# Billing provider



## NMURPHY8366 (Apr 11, 2017)

Hello. I work for a pain management company and they are using a provider as the billing provider who was not present at that office on that particular dos. Can this be done?


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## thomas7331 (Apr 11, 2017)

Generally speaking, professional claims have fields for the entity who will be paid, sometimes called the 'billing provider', and the entity who performed the services, the 'servicing provider'.  The servicing provider must be the provider who actually performed the services, or was present in the office for any services billed as 'incident to' and that NPI goes in box 24J of the paper form.  That provider may assign their benefits to another provider or group, for example if they are an employee of a practice or another physician, and that is the provider which would be billed on the claim as the 'billing provider' in box 31 of the form - since that provider is an ownership entity, they do not necessarily have to be present in the office.


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## CodingKing (Apr 11, 2017)

If its a group practice, the practice should have its own TIN and type 2 NPI. Unless its a solo practitioner, the pay to NPI should not be an individual type 1 NPI. Dr may own the group but a group is not a person.


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## NMURPHY8366 (Apr 12, 2017)

*billing provider*

I know where the billing provider goes versus rendering provider and I'm fimiliar with the fields on a claim, I guess I was more concerned if you could bill a claim with a billing provider who was not present in the office at the time of service?  Also, if an MA sees the patient, can you bill the claim with the claim with the billing and rendering provider under the provider's name if he did not perform the visit that day?  Last question is, can you use the CEO's name as the referring provider on your claims?


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## thomas7331 (Apr 12, 2017)

NMURPHY8366 said:


> I know where the billing provider goes versus rendering provider and I'm fimiliar with the fields on a claim, I guess I was more concerned if you could bill a claim with a billing provider who was not present in the office at the time of service?  Also, if an MA sees the patient, can you bill the claim with the claim with the billing and rendering provider under the provider's name if he did not perform the visit that day?  Last question is, can you use the CEO's name as the referring provider on your claims?



These are hard questions to answer without knowing the specifics and without being able to look at the claims and the medical records.  A billing provider does not have to be in the office if, as CodingKing points out above, this is a 'pay to' provider and if the rendering provider is correctly represented on the claim.  And a MA can see a patient and bill the claim under a supervising provider's name if the services meet the definitions of 'incident to' and the supervision requirements are met - the provider does not necessarily have to see the patient that day.  

As far as the referring provider, that's a more difficult question.  The referring provider should be just that - the provider who referred the patient or ordered the service.  Can the CEO's name is be used?  Yes, if that's who requested the service.  If not, then the claims are potentially inaccurate.  Inaccurate claims in the best case are poor quality issue, but in the worst case only a legal or fraud issue if they are causing a material difference in how the claims are paid.  To know whether or not this is a big concern would require looking at the situation in a lot more detail.


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## NMURPHY8366 (Apr 12, 2017)

thank you Thomas1733. I appreciate your advice on this. I came from a Hospital base setting to a pain management setting and they do things alot differently here. I was always told in school that the billing provider does not have to see the patient, however he/she had to be present in that office in order to use them on the claim. So thats where my confusion came in. Do you know where I can get documentation on the referring provider question?  I want to make I and my manager understands when its appropriate to use the CEO in the referring physician field.


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