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Thread Topic: billing ins for a dr that is not par
Topic Originator: curious
Post Date August 6, 2006 @ 11:56 AM
billing ins for a dr that is not par

August 6, 2006 @ 11:56 AM Reply  |  Email Friend   |  |Print  |  Top

My question is that we have 3 doctors in our practice.  Only one of the doctors doesn't particpate with a few insurances.  There have been instances where patients have been seen by this non par doctor for their insurance however the claim was billed under one of the other doctors that are par so the claim doesnt get processed as out of network.  Is this legal if the par doctor were billing the claim under signs off on the chart notes for the non par doctor who actually saw the patient?

not curious
August 6, 2006 @ 12:53 PM Reply  |  Email Friend   |  |Print  |  Top

This is commonly called "fraud".

August 8, 2006 @ 4:32 PM Reply  |  Email Friend   |  |Print  |  Top

i'm fully aware of term fraud.  my question is, is it legal to bill out under the par (in network) doctor if the in network doctor is signing the par doctors notes

August 8, 2006 @ 6:35 PM Reply  |  Email Friend   |  |Print  |  Top

Of course no one has to tell you that this is a big problem. Try contacting your local Medicare to see if using  the Q5 modifier will be appropriate.

August 8, 2006 @ 7:50 PM Reply  |  Email Friend   |  |Print  |  Top

Okay, the way I read the original post is that, in order to get paid and ONLY in order to get paid, the physician who happens to be a member of XYZ insurance company jots down a "seen and agree" note just to give the appearance that he is the one seeing the patient, so they can bill it under his name and not be denied payment for "not a member provider".

It would only be appropriate if the practitioner who actually SAW the patient (as opposed to just putting a bogus note in a chart) was a student or a practitioner whose procedures are "incidental to" such as a PA or NP.  The one poster was right to say this would be called fraud.  The physicians have devised a plan whereby they are getting payment for services they are not entitled to payment for.

The Q5 modifier (reciprocal billing) would be equally inappropriate becuase

1) The provider whose number is being billed under must be unavailable to provide the visit services - clearly this one is available if he's signing charts.
2) The Medicare patient must have arranged to receive or seek to receive the services from the provider who is billing under his number - which evidently did not happen or there wouldn't be a problem - they would have just had the appointment with the member provider.
3) The substitute physician must not provide the visit services to patients over a continuous period of more than 60 days - which may or may not apply in this case, but the rest makes it irrelevant.

Furthermore, as far as I know, Q5 is only recognized by Medicare, and the original poster makes it sound like this is SOP no matter who the payer.

So, curious, unless there's facts that aren't in evidence, I agree that this is a big problem.

August 9, 2006 @ 2:33 PM Reply  |  Email Friend   |  |Print  |  Top

This is insurance fraud. I would recommend a very swift voluntary disclosure accompanied by a refund check

Ms Seay
August 9, 2006 @ 3:23 PM Reply  |  Email Friend   |  |Print  |  Top

As the other replies have stated billing under a par physician just to get paid because the providing physician is non par is absolute fraud. Should the insurance company find out the true provider of services, a refund will be necessary, and ypur office could face fines and penalties, such as the par physician being excluded from the carrier. All incidents that have occured should be written up in your compliance plan, and a good faith effort to refund the monies is appropriate.

August 13, 2006 @ 11:59 AM Reply  |  Email Friend   |  |Print  |  Top

I agree with all of your replies.  I have tried contacting our states insurance commissioner and have not received a returned phone call back.  I will try to contact them again.  Now, the hard part is I'm the only biller in our facility and I have argued this situation with my boss and she got really nasty with me.  What would all  of you do in my situation, I feel like if I keep pressing the issue without written proof that this is fraud she may fire me.

