Billing > Billing
Billing for lcsw
Healthy:
Hi all,
I have a question if any one can help me, I am very confused.
I do billing for mental health,provider has hired a lcsw and she is credential with some insurances but not with Cigna and united health care because both are not taking any more lcsw on their panels.
Question is that lcsw does see Cigna members and MD supervise her,can I bill lcsw services under MD as supervising physician? And if yes how? Do I have to use NPI for MD as supervising and rendering provider as lcsw and billing provider NPI for group? And do I have to use any modifier?
Please answer me in detail.
Thanks to all.
RichardP:
Healthy, you said: provider has hired a lcsw ...
You have an employer / employee situation here, so the information at the following link applies. The post is talking about Medicare, but the info is relevant to commercial carriers also. You can bill for the work of the lcsw using the provider's NPI number. The link tells you how.
http://www.medicalbillinglive.com/members/index.php?topic=7045.msg21031#msg21031
Healthy:
My mistake. Actually she is not on salary. She gets paid per patient but we use group NPI for billing.
All of therapists are licensed and have their own NPI and all NPI are linked to group NPI.
RichardP:
Health, you said: She gets paid per patient ... Who pays her? Your Group? Or the insurance carrier? The answer to who pays her? will determine what my answer to you should be.
It sounds like you are discussing a Group practice, and the legal entity that is the Group has a Group NPI. It sounds like any billing would require the Group NPI (Type 2 - who gets paid) and the individual practitioner NPI (Type 1 - who did the work). I am assuming this is the case in your situation, so here are a few points to consider, based on my assumption.
If this collection of workers meets the CMS definition of "Group", then payment may not be sent to any individual practitioner within the Group for work done under the name of the Group. Payment must be sent to the legal entity that is your Group name. Payment for the charges goes to the Group, and the Group pays the individual practitioners / subcontractors for work done under the name of the Group. (Note that, if the Group allows a practitioner to work outside of the Group name, this restriction is not in force for that work done outside of the Group.)
Also, for a collection of workers who meet the CMS definition of "Group", no individual practitioner within the Group may be a participating provider in an insurance carrier plan - while working for, and being paid by, the Group. Rather, the participating provider would be the legal entity that is your Group name. (Note that, if the Group allows a practitioner to work outside of the Group name, this restriction is not in force for that work done outside of the Group.)
A nurse practitioner, and maybe a lcsw, can do business in their own name, just like a doctor (assuming certain conditions are met). In this situation, the Type 1 NPI (who did the work) and the Type 2 NPI (who gets paid) on the billing document would both belong to the nurse pratitioner or lcsw. I know that at least the nurse practitioner will get paid less if s/he bills in her own name this way. Which leads at least the nurse practioner to often bill under her employer's Type 2 NPI (who gets paid), while providing her Type 1 NPI (who did the work). Her employer gets paid at the higer rate, and turns around and pays her. The amount the employer pays her is up to the employer.
In your situation, it sounds like the employer of the lcsw is the Group. If your setup meets the CMS definition of "Group", then your Group is the participating provider in CIGNA and United Health Care - not the individual practitioners. Your lcsw would do the work, and a bill would be submitted to either CIGNA or UHC with the Group's Type 2 NPI (who gets paid) and the lcsw's Type 1 NPI (who did the work). Because the charges are being billed in the name of the Group, and the insurance carriers would recognize that the Group is a participating provider, the charges would be paid at the contracted rate. This is the required configuration for billing unless your lcsw is authorized to bill under her own name. But, if your lcsw is being paid for her work by your group, she is not allowed to bill under her own name even if she is authorized to. Billing under her own name would cause payment to go directly to her, and not to your Group. And if your Group is paying the lcsw for her work ... and she gets the money from the insurance carrier instead of your Group getting it ...
The fact that your lcsw is not credentialed with CIGNA or UHC would be an issue only if she were billing under her own name. Since she is being paid for her work by the Group, she should bill in the Group's name, not her own.
PMRNC:
--- Quote ---In your situation, it sounds like the employer of the lcsw is the Group. If your setup meets the CMS definition of "Group", then your Group is the participating provider in CIGNA and United Health Care - not the individual practitioners.
--- End quote ---
That is true however the carriers do require each joining group member to be included in the credentialing. If a group adds a provider to the group they have to notify the carrier, whether the network is closed or not. They have to submit all the paperwork as with the other providers.
--- Quote ---Your lcsw would do the work, and a bill would be submitted to either CIGNA or UHC with the Group's Type 2 NPI (who gets paid) and the lcsw's Type 1 NPI (who did the work). Because the charges are being billed in the name of the Group, and the insurance carriers would recognize that the Group is a participating provider, the charges would be paid at the contracted rate. This is the required configuration for billing unless your lcsw is authorized to bill under her own name. But, if your lcsw is being paid for her work by your group, she is not allowed to bill under her own name even if she is authorized to. Billing under her own name would cause payment to go directly to her, and not to your Group. And if your Group is paying the lcsw for her work ... and she gets the money from the insurance carrier instead of your Group getting it .
--- End quote ---
Again, true but again, the provider HAS to be credentialed With the group, otherwise the carrier would not have any clue as to the credentials of the provider, Cigna and UHC also have TPA's for most of their plans for mental health. For example UHC uses UBH and all providers have to be credentialed within the group. cigna has a few different TPA's but they all work the same way. EACH provider within the group is required to be credentialed within the group.
Just as as side note, closed networks don't always mean you can't join, if your provider/group is within a geographical location where they provide services and don't have other providers within a certain distance they can credential on an exception. Mental health providers are scarce so the closed network status should NOT be a problem because again those major carriers use TPA's and you would credential with them. For example if BCBS had closed network, a mental health provider can still credential with Magellan Behavior Health. I've never had a problem with closed networks and my mental health providers.
When I run into situations like this I don't try to figure out the legal structure of the group as that's outside my scope so I have the group consult with their attorney. I've run into situations where I was told a provider was now a part of a group and then had carrier come back and not cover because the provider wasn't credentialed with the group. Your still disclosing the rendering provider on the claims.. OR you should be anyway.
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