Author Topic: Third Party Billing Regulations by State  (Read 4478 times)

Scott

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Third Party Billing Regulations by State
« on: January 23, 2015, 02:17:52 PM »
I own a small medical/pharmacy billing company in California.  I've recently been asked to do some billing in New Jersey for some chiropractors.  In my research it looks like NJ requires me to file a 3rd Party Billing Service Application.  Can someone confirm that?

It also got me thinking that there may be other states with similar requirements.  Does anyone know which other states require an application to perform billing services?

Thanks

PMRNC

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Re: Third Party Billing Regulations by State
« Reply #1 on: January 23, 2015, 02:55:22 PM »
YES.. NJ requires third party medical billing registration. http://www.state.nj.us/dobi/division_insurance/managedcare/tpapage.htm#tpb
Linda Walker
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Scott

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Re: Third Party Billing Regulations by State
« Reply #2 on: January 23, 2015, 04:37:01 PM »
Thanks Linda.  Do you know if they are the only state with such a requirement?

PMRNC

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Re: Third Party Billing Regulations by State
« Reply #3 on: January 23, 2015, 04:51:52 PM »
No, I believe there are 3 other states that have such requirements.
Linda Walker
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Scott

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Re: Third Party Billing Regulations by State
« Reply #4 on: January 23, 2015, 05:02:55 PM »
Do you know off-hand which ones they are?  Appreciate your help.

tallmanusa

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Re: Third Party Billing Regulations by State
« Reply #5 on: January 26, 2015, 09:44:09 AM »
So far as I know, there is only one state, New Jersey that has licensing/ certification requirements, I don't know of any other state in the country with such requirements.

There are three states, California, New York and Florida, which prohibit percentage fee for billing for medicaid. It should be noted that the prohibition is for the provider, not the biller; the provider has an arrangement with the medicaid, the biller does not.
It should also be noted that even in these three states, there is no prohibition for percentage billing for commercial insurances and medicare, ONLY medicaid.
« Last Edit: January 26, 2015, 10:41:52 AM by tallmanusa »

PMRNC

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Re: Third Party Billing Regulations by State
« Reply #6 on: January 26, 2015, 10:33:33 AM »
 
Quote
there is no prohibition for percentage billing for commercial insurances and medicare, ONLY medicaid.

that is incorrect. In NY/Florida for example the laws are state statutes.. in NY it's part of education and public health law. THESE are not "governed" by CMS at all. Those additional states ..another example is Arizona under public licensing laws of conduct is that labs cannot fee-split. In Colorado, State board of Chiropractic has their rules on fee-splitting. Some of these are under licensing and public education laws.  I've spent years researching these.

Incidentally... NY also has 18 NYCRR 504.9
“persons submitting claims, verifying client eligibility, or obtaining service authorizations for or on behalf of providers, except those individuals employed by providers . . .must enroll in the medical assistance program. . .” need to register with OMIG (office of Medicaid Inspector General) Really good PPT here on 3rd party billing companies.
www.omig.ny.gov/.../1-12-11_third_party_billing_final.ppt
« Last Edit: January 26, 2015, 10:44:55 AM by PMRNC »
Linda Walker
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tallmanusa

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Re: Third Party Billing Regulations by State
« Reply #7 on: January 26, 2015, 10:50:46 AM »
Could you kindly give us links to where it says medical billing companies cannot bill, OR require licensing in those other states?

Arizona may have prohibition against fee splitting for labs, we are not a lab.

Colorado State Board of Chiropractors may have their rules,  the onus is on the Chiropractor to follow the rules of his state.

Again, we would appreciate a link where it says that there is some kind of law that prohibits US, medical billers from conducting our business on a percentage basis.

tallmanusa

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Re: Third Party Billing Regulations by State
« Reply #8 on: January 26, 2015, 11:07:50 AM »
The link you gave for NY is " not found ".

The correct link is as follows:
https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=ny%2018%20nycrr%20504.9

This is a Google search; look at the very first one  in PDF describing the  18 NYCRR 504.9  law. It applies specifically to medicaid billing. I could not find anything that relates to commercial insurers or medicare.

PMRNC

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Re: Third Party Billing Regulations by State
« Reply #9 on: January 26, 2015, 11:43:32 AM »
I was only referring to that PPT as a good "basic" understanding of exactly what "MEDICAID" considers a third party in regards to the question asked about other state registration requirements. Was meant to explain that if billing NY Medicaid registration is required and defines under what circumstances. You can also get the same info at emedny.org as well.   

