# Is this legal?



## dballard2004 (Jul 26, 2011)

Has anyone else experieinced this before.....I am speaking here about retail clinics.


We have a specific payer that will not allow mid level providers (mainly NPs) to bill anything higher than a 99213.  Even if the visit meets the criteria and medical necessity for a 99214 or 99215, we have to downcode to a level 3 visit.  This payer's rationele is that retail clinics are not intended to take the place of or act as a PCP's office and are only intended to be used as a convenience for certain services.  

I have experienced this before with other payers and mid level providers in a physician's office.

My mid level providers who work on the retail side are angry and upset by this.  They are questioning if this is legal and how this payer can tell us that we can't code our patients as a 99214 if it is warranted.  Personally, I have experienced this before, so I don't think we have a leg to stand on here, but I am curious about what other think of this.

Thanks.


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## btadlock1 (Jul 26, 2011)

dballard2004 said:


> Has anyone else experieinced this before.....I am speaking here about retail clinics.
> 
> 
> We have a specific payer that will not allow mid level providers (mainly NPs) to bill anything higher than a 99213.  Even if the visit meets the criteria and medical necessity for a 99214 or 99215, we have to downcode to a level 3 visit.  This payer's rationele is that retail clinics are not intended to take the place of or act as a PCP's office and are only intended to be used as a convenience for certain services.
> ...



I _sort of _understand their rationale to an extent; retail clinics are supposed to be for acute minor problems (eg, colds, sinus infections, etc.) - things that are supposed to be within the '99213' problem area. Patients that require management of several chronic issues should be taking those to a PCP, so that only leaves high level visits for more problematic acute conditions.
The issue here is, you can't *control *who walks into your retail clinic. If someone comes in with a more severe problem and it can be evaluated and/or treated there within the provider's scope of practice, are you supposed to turn them away because they're "too severe"? I don't think that would be ethical or legal, and that's the position they're trying to put you in. 

If they have written protocol regarding this issue, you may have your hands tied - particularly if it's stated in your contract. Even if it _is_ the rule, though, they should be willing to make exceptions on a case-by-case basis. I would try appealing with medical records showing why a higher level visit is justified, acknowledging that it's not the norm for the typical patient encounters at that location, and emphasizing how much money you inevitably saved them by avoiding a trip to the ER over something that could be handled at a lower rate of reimbursement. Then I'd review my contract with this payer to see if it's worth it to renegotiate in the future. If you don't get anywhere, take this to the state board in charge of licensing your practitioner and to your state's insurance department. You may even be able to get assistance from a provider advocacy group - I know that many APN's and PA's have state-wide organizations that would be glad to assist you in a situation like this one. Good luck to you!


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## mitchellde (Jul 26, 2011)

I have come accross some states where they have policies that a midlevel may not PERFORM higher than a level 3 or 4 level of care, with the rationale that patients needing that intensive of service must be evaluated by an MD/DO.  I do not like the idea of downcoding but a retail clinic seeing a patient with a level 4 or 5 does not sound right.


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## dballard2004 (Jul 26, 2011)

My thanks to both of you for your insight.

What is happening here is not really all that unusual in the payer world.  I have experienced this before with other payers.  We have a couple of payers who will not credential a mid level provider (NP or PA) working in a physician's office.  We have to bill the mid level provider's services under the physician with HCPCS modifier SA to indicate the services were being performed by the mid level provider so payment can be assigned.

Again, this is not unusual at all because doesn't Medicare only reimburse a mid level provider at 85% of the fee schedule?


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