Gastroenterology Coding Alert

Practice Management:

Think Twice Before Billing Encounters Under Another Physician’s Credentials

Published on Tue Sep 26, 2023

Hint: Situations where you can legally use another physician’s information must meet specific criteria.

Picture this: Your practice recently hired a new gastroenterologist who is contracted with only two payers. One of the other doctors is frustrated that the new employee cannot yet shoulder much of the workload. The established doctor says, “Just use my information to bill the new doc’s encounters.”

This might bring in some money, but would following through be flirting with disaster? At the very least, you should expect an uncomfortable visit from a federal regulatory agency.

Go by the Book

The Office of Inspector General (OIG), which audits organizations for fraud, emphasizes that most stakeholders in the U.S. healthcare system rely on physician honesty for both quality of patient care and integrity of documentation and reporting of that care.

The OIG explains: “Because the Government invests so much trust in physicians on the front end, Congress provided powerful criminal, civil, and administrative enforcement tools for instances when unscrupulous providers abuse that trust. The Government has broad capabilities to audit claims and investigate providers when it has a reason to suspect fraud. Suspicion of fraud and abuse may be raised by irregular billing patterns or reports from others, including your staff, competitors, and patients.”

Of course, there are some situations where providers can bill their services under another physician’s information. Many commercial carriers follow the lead of the Centers for Medicare & Medicaid Services (CMS) when determining when organizations can legally bill services in this manner.

For example, Medicare may reimburse an organization when an encounter involves incident-to services, Locum Tenens agreements, or reciprocal billing. Providers may be legally allowed to bill the services they provide under a different physician’s information, but only when very specific criteria are met. In some of these situations, like incident-to services, the reimbursement rate may be different for nonphysician practitioners (NPPs) than physicians.

Different payers may have different policies for each of these situations, but MACs provide information on Medicare’s perspective on these situations — which, again, tend to form the foundation for many commercial carrier policies.

Intentionally billing services rendered by one “uncredentialed” physician under a credentialed physician’s information probably does not fall into any of the aforementioned scenarios.

Do This Instead

If you could turn back time, you could start credentialing the new physician before their first day of work. “I recommend as soon as contracts are signed,” says Christine M. Speroni, CPC, CEMC, manager of revenue cycle at NHPP Gynecologic Oncology.

But even if you’re a wizard at credentialing new providers, you may still have some lag time. Speroni offers some recommendations on how to utilize a provider while minimizing any compromising behavior.

Funnel self-pay patients and patients who have the credentialed insurance to the new provider. While you may spread patients out to various physicians in the practice eventually, right now you can try and schedule patients according to their payer.

Check the retroactive participation date for respective payers. Some payers may allow retroactive participation for providers they credential; if you find any that do, make sure patients with that insurance are also funneled to the new provider.

Assign the new provider to attend to services that aren’t billable. There’s plenty of work for providers that cannot be billed, including services like prescription renewal phone calls, talking through test results with patients, postoperative care that falls under global care, peer-to-peer authorization reviews, or rounding at a hospital if another physician also saw the respective patients that same day.

Describe the new provider as out of network, and let patients decide whether to see them. If you go this route, make sure you provide good faith estimates to patients. Patients may want to see the new, out of network provider if they will be seen earlier than a fully booked credentialed physician.