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Ethical, legal or illegal

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ask821:
I am new to billing and the facility I work for has hired a contracted physician. We are waiting on reassignment of his Medicare and Medicaid with our facility tax ID#.
Upper management is wanting to ask the Physician to have his office/billing service file claims for his services performed at our facility and him in turn reimburse our facility for payment on claims we can not bill for.
The other biller and I are very leery if this is ethical, legal or just plain fraudulent.
Any advice and/or suggestions are greatly appreciated.

ASK

RichardP:

--- Quote from: ask821 on November 30, 2013, 01:14:44 PM ---...We are waiting on reassignment of his Medicare and Medicaid with our facility tax ID#.
--- End quote ---

Do they want the hired doctor to bill for his own work only until the assignment of his Medicare and Medicaid is effective?  There are several ways to respond to this, depending on how you answer this question.

ask821:
The doctor was hired & started back in August to render services at our facility and we would bill and receive payment for those services. The doctor has been added to our roster for commercial insurances and I have already billed those insurances for his services. Just not Medicaid, as we are still awaiting reassignment of benefits for Medicare then Medicaid. He is a pediatric specialist, so there will be no claims submitted to Medicare, just Medicaid.

Management realized they put the cart before the horse, so to speak, hiring him so quickly without waiting for the proper credentialing and are now wanting his office/billing company to bill for the services rendered at our facility for just Medicaid.

Red flags keep popping up and I am uncomfortable with this and appreciate any advice given on how to handle this situation and protect myself if in fact this is illegal.

To answer your question Richard, yes.

RichardP:
A doctor can work on his own behalf, and bill on his own behalf.  He can also hire other doctors to work for him and pay them a salary, and bill to receive payment for the work done by the hirelings.  In this case, the hiring doctor is the billing agent.  It is to him that all payors will submit payment, based on their contracts (or lack of them) with that billing agent (the hiring doctor).

Conversely, a doctor, without giving up his right to work for himself and bill on his own behalf, can hire himself out to another doctor or legitimate medical organization.  A legitimate medical organization can hire doctors and pay them a salary, and bill to receive payment for the work done by the hirelings.  In this case, the hiring organization is the billing agent.  It is to the organization that all payors will submit payment, based on their contracts (or lack of them) with that billing agent (the hiring organization).

In your case, the only issue is whose Medicaid patients your hired doctor will be seeing.  If he is seeing patients that frequent your facility, they should have already assigned their benefits to your facility.  In this case, your facility can bill for the services performed by the hired doctor with no problem.  Medicaid will pay your organization, based on whatever contract it has with them (or doesn't have).  Your organization will pay the hired doctor his agreed-upon salary for the work he performs.

On the other hand, if the hired doctor is bringing patients with him, they need to reassign their benefits to your facility in order for your facility to get paid (otherwise, payment will go to the patients, and you will have to try to get payment from them).

It does not appear that your hired doctor needs to bill for his services to the Medicaid folks he sees, although he could.  If he did bill himself, as the billing agent, he would just need to put your organization's address as his place of service.  The assignment of benefits is actually irrelevant - other than, if Medicaid pays the patient, the doctor probably won't ever collect payment.  Medicaid rules vary from state to state, so you would need to check with your state Medicaid program about this.  They maybe need to have been notified of his additional place of service (your organization) before he can list this as a place of service on his CMS 1500 Forms.  On the other hand, if he saw the patients at your location, he can get in big-time trouble if he lists his private practice as the place of service on the CMS 1500 Forms - should he decide to bill himself.

I see nothing in what you've said that would prevent your organization from billing, as the billing agent, for all services rendered by the hired doctor.  The logic for this is laid out below.
--------------

Here is some background information.  If any of this is confusing, ask more questions.

I assume your organization, the one that is doing the hiring, has its own Taxpayer ID Number and Type 2 NPI Number.  If you don't know, you need to find out.  If your organization does not have these, let us know.  The following applies (and makes sense) only if your organization is structured as the billing agent and has its own Type 2 NPI Number for billing purposes.

From here to the end is quoted from this link:

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

[Edit:  as of 4-18-13, the following quote is found under Section A of Page 59]

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf

The question of reassignment arises only when assigned payment is made to someone other than the physician or other practitioner or supplier that furnished the services.

A supplier may be an individual, partnership, corporation, trust, or estate. Any services furnished by an employee of the supplier are considered furnished by the supplier if those services are within the scope of the employment.   [end quote]

Doctors groups may hire physicians and pay them a salary.  A doctor who has incorporated may hire physicians and pay them a salary.  A doctor acting as a sole proprietorship may hire physicians and pay them a salary.  All work done is billed under the name of the hiring group or physician.  The hiring group or physician gets paid and then pays the hireling(s) a salary.

One of the points of the NPI numbers was to make this relationship more clear to CMS.  Hence the Type 1 (who did the work) and Type 2 (who gets paid) NPI numbers.  Both must be used on the CMS 1500 form that is submitted to Medicare.  One tells CMS who did the work, and the other tells CMS who gets paid.  In the case of a solo practitioner, both of the NPI numbers provided on the CMS 1500 form belong to him.  In the case where the work was actually performed by a hireling, the CMS 1500 form must contain the Type 1 NPI number for who did the work (the hireling), plus the Type 2 NPI number for who gets paid (the hirer).

On the CMS 1500 Form, the Type 2 NPI number for who gets paid goes in Box 33.  The Type 1 NPI number for who did the work goes in Box 24J.  The Type 1 NPI number for the referring doctor (if any) goes in Box 17a.  This is how we do it and we have no problems getting paid.

tallmanusa:
Thanks Richard for a detailed answer.
I come across this problem sometimes when a clinic manager wants to sign our contract on behalf of the entity and not the provider.

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