General Category > General Questions
Third Party Billing Regulations by State
tallmanusa:
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.
PMRNC:
--- Quote ---there is no prohibition for percentage billing for commercial insurances and medicare, ONLY medicaid.
--- End quote ---
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
tallmanusa:
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:
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:
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
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