Sympathy for "courious"
August 13, 2006 @ 7:11 PM Reply  |  Email Friend   |  |Print  |  Top

I have to agree with the last comment made by "courious". I also agree this is fraud, but she asked a question to the BC Advantage "forum" to see if any "fellow medical billers" help her clarify if she is doing anything illegal. You all are jumping down her throat like a bunch of pack wolves.  She isn't the enemy here.  Just answer her with a helpful answer so she has some ligitimate proof to take to her boss and not get fired.  What would you do if you had a question about "ethical billning" and you would loose your job just for asking a question? She isn't saying she had billed under the "non-par" doctor, only that she is concerned that this may be illegal, and suspects that they may possibly ask her to bill it this way.  She came to us for advice on whether it is illegal, and  how to help her out without it costing her a job!!
So, dear courious, while these other replys were not helpful, unfortunately, I'm not a legal expert here, but do feel this is fraud.     I suggest you get out the participating contract and just show them the guidelines on who in the group is legally allowed to see that patient, and ask them if you can ask the front desk to only set up appointment's with the "par" dr in the future.   If they fire you, I'd say, CALL A LAWYER!!  I applaud you for your "good ethics in billing".  Many would not ask for fear of loosing their job, and would just have done it anyway.  As a fellow "medical biller", I am proud that you would ask this question.  To the others, get real, and just answer forums with respect to the writter of the forum, and stop answering with your "better then you attitude!
Sympathy for "courious"

August 13, 2006 @ 9:45 PM Reply  |  Email Friend   |  |Print  |  Top

I would love to talk to you about your vicious post, sympathy, but I can't see you for that huge chip you have on your shoulder.

I see no one that got "nasty".  The first poster appears to be flip, but it could also have been a lame attempt at humor.  Either way, it's not "nasty".  And I certainly don't see any judement.  I'm sure someone would have provided cites if the original poster had made it clear she needed cites.   It does not at all appear to me that she knew this was fraud and that she was merely seeking cites to take to her boss.  Quite the contrary, not until the third message, posted today,  was it made clear that she FELT like it was fraud, and was seeking factual cites to back up her contention.

Now, tell me, where's YOUR cite for the OP, and what constructive, helpful words have YOU added to the discussion?  Other than call a lawyer if she gets fired?

August 14, 2006 @ 2:47 PM Reply  |  Email Friend   |  |Print  |  Top

No, it is not - Only the MD who performed the service may bill for it except under particular circumstances such as incident to for Medicare or PATH services. As I said in my earlier e-mail regardless of the counter signature this would be a fraudulent practice

Steve Verno
August 15, 2006 @ 4:26 PM Reply  |  Email Friend   |  |Print  |  Top

To add my 2 cents less deductible.

When a provider is non-par and treats a patient, but the claim is submitted under a par provider's name just to get the claim paid, is considered fraud.  

This happened to me.  I went and was seen by Dr. A.  I know Dr. A. When I received my EOB, it showed the claim was billed under the name of Dr. B.  I also know Dr. B.  I called and told the company that I was never seen by Dr. B and that the claim should have been sent under the name of Dr. A.  I was told this is how they process claims for non-par providers.  I informed them that they could not do what they did and I was told I didn't know what I was talking about.  Long story short, I filed a complaint with my insurance company and I filed a complaint with the OIG.  This company is no longer in business.

A provider cannot submit a claim for services that he/she did not provide.  The only time when services are rendered by a provider and submitted under another provider's name is when you have a Locum Tenens situation and the use of Modifier Q6 would be required, or if you have a reciprocal billing arrangement.  The situations under both Locum Tenens and Reciprocal Billing Arrangement are similar.  Q5 would be the modifier for Reciprocal Billing.  But, if the provider is working for a practice, Locum Tenens and reciprocal Billing is not allowed.  

Now, I work for several medical billing practices.  Each practice is set up as a group arrangement.  Each provider is an employee and member of the group.  When you have a group practice, many times the contract with the insurance company is as a group contract.  The claims are submitted under the Group Tax ID number and under the Group name.  The individual provider would have his/her name listed in block 31 as the rendering provider.  The claim is processed under the Group Contract and paid per the terms of that contract.  One insurance company wants the Group to be contracted with each group provider also having individual contracts.  That is the worst thing to do because the carrier will ignore the group contract and pay per individual provider.  We ended up terminating the individual provider contracts to force the carrier to honor the group contract.

August 15, 2006 @ 4:54 PM Reply  |  Email Friend   |  |Print  |  Top

Curious, I applaude you trying to contact your insurance commisioner, this is exactly the correct thing to do in the absence of any governing cites or regulations from the plan at issue. If in fact you the claims are medicare (and perhaps your boss would take a medicare cite under advisement since many of the MC plans follow Medicare) you may find a cite in the IOM manuals I believe 100-2. Also you migh try reviewing the information on the back of the CMS 1500 form where under physician signature it states "i  certify the services listed above were medically indicated and necessary ......and were personally furnished by me or an employee under my personal direction" Clearly the other MD was not under another MD's personal direction???


