Author Topic: Sub-contracted provider  (Read 2668 times)

billme

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Sub-contracted provider
« on: July 09, 2013, 02:01:44 PM »
Our EMG provider is retiring soon. The remaining providers want to bring in a sub-contracting provider who will do only EMG's. I have looked all over the internet for information regarding how to bill for a sub-contracting provider but have found next to nothing. A few of my questions are-
1) Do I bill using his info?    2) Can we only test patients with insurances that he is credentialed/participating with, or will he need to be credentialed through our practice?
I have been doing Medical Billing for almost 20 years and have not come across this situation. Any help will be greatly appreciated.
 :)

PMRNC

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Re: Sub-contracted provider
« Reply #1 on: July 09, 2013, 02:20:46 PM »
You are going to want to consult with a legal professional on this one for the setup/structure first, from there you will decide on how the entity will continue and be able to have more answers on billing.
Linda Walker
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RichardP

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Re: Sub-contracted provider
« Reply #2 on: July 09, 2013, 03:10:31 PM »
billme - if you have been billing for these providers than surely you know the answer to this question: who is the billing entity?  Whose NPI number have you been putting in Box 33a of the CMS 1500 Form?

You either have a legal doctors group - in which case, the group is formally constructed as a legal entity and has its own NPI Number which is used in Box 33a of the CMS 1500 Form, or each doctor is his own billing entity - and each doctor places their own NPI Number in Box 33a of CMS Form 1500.

Next, find out how the sub-contractor is going to be paid.  Will he earn his money by the insurance companies paying him directly (that would mean he is the billing entity), or will one of the providers pay him (he is an employee of that provider) or do you have a doctors group with its own NPI Number and the doctors group will pay him (he is an employee of the doctors group)?

It really is that simple.  Either the subcontractor is going to be his own billing entity, or he is an employee of a billing entity.

Only if the subcontractor is the billing entity would you put his information in Box 33 of the CMS 1500 Form.  If the subcontractor is an employee (paid either by the doctors group or by one of your providers), then the hiring entity/billing entity's information goes in Box 33 of the CMS 1500 Form.

The billing entity's Type 2 NPI Number (who gets paid) goes in Box 33a of the CMS 1500 Form.  If you are billing Medicare, you must also place the Type 1 NPI Number (who did the work) of the person who did the actual work in Box 24J of the CMS 1500 Form.

If your subcontractor is the billing entity (will get paid personally by the insurance companies), then both of these NPI Numbers will belong to the subcontractor.  If your subcontract is an employee and will get paid either by the doctors group or by the hiring provider, then the hiring entity's Type 2 NPI Number goes in Box 33a and the employee's (subcontractor's) Type 1 NPI Number goes in Box 24J - only if/when you bill Medicare and any other insurance carrier that requires the Type 1 NPI Number to be there.  You don't need legal advice to figure this part out.  This is information you already have to know in order to bill correctly.

If the subcontractor is an employee, then it is his employer's contracts with the individual insurance carriers that govern.  If the subcontractor is the billing entity (expects to get paid directly from insurance carriers), then it is the subcontractor's contracts with the individual insurance carriers that govern.

Come back with any other questions you might have.

PMRNC

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Re: Sub-contracted provider
« Reply #3 on: July 09, 2013, 03:39:13 PM »
I'm sorry I disagree Richard.. this is an "entity" question since they already claimed they are "Bringing on" contractors
Linda Walker
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RichardP

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Re: Sub-contracted provider
« Reply #4 on: July 09, 2013, 07:08:38 PM »
I'm sorry I disagree Richard.. this is an "entity" question since they already claimed they are "Bringing on" contractors

I don't know what you are disagreeing with.  I would like to learn if you would care to point it out.

My point is this:  the new guy is either going to be paid by the insurance carriers or he is going to be paid by the entity that hires him.  (A true sub-contractor is not an employee, according to the IRS.  But I used the term "employee" simply to indicate that situation where the hiring entity would be paying him vs. the insurance carriers paying him.)

Is there a category other than these two that apply?  Sounds like I'm about to learn something.

billme

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Re: Sub-contracted provider
« Reply #5 on: July 10, 2013, 10:43:31 AM »
Thanks Richard.
Your reply pretty much matches my own thoughts. Like I'd said, I've not encountered this before, can't find anything online and unfortunately the insurance companies themselves are absolutely no help whatsoever. None of them will teach you how to bill something even by their own guidelines.
. . . anyway  Thank you again.
karen

RichardP

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Re: Sub-contracted provider
« Reply #6 on: July 10, 2013, 11:47:42 AM »
You are welcome Karen.  We already had a discussion similar to this one several months ago wherein I provided a link to what CMS had to say about the matter.  I couldn't find it quickly enough yesterday to include it in my response, but here it is now - in case you want a broader perspective on the issue.

http://www.medicalbillinglive.com/members/index.php?topic=7045.msg21031#msg21031