATE insurance)
« Reply #2 on: September 01, 2019, 09:34:28 PM »
Thank you for your reply, PMRNC. I was able to find that little snippet from the UHC contract. But I'm just wondering if there are any other sources I can cite, from an authority in the field?

Please explain to me like I'm a 3 year old. Is Medicare the final authority for everything? I'm not sure how the law works here. Again, I'm talking strictly business to business. Insurance company to Provider, no Federal money.

We don't have a practice lawyer; at least not one who's easily accessible.

PMRNC

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Re: Concerns About Billing Under Another Provider (PRIVATE insurance)
« Reply #3 on: September 02, 2019, 10:57:38 AM »
You are not going to find "an authority" over all commercial carrier guidelines, that's what contracts are for.either they allow for the non credentialed provider to bill or they don't. In some cases (again depending on the contract) you can use the practice/clinic name for those contracts that would allow for it.

Another option if applicable is Locum Tenens or a reciprocal billing agreement with the non credentialed provider, you could look into those two options. Locum can only bill for I think 60 days  and other rules should be followed.

IN the rare event it's not stated in other payer contracts keep in mind it could be processed but will not be paid at in network rate and the patient may or may not be billed, some contracts are not going to spell it out as UHC does as they may just say "credentialed" providers ...  leaving it again, common sense.  MOST carriers follow Medicare rules.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Medical Billing Forum

Re: Concerns About Billing Under Another Provider (PRIVATE insurance)
« Reply #3 on: September 02, 2019, 10:57:38 AM »