August 31, 2006 @ 7:36 AM Reply  |  Email Friend   |  |Print  |  Top

I bill for a doctor who is non-par with BCBS.  We get paid (most of the time) but our big problem is BCBS sends the check to the patient.  The patient cashes the check and unless we take them to court we hardly ever get the money.  Any help on how we can get the patient to turn over the check?

Steve Verno
August 31, 2006 @ 9:00 AM Reply  |  Email Friend   |  |Print  |  Top

First thing, if your doctor is non-par, the insurance company has no legal obligation to send you anything at all.  Their obligation is to pay the benefit and to pay it to their member.  The exception is if the patient signed an Assignment of Benefit form and your State has a law that demands the insurance company accept it, but if there is no law, then the insurance company can ignore the AOB.

You have 4 choices.  
1)  Stop sending the claim for the member.  Per their contract with their insurance company, when they seek care ofrom an out of network provider, it is their responsibility to send their own claim. All you are doing is giving the patient a nice Christmas present by sending the claim so they can get the money.

2)  Collect from the member at the time of service.  You must talk to the patient about their financial responsibilities before they are seen.  You must tell the patient you are non-par and allow the patient to have the freedom of choice decision to continue with the care, knowing they have to pay or to leave and seek care from a par provider.  Now I know some will say that you don't want to do that because you'll lose patients. Well, look at it this way,  You just gave medical care for free.  You sent the claim thereby giving the member money.  The member doesn't care about you and won't pay, so what's the difference.  Only here, you spent time and money and lost it in administrative expenses and the doctor lost revenue by treating a non-paying patient.

3) You can send the patient a letter, informing them that you know they received the payment of their benefit.  They have 30 days to pay the delinquent bill.  If they do not pay, you will send a letter to the Internal Revenue Service and report them for receiving income.  You will inform the patient you will ask the IRS to audit their tax return to ensure they reported the money on their tax return.  You will also send their account to your debt collectiom agenc and once you do, not only will they have to pay 100% of the doctor's bill, but they will also have to pay the debt collection agency's fee which can be as high as 50%.  In addition to sending the patient the letter, send the insurance company a letter, informing them that they have to send their member, a 1099 form because their member must report the money on their income tax return.  if they send you the 1099, you will report this to the IRS.  Also inform the insurance company that from now on, their members will code and submit their own claims themselves.  If you do not receive payment, report the patient to the IRS.

4)  Your least favorite option is to become contracted with the insurance company.

Ms. Seay
August 31, 2006 @ 9:37 AM Reply  |  Email Friend   |  |Print  |  Top

Sympathy for curious may be sympathetic, however has no clue about billing. If you re-read the initial post, you will see that this biller indicates the office has billed charges under a non-rendering physician. The writer may not have personally performed the billing however, they are completely aware that is was done.
OKAY Here is the problem. Most medical practices are not going to find any generic "documentation" explaining fraud and/or abuse. This is why alot of practices find out the consequences the hard way. Curious may be able to find verbaige in the practices's contract with the insurance plan, and in in the Medicare Manual(which is exhaustive, so I do not recommend).
Curious your situtation is not unique, and this is why you are hearing the same word "FRAUD" over and over again. The problem is unless your practice has experienced the adverse effects of this billing practice, your case will be difficult to argue. Having someone who has worked for many practices in clearer up matter after the billing was discovered is probably the only way to get someone to listen to what you already know. Please feel free to contact me, and I will help you further. As I too, am sympathetic to your issue, I am offering my help to you without any fees or obligation.
Email me at, if you would like to discuss this further.

September 12, 2007 @ 2:57 PM Reply  |  Email Friend   |  |Print  |  Top

Imaging is the doc give the patient wrong dosage/wrong prescription?
or worst is going to be a surgery and the doc left accidentaly one of the instrument inside the patient. Who will be responsible?
The one got the money or the one did the procedure?
That is a big no no.

