Wiki Legal???

[Jclong]

Are you allowed to change the provider you billed under with the primary insurance (billed under supervising physician), then use the provider of service when billing Medicare as the secondary payer? I'm just unsure if we should change a provider when we have received payment to get paid and then bill under another provider. Please help I need some guidance!!

 

[thomas7331]

I would think it would be a rare case where you would do this, but as long as both your primary and secondary claims are accurate, supported by documentation and in compliance with each payer's requirements for billing under the appropriate provider's credentials, changing the provider should not be an issue. It's only if you are putting a provider on one of the claims in a case that does not meet guidelines (e.g. billing under a supervising physician when 'incident to' requirements have not been met) in order to get a payment that would not otherwise be made that you could potentially run into problems.

 

[Jclong]

Thank you Thomas. I've just been hesitant to change due to payment under one provider due to the provider not being credentialed with an insurance and changing to get payment from Medicare. I just wanted to make sure we are in compliance with this.

 

[thomas7331]

Thank you Thomas. I've just been hesitant to change due to payment under one provider due to the provider not being credentialed with an insurance and changing to get payment from Medicare. I just wanted to make sure we are in compliance with this.

It sounds like maybe your primary claim is the one that is billed incorrectly? It would not be compliant to bill under a provider who didn't perform the service just because the actual provider isn't credentialed unless you have explicit instructions from the payer to do so. If you're changing the claim back to the correct provider, your secondary claim to Medicare will have the correct information but your primary claim could be a problem. And if the primary payer paid incorrectly based on the information on that claim, then the Medicare secondary payer will be coordinating benefits against an incorrectly paid claim. I'd be very cautious about this kind of thing.

 

[renae4028]

Yes this can happen. If the commercial insurance does not allow mid level providers or accept the MLP's NPI or your not credentialed then, depending on the payor policy, you would need to bill to the supervising MD's NPI. Medicare would go to MLP. It really comes down to payor policy and if you are par or non-par. Sometimes the commercial insurance will have medicare crossover claim software and automatically switch the crossover claims around as long as you have the MD's info in the box they indicate in policy. Then the system will pick that info up and switch automatically.

However, if you do have a contract with payor and you are par and just the MLP is new/waiting to get credentialed then I would suggest you hold claims until credentialing is complete for the MLP. unless you can find something in policy indicating to bill under MD when waiting for credentialing.

Shana Kirtley, CCS, CPC
Research Analyst, Coding Policy
TeamHealth