As for fee splitting.. I have spent last 10 years or so doing extensive research into the state laws which PROHIBIT PHYSICIANS from "fee-splitting" arrangements. For NY..the statue reads: Permitting any person to share in the fees for professional services, other than: a partner, employee, associate in a professional firm or corporation, professional subcontractor or consultant authorized to practice medicine, or a legally authorized trainee practicing under the supervision of a licensee. This prohibition shall include any arrangement or agreement whereby the amount received in payment for furnishing space, facilities, equipment or personnel services used by a licensee constitutes a percentage of, or is otherwise dependent upon,
the income or receipts of the licensee from such practice, except as otherwise provided by law with respect to a facility licensed pursuant to article twenty-eight of the public health law or article thirteen of the mental hygiene law;

I know of no law that says a billing company cannot charge a % in those states because the STATE STATUTES are under education, health laws and licensing laws (professional conduct).  I would further say that if you are in a state where a physician is prohibited from entering into a fee-splitting arrangement it would be highly unethical, unprofessional and could also therefore render your contract null/void.

I have several of the actual, exact statutes, case precedence's and guidelines in our members only area at www.billerswebsite.com
« Last Edit: January 26, 2015, 11:47:35 AM by PMRNC »
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
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tallmanusa

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Re: Third Party Billing Regulations by State
« Reply #10 on: January 26, 2015, 02:49:56 PM »
What is the situation in Arizona?

Do they require registration?

PMRNC

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Re: Third Party Billing Regulations by State
« Reply #11 on: January 27, 2015, 06:31:13 PM »
Like I said,I've spent many years researching.   we have many of the laws and exact statues in our members only at www.billerswebsite.com
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

tallmanusa

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Re: Third Party Billing Regulations by State
« Reply #12 on: January 28, 2015, 08:30:49 PM »
Licensing requirements are important to us, we service well over 200 clients nationwide. We reached out to HBMA, studied the laws in various states, and here is what we found.

1. New Jersey requires registration/ certification, in very clear terms.

2. New York requires registration if you are billing to medicaid, I did not find any  such requirements for commercial insurances and medicare.

3. Arizona, requires no patient collection efforts, even patient statements to be sent by billers are limited. We service Arizona, just NEVER have any contact with the patients and don't send any statements.
We never receive any money for providers anyway, anywhere. That is a non issue.

4. Maryland, I am unclear for this state, I am still researching on this one.

My concern has been what the state laws require from us billers, whatever they require from the providers is not my concern, the providers should know what their state requires from them. Just like I follow the law applicable to us, they  should follow the law applicable to them.

If anyone has different information I would stand corrected.

PMRNC

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Re: Third Party Billing Regulations by State
« Reply #13 on: January 29, 2015, 07:27:38 AM »
Quote
Quote
My concern has been what the state laws require from us billers, whatever they require from the providers is not my concern, the providers should know what their state requires from them. Just like I follow the law applicable to us, they  should follow the law applicable to them.
In regards to operation of a medical billing company I agree to a point. I think that it would be irresponsible for any billing company to enter into any contract that would hurt a physicians license in any way. I see this as a marketing opportunity as well. On the flip side the billing company takes a chance of having their contract made null/void if they enter into one in a state where a physician is prohibited to do so. The recorded cases on record show the contracts as null/void on top of a physician being sanctioned. While it may be illegal for a physician, not the billing company, I think it's prudent for any billing company to look out for their clients, that is what we do!

 I think where the confusion came from was that the person asked about registration and in a later post you pointed out the fee-splitting. Which may have been where the confusion came in.  I'm not here to debate the laws. 
Quote
There are three states, California, New York and Florida, which prohibit percentage fee for billing for medicaid. It should be noted that the prohibition is for the provider, not the biller; the provider has an arrangement with the medicaid, the biller does not.

I'd also like to point out that the HBMA was the one that back in 2000 decided to tell billers it was ok.. then later backtracked after a couple of years telling billers it was ok. 

« Last Edit: January 29, 2015, 07:31:03 AM by PMRNC »
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
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tallmanusa

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Re: Third Party Billing Regulations by State
« Reply #14 on: January 29, 2015, 10:37:43 AM »
Our contracts have the following standard clause.

CHOICE OF LAW AND FORUM. This Agreement shall be interpreted, construed, and enforced in all respects in accordance with the laws of the State of Massachusetts. The parties irrevocably agree that any action to enforce the provisions of this Agreement, or arising under or by reason of this Agreement, shall be brought solely in the Superior Court of Massachusetts, Middlesex County venue.

The choice of venue and law is standard for any contract. The contract cannot be voided without a court hearing where the venue was chosen by the parties under the laws of the state already chosen. That is the way legal contracts are drawn in United States.

There are fifty states, I don't know the laws applicable to someone else conduct in every state. And I am supposed to know the law in 50 states concerning the providers conduct, and the provider does not know the law in his own state where he has a license?

If he is such an idiot, I don't want to work with him.
He should know the law in his state that affect him, and act accordingly, if he does not, he is not our client.
Incidentally, we don't always accept everyone who wants us to do their billing.