October 10, 2007 @ 7:32 PM Reply  |  Email Friend   |  |Print  |  Top

It is BCBS policy to pay out of net payments to the patients, unless in a state where Assignment of benefits is protected.  In Texas, assignment of benefits is protected, therefore BCBS must pay all payments to the provider assuming an assignment of benefits is in place.  My company has facilities in other states as well, and in those states we use a Blue Cross Blue Shield Out of Net agreement, it is basically a form explaining to the patient what is going to happen after they are seen.  They then sign the form agreeing when BCBS pays them they turn around and make payment to the provider.  I feel the benefit of this form is not so much in the paperwork itself, but in explaining it to the patient beforehand, and having them sign an acknowledgement that they understand.

October 10, 2007 @ 8:01 PM Reply  |  Email Friend   |  |Print  |  Top

Hi, the only way it would'nt be fraud was if your par all your dr's we're under one par dr's upin.  If they bill individually then it would be considered fraud. ex: pharmacist can only fill certain prescriptions, your asst does it but puts pharm name on presc.??? I would check with MCR, don't tell them what your clinic did though....... Good luck..

Steve Verno
October 11, 2007 @ 8:54 AM Reply  |  Email Friend   |  |Print  |  Top

BCBS, Aetna and United Healthcare all have policies that send payment to the patient when the doctor is not par.  Why do they do that?  They want the doctor to feel the pressure of not being paid so that the doctor does contract and does so by giving away most of his/her rights and to be paid an unfairly low reimbursement rate.

Now, the insurance company can do this because their contract with their member requires them to do this.

How can you fight back?  You have to take a bold step and stick to our guns.  You contract the carrier and inform them that (1)  as a non-contracted provider, you will cease sending anymore claims as a courtesy to their member so that their member gets a nice check to spend as they please.  You will demand that their member submit their own claim and (2) you inform the carrier that you will demand their members pay for the services at the time of service at 100% of your usual and customary charges.  

You MUST inform the non-par patient of your policy regarding this issue. The patient must then exercise their freedom of choice decision to continue with the care, knowing what their fiduciary requirement will be or to seek care from a network provider.

Why continue to play the insurance companies games by having you provide the care, send the claim, have them send the payment to the member, and then you fight with the patient to pay you and end up getting nothing because the patient spent the money and you complain how mean the insurance company is with you.

As I said, this is going to be a rough road to take, but it does work if you stick with it. Remember this, do you want to be paid or do you want to provide free medical care because that is what you are doing.  Your doctor spent the time with the patient, you spent money out of your pocket by sending the claim, and then sending statement after statement after statement to get nothing.  If you don't want to fight back, then just tell the non-par patient that their medical care is free.

My practices don't play the insurance companies games. We don't send the claims.  We require the patients to pay.  The insurance companies call us and complain, but I tell them we have no obligation to send a claim and I point out the section in the patients benefit manual that says if the patient seeks care from an out of netwok provider, the member has to submit their own claim.  I tell the carrier we will be glad to send the claim if they agree, in writing, to pay us 100% of our charges by sending the claim as a courtesy and we demand payment in 30 days with no games played by the carrier.  We are not signing a contract, just a letter of agreement with sending the claim. If they play any games, no more claims get sent and nothing they say will change our minds.  We also educate their member on what their insurance company is doing with their claims.  The carriers don't like what we do but there is nothing they can do about it.

Fired for exposing fraud
October 11, 2007 @ 5:06 PM Reply  |  Email Friend   |  |Print  |  Top

I was fired today because I told the physicains office that I was working for that they were doing things unethically and illegally. I found examples of these wrong doings and exposed the wrong doings to the manager and was told to drop it. That I believe is the whisle blowers act. I am contacting an lawyer and the OIG. Stand up for what is right!!

Steve Verno
October 11, 2007 @ 11:02 PM Reply  |  Email Friend   |  |Print  |  Top

Just be careful that what you are reporting is deemed to be illegal, and/or unethical.  Many times Ive been told what I am doing is illegal and fraud, when in fact, it was not.  What I was doing was backd up by coding guidelines and letters from the AMA.

See, I was told I was comitting fraud because I was billing an EKG Interp with an Emergency ED Code.

Fired for exposing fraud
October 12, 2007 @ 8:31 AM Reply  |  Email Friend   |  |Print  |  Top

I have done plenty of research, spoke with and recv guidelines from cms. This was a new practice and their wrong doing was ignorance, but the fact that they wouldnt accept the clear cpt guidelines and insurance regulations is negligence. Things that are ethical and moral were not being done.  See my post on Refunding patients.

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