Poll

Is it legal to submit claims under another provider in the group while the actual provider is in the credentialling process with a Pryor?

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Author Topic: Non-credentialed providers  (Read 5624 times)

Wondering

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Non-credentialed providers
« on: June 02, 2012, 11:07:23 AM »
New physician joins the practice and is in the process of being credentialed by a payor. The new physician sees patients with this payors insurance. Can the claims be filed under one of the other providers until this physician is credentialed ?

PMRNC

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Re: Non-credentialed providers
« Reply #1 on: June 02, 2012, 03:24:33 PM »
No
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
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Wondering

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Re: Non-credentialed providers
« Reply #2 on: June 03, 2012, 04:45:28 PM »
Thank you. Had it suggested and it did not seem like the right thing to do. Would you consider that fraudulent billing?

PMRNC

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Re: Non-credentialed providers
« Reply #3 on: June 03, 2012, 07:20:59 PM »
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Thank you. Had it suggested and it did not seem like the right thing to do. Would you consider that fraudulent billing?

Yes, it would be not only for the provider but whomever billing it as well since it's reporting a provider providing services that did not provide services. If the patient has not been seen it's best to disclose to the patient that physician is not yet in-network and see if another provider in practice can see them or have them pay their out of pocket and bill it and it will be paid as non-par.   If you are the one doing the billing.. don't bill out anything you know or suspect to be wrong, it's your neck on the line as well.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Angie

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Re: Non-credentialed providers
« Reply #4 on: July 17, 2012, 02:56:33 PM »
What if they are in the process of getting their license and are being supervised by the Ph.D.; Can they bill it under the Ph.D. since he is the supervising?

Michele

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Re: Non-credentialed providers
« Reply #5 on: July 17, 2012, 06:11:31 PM »
If the provider is not yet licensed and is being supervised then yes it can be billed under the supervising PhD.  Just check state laws too to be safe.
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PMRNC

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Re: Non-credentialed providers
« Reply #6 on: July 18, 2012, 12:02:06 PM »
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If the provider is not yet licensed and is being supervised then yes it can be billed under the supervising PhD.  Just check state laws too to be safe.

BE EXTREMELY cautions with these.. I have had 2 clients in the past that were "supposed" to be supervising, caught them not adhering when the supervising provider (PHD) went on a 2 week fishing trip, yet I was getting faxed claims. As per my attorney since I KNEW the supervising provider was NOT supervising it was blatant fraud and I'd be responsible for claims filed at that point (because I knew).  I had to terminate the client ON the spot and report it to cover my ass since it was likely they were doing it all along. didn't want to report it but my attorney said it was the only way to ensure I was protected from previous fraud I may have billed.   I had another client .. SAME exact scenario except they decided to tell me it was ok since his wife would be in the office (and she was not a provider. lol).. had to terminate them as well as they refused to listen to me.     Remember that you are JUST as responsible in those situations as the supervising provider. Be aware, be alert and MAKE SURE YOUR CONTRACT PROTECTS YOU
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Angie

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Re: Non-credentialed providers
« Reply #7 on: July 18, 2012, 12:12:40 PM »
Thank you Linda!
I actually am employed by them so I don't have a contract and I don't work on site I work from my home for them. Would I be held liable if I prepared something and didn't know if they were being supervised or not? or would it be my employer? To my knowledge she is being supervised and all of the notes are signed by her and the supervising MD but since I am not there to actually witness it......Little scary....Any suggestions?
Also we are OON with all insurance companies and are private pay; it is clearly stated in our contract and the clients pay at the time of service so we are good there we only provide these statements for the patients that request them as they are trying to seek reimbursement from their insurance companies.

PMRNC

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Re: Non-credentialed providers
« Reply #8 on: July 18, 2012, 03:54:42 PM »
your contractual relationship is of NO matter to the federal government under Anti=kickback and fraud statutes.. There have been MANY independent consultants, billing companies and even salary/hourly paid employee's held individually responsible.

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Would I be held liable if I prepared something and didn't know if they were being supervised or not? or would it be my employer?

You are both responsible, they are responsible NOT to break the law and you are responsible for knowing what's going on. There is no room for ignorance when it comes to fraud/abuse, the law says you SHOULD know.  A good contract will help drive this fact home (though it wouldn't protect you, just make it known to the client you won't tolerate any funny business)

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To my knowledge she is being supervised and all of the notes are signed by her and the supervising MD but since I am not there to actually witness it......Little scary....Any suggestions?

Well, I always advise to make sure you keep good documentation, have good Errors & Omissions insurance and make sure your client is fully aware of your responsibilities and theirs via a SOLID good contract.  Even a suspicion of something not right could be cause for concern if you file claims with that suspicion. Bottom line is you don't want to find out the hard way so protect and cover yourself.   I'm not saying there are not legit physicians doing this of course, there are.. I'm just saying to beware of possible situations that could arise.  A good compliance plan will also include situations like this that you could refer to if/and when you have to.

 
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com