Wiki Incident to

[dgarrett10]

Provider wants all his claims to be billed as incident to. Most of his claims do not meet incident to Medicare guidelines. I have educated him and management on incident to billing. He says everybody bills all claims incident to, but I have a problem billing claims incident to, that do not qualify. He seems to think that he can't be audited. I feel I have done my part, but I refuse to bill claims out that are not truly incident to. PLEASE help should I bill these out at the providers request or find other employment? No one seems to think it's a problem but me even with the Medicare guidelines.

 

[CodingKing]

If nothing you try/do works, it may be time to find another job. By just submitting them you could be violating the false claims act. If they threaten to fire you if you don't you can only claim duress so long. If the numbers are high consider consulting a qui tam lawyer if Medicare/Medicaid is involved, just be sure to document as much as you can to cover your rear.

Maybe see what others have to say on here before taking drastic measures.

 

[thomas7331]

Can you perhaps explain a little more or give some examples of what services these are and why the provider wants them billed 'incident to'? Whose services does he want billed 'incident to' whom? And why you feel that they do not meet the guidelines?

 

[dgarrett10]

incident to

PA claims, no plan of care documented by provider for initial visit, diagnosis not related to prior visits seen by provider, AWV's, nursing home visits seen by PA, provider is out of office and still wants to bill incident to, New patients are seen by PA, and patient comes in with a new problem only seeing PA. I have provided the Incident to guidelines, but provider insist on billing every claim the PA sees as incident to? HELP

 

[thomas7331]

PA claims, no plan of care documented by provider for initial visit, diagnosis not related to prior visits seen by provider, AWV's, nursing home visits seen by PA, provider is out of office and still wants to bill incident to, New patients are seen by PA, and patient comes in with a new problem only seeing PA. I have provided the Incident to guidelines, but provider insist on billing every claim the PA sees as incident to? HELP

You are correct then, and these situations do not qualify to be billed under a supervising physician. And for Medicare at least, this would indeed cause an overpayment since a PA is paid at a reduced rate, so these would be false claims. If showing them the guidelines is not sufficient and you cannot resolve this on your own, then I'd recommend as a next step finding a neutral outside person to offer an opinion. Would the providers be willing to accept the opinion of a professional audit firm or compliance consultant? Or perhaps you could ask that the practice's legal advisors weigh in on this? Another thought I'd recommend is going through some OIG and professional compliance publications - you should be able to find examples of some physician practices that have actually been cited or penalized for improper billing of 'incident to' services - print those out and show them to your providers to help them understand the risk they're putting themselves at by doing this. If all else fails, then CodingKing's advice in the post above might be the only way to go, but if you are persistent and professional, and make it clear to them that doing the right thing is for their own benefit, hopefully you will be able to get through to them.