Wiki Optumn Health/UHC medical review questions

[ppma]

I have one UHC contracted provider and one non UHC ontracted provider in the same office. There is a patient who has been seeing both doctors, couple of times pt was seen by the non contracted provider but billed under the contracted provider's name. If UHC requests for the medical review, will the contracted provider have trouble for billing a dos was not seen by him? I would appreciate for any input for this situation. Thanks in advance!

 

[ajs]

I have one UHC contracted provider and one non UHC ontracted provider in the same office. There is a patient who has been seeing both doctors, couple of times pt was seen by the non contracted provider but billed under the contracted provider's name. If UHC requests for the medical review, will the contracted provider have trouble for billing a dos was not seen by him? I would appreciate for any input for this situation. Thanks in advance!

In a word, yes. If the patient is seen by the non-contracted provider, then you must bill under that provider and the patient needs to know that they may be responsible for a larger out of pocket expense. If the non-contracted provider was "on-call" for the contracted provider who was not in the office, you might be able to justify it that way. But in general you must bill under the provider who actually sees the patient, and in an audit UHC will probably be asking for a refund.

 

[losborn]

Arlene is correct.
First of all, the Par and non-PAR rates will be different; and secondly, the claim must identify the rendering physician. Indicating the wrong physician provided the care could even open liability under the Flase Claims Act if a pattern can be established.

Lin

CPC, CEMC, CPMA

 

[ppma]

Thanks for both of your input!!