Melissa*Ever*Evolving
Networker
Hello, I have a difficult situation.
MD Anesthesiologist has been banned from Medicare enrollment but still has their license.
This group uses this provider as out of network for commercial carriers.
No enrollment needed to be done, so they submit commercial claims using this MD's information.
This MD occasionally will see Medicare cases due to the other Medicare-enrolled provider not being available.
A) Should this be allowed as fee-for-time billing (Q6 modifier) under the enrolled provider?
B) Since they are not credentialed as in network providers with other insurances, are they really considered to be working within the same group? Would the reciprocal billing modifier Q5 be more appropriate under the enrolled provider?
C) Or is this a situation that needs to simply not be done since the MD has no billing rights to Medicare and therefore cannot bill through other reciprocal methods? (I couldn't find anything supporting this in CMS Manuals, but if you can, please share.
Please site any sources that you may have to backup the answer so I can share with my providers.
Thank you for your feedback!
~Melissa, CPC
MD Anesthesiologist has been banned from Medicare enrollment but still has their license.
This group uses this provider as out of network for commercial carriers.
No enrollment needed to be done, so they submit commercial claims using this MD's information.
This MD occasionally will see Medicare cases due to the other Medicare-enrolled provider not being available.
A) Should this be allowed as fee-for-time billing (Q6 modifier) under the enrolled provider?
B) Since they are not credentialed as in network providers with other insurances, are they really considered to be working within the same group? Would the reciprocal billing modifier Q5 be more appropriate under the enrolled provider?
C) Or is this a situation that needs to simply not be done since the MD has no billing rights to Medicare and therefore cannot bill through other reciprocal methods? (I couldn't find anything supporting this in CMS Manuals, but if you can, please share.
Please site any sources that you may have to backup the answer so I can share with my providers.
Thank you for your feedback!
~Melissa, CPC