Medicare Compliance & Reimbursement
Avoid On-Call Fraud Accusations with These FAQs
Beware: You can't capture ER coverage services with after-hours codes. If you bill incorrectly when your physician covers for others -- or when another physician covers for your physician -- you could be setting yourself up for charges of fraud. Don't stress: Remember just a few simple answers to the top three on-call billing questions, and you'll be ready to correctly file claims. 1. Which Physician Bills for the Services? If your physician is on call and handling patient services for another physician, don't fall into the trap of letting the other physician bill for the services. Even though a patient sees a particular physician, that does not mean that physician can bill for any services related to that patient's care. When your physician provides a service, even while on call for another doctor, you should bill the services. Check the NPI: Each doctor who sees a patient should bill for the appropriate services rendered, under his/her own NPI (National Provider Identifier) number. The key: Whoever sees the patient face to face and documents and signs his/her name should be the one billing for those services provided regardless of who the admitting surgeon is. 2. How Do You Report On-Call ER Services? Often, physicians see patients in the emergency department while on call. Don't turn to the after-hours codes to bill for these services when the hospital pays your physician for on-call status. Reasoning: If the hospital is already paying the physician to be the on-call physician in the emergency room (ER), you cannot double-bill for his services. You should bill the after-hours codes 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed [e.g., holidays, Saturday or Sunday], in addition to basic service) and 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) only when your physician sees a patient in your office outside regular office hours and another third party is not compensating him for his time. Example: If your office closes at 5 p.m. but your physician sees a patient on an emergency basis at 7 p.m., report 99050 in addition to any other services provided. If your physician saw the patient in the emergency room at 7 p.m., you should not report 99050. Keep in mind: Not all insurers will pay you for the after-hours codes. 3. Can We Skip Billing Altogether? You may be tempted to simply arrange a quid-pro-quo arrangement with other practices for your physicians to cover for one another at various times. This sets your practice up for financial liability and lost reimbursement, however. "Reciprocal billing" works only for two practices that have similar size practices with similar patient make-ups (similar acuity) and whose doctors perform nearly equal coverage. Here's why: While this type of arrangement saves on paperwork, assuming that the workloads between the physicians will all even out over time isn't realistic. One physician might end up with a very time-consuming patient to deal with -- for example, one who just had surgery. Assuming that the inequities will all balance outin the end just doesn't work. Each physician should bill for the work he performs. Tip: You may want to consider having a healthcare attorney review your on-call billing arrangements to be sure you're not fraudulently reporting services. Medicare, however, does recognize "reciprocal billing" and even has a modifier to indicate when you are participating in reciprocal billing. You'll use modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement) to indicate to your Medicare carriers that you're participating in a reciprocal billing arrangement. Private payers, on the other hand, don't require a modifier when you're doing reciprocal billing. Caution: Remember, by using the Q5 modifier, you are telling Medicare that the billing physician is not the actual rendering physician. Without a modifier, a private payer who has not given you a sanction in writing for reciprocal billing may construe it as billing for services that were not provided.
Medicare Compliance & Reimbursement
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