Wiki Co-Management

[LRizzitano]

The ophthalmology office I work for does some co-management with some local optometrists. One of the offices uses a billing agency and is having some difficulties with these claims and has ended up not getting paid and giving up on more than a few occasions due to the cost of resending the claims and the amount of the reimbursement. Is it legal for us to bill the surgeries without the co-management modifiers and just give them a check for what the 20% would be?? I will keep a spreadsheet and a file with the EOPs so if there were ever a question in regard to the amount, we have the initial payment information.

We understand this is not the ideal. We co-manage with other offices without an issue. It is really a matter of no longer doing co-management with him due to the "administrative headaches" as he calls it. We are just trying to confirm that this is legal.

Thanks
Lisa

 

[thomas7331]

To confirm if something is legal or not, you would really need to ask an attorney who has knowledge of your state and local laws.

From the perspective of the payer, my thoughts are that as long as it makes no difference in the amount that is paid, then this is likely not going to be an issue for them. In other words, if you know for a fact that the 20% that you'd be giving these optometrists would be the same amount that they'd be getting if they billed their portion to the payer independently, and that the optometrists are in the same networks and will incur the same patient share as they would in either situation, then the payer is unlikely to give you trouble with this. But if the optometrists are under a different contract with the payer and would receive a different amount for their services, or the patients' benefits would be any different, then I would strongly advise against doing this as you'd be reporting inaccurate information on your claims that materially affects payment, which could put you at risk.

But you also need to consider that from a tax reporting perspective, if your optometrists are under a different TIN than your eye surgeons, then in addition to paying them the 20%, you'll need to be doing the tax reporting for this transaction since it's not an internal transfer of funds within the organization, and the payer will have reported that revenue under the surgeon's TIN. So in addition to getting an attorney to look at the legality, you'll need to involve your accountants to ensure that all the revenue is reported correctly. It may end up being a bigger administrative burden to consider all of this than just dealing with the denials.