Wiki using the same Dr to bill as surgeon and assistant surgeon

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chrisgiron2

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I have recently taken over the coding and billing for a large obgyn practice. When the Dr does a c section sometimes they use assistants that are not in network with our plan. The past billing company has been billing the insurance company for the Dr's portion of the surgery and also using that same Dr's name to bill for the assistant surgeon when those not in network are used. I this legal? Please help !!!!! Is there something in writing i can show my supervisor that is is incorrect?
 
I literally just had this conversation with our senior partner and it's definitely illegal to bill under a provider that did not perform the service. A simple google search and you will find tons of providers that have had to pay money back to Medicaid and Medicare for doing this. The only way I can see them getting away with this is in the past is because the billing Doctor was actually supervising the surgery since he is listed as the primary surgeon. I am more intrigued on how they are getting paid on both the primary and assistant codes if the same surgeon is listed. Anyway, I hope this helps you find what you need and if you find any information that contradicts what I have posted, please share it. I am always looking for more information regarding this. Thanks

Sincerely,

Chelsea
 
a physician cannot physically be two people at the same time. I am surprised you have not received takebacks on this if you were paid. It is wrong to represent a service as something other than what it was in order to receive reimbursement. If the assistant is out of network then you must let that be, if you knew this ahead of time then you knew it is was wrong to use them as an assist without first informing the patient. There are so many ways this is wrong, go and look at your fraud and abuse information, that would be a great starting point.
 
Agree 100% with the above responses. Billing one physician's services under a different provider's credentials is only allowed in certain circumstances such as locum tenens arrangements or 'incident to' billing, but neither of those would apply in the scenario you describe. If the past billing company was putting a different physician's credentials on the claim than the one who performed the service, that is incorrect information on the claim and, simply put, a false claim. If this is being done intentionally to obtain payment that would not otherwise be made, then it could be considered fraudulent. You shouldn't need something in writing for this - on the contrary, the 'burden of proof' should be on the billing company or your supervisor to show that there is a payer policy or something in writing that would show that the payer has specifically instructed that they wish the claims to submitted this way.

Here's an example of a practice that was investigated for similar wrongdoing: https://www.justice.gov/usao-wdpa/pr/false-claims-act-violation-upmc-resolved-25-million
 
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most assistants aren't contracted with insurance because the plans don't allow them to be. My assistants still bill out to the insurance, but have a max bill rate of $350-$400 to the patient if the claims denies
 
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