Regulation of Medicine

Article

Billing Under Another Provider's Number Can Land Physicians in Hot Water

By: Raj Shah, Esq., Baker Swain

In 2018, CityMD, the largest urgent care company in the New York area, paid over $6.6 million to resolve allegations under the False Claims Act that non-credentialed physicians billed the government using the National Provider Identification (NPI) numbers of physicians who did not provide the services. Similarly, in 2021, a West Virginia hospital had to pay the government over $320,000 to resolve allegations that it had filed claims for services performed by a non-credentialed physician who used the NPI of a credentialed physician. Likewise, an Oklahoma physician agreed to pay the government $580,000 to resolve allegations that the physician violated the False Claims Act because the physician allowed the company that employed him to use his NPI to bill Medicare for physical therapy evaluation and management services furnished by other providers.

As a reminder, services generally must be billed under the name and NPI of the provider who actually performed the services. Billing under one provider’s name and NPI for services that are furnished by another provider may be fraudulent if the identity of the person performing the services would be material to the government’s decision to pay the claim.

The government does, however, generally permit the services of one provider to be billed under the name and NPI of another provider in two circumstances. First, where the services of auxiliary personnel (including both physicians and non-physician practitioners) are billed “incident to” the professional services of a physician. Second, where the services of a substitute physician are billed under the regular, but unavailable, physician’s name and NPI on a temporary basis (“locum tenens”[1] and “reciprocal billing” arrangements).

The “incident to” billing rules have strict requirements and only apply to certain services. The requirements can be found here starting at section 60. Locum tenens and reciprocal billing arrangements have very specific and stringent requirements, which can be found here in sections 30.2.10 and 30.2.11. Failure to strictly comply with the requirements for each billing arrangement could subject providers to significant liability under the False Claims Act.

Importantly, the “incident to,” locum tenens, and reciprocal billing rules are Medicare rules and may not apply in the context of private payer billing. Check with your commercial payer to determine whether billing the services of one provider under another provider’s name and NPI is allowed under your contract. Also check with your commercial payer to see if your contract describes the process for billing under the “incident to,” locum tenens, and reciprocal billing arrangements.

Key Takeaway    

Before billing for services by one provider under the name and NPI of another provider, healthcare organizations must be intimately familiar with the rules and requirements where such billing is allowed. Although practices may be able to bill non-credentialed physician’s services with a credentialed physician’s NPI under Medicare’s “incident to” rules, commercial payers may not allow “incident to” billing. Similarly, commercial payers may not allow locum tenens or reciprocal billing arrangements.

Billing under another provider’s name and NPI without complying with Medicare’s strict requirements for “incident to,” locum tenens, and reciprocal billing arrangements can spell big trouble for healthcare organizations, including fines and treble damages under the False Claims Act for claims submitted to the government. Billing under another provider’s name and NPI can also violate commercial payer contracts and include criminal liability under the federal health care fraud statute for claims submitted either to the government or to private insurance providers.

Best Practices

In instances where you have to bill services under another physician’s NPI number, here are the best practices to ensure compliance

Know your health plan contracts.

Although Medicare allows for “incident to,” locum tenens, and reciprocal billing arrangements in certain, narrow circumstances, private billers may not. Billing providers will indicate whether they cover billing under these arrangements in your contract.

Include direct supervision attestation statements for “incident to” billing arrangements.

Permissible “incident to” billing requires direct supervision from the supervising physician. These statements should document how the supervising physician supervised the non-credentialed physician during the patient encounter.

Document everything when billing under these arrangements.

A healthcare organization must retain records of the locum physician’s NPI and all the services that the locum physician provided. Having this documentation will benefit the organization in the event of an audit.

Develop processes and procedures for system billing edits.

Billing errors are common when billing under these arrangements. Choosing the incorrect billing arrangement can lead to regulatory penalties and audits. Communication among practitioners, clinical staff, and billing staff (if applicable) is essential to determine accuracy when billing under these arrangements.

Develop processes and procedures for tracking locum tenens physicians and reciprocal billing arrangements.

Billing requirements for locum tenens and reciprocal billing arrangements also have timing requirements for when to bill the substitute or regular physician. Tracking how long the regular physician has been absent and how long the locum tenens physician has been at the organization will help prevent these types of billing errors.

 

Additional Resources

McBrayer, PLLC – “Incident to” Billing – Easy to Get Wrong

Experity – Billing for Non-Credentialed & Non-Contracted Providers

HBE Advisors LLC – “Incident to” and Fee-for-Time Arrangements (Locum Tenens): A Roadmap for Compliance

Noridian Healthcare Solutions LLC – Fee-for-Time Compensation Arrangements and Reciprocal Billing

 

[1] The Centers for Medicare & Medicaid Services (CMS) now uses the term “fee-for-time compensation arrangement” to refer to locum tenens billing arrangements. This article uses the historical term “locum tenens” for these arrangements.

 

07/21

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Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.