Question:
I have been presented with the opportunity to join a growing practice. After meeting with the lead clinician I have the feeling something is not right in terms of medical billing practices. I don’t know a lot about getting started in private practice from a business sense and I feel that I should trust my instincts and not become involved but I am so green I wonder if I am actually missing out on a opportunity. Here is the basis of my concern…the lead clinician is paneled with insurance companies that are now closed in our area to new providers.
She has offered to add new clinicians to her panel. While the clinicians are being considered for paneling under the group’s contract she will refer patients to the new clinician (so you have business getting started) and bill under her NPI until you are accepted. She will also refer clients to you from her insurance contracts which do not have group provisions and bill under her NPI and then charge you an administrative fee when she is reimbursed and cut you a check minus the fee.
I am not experienced enough to know if this is how group practices typically work or if she is receiving some hidden benefit from appointing herself as the administrator of fees for services. I have much to learn about the business end of psychotherapy but I don’t want my first experience to be one where I am taken advantage of or found liable for something when I was simply unaware.
Any insights you might have to offer are appreciated.
Thanks!
Kara
Credentialing Answer:
Dear Kara, trust your instincts!
By billing under his or her NPI number, the provider/employer is likely committing insurance fraud, which is very serious. That being said, no one can know everything about every contract–so I do not want to accuse someone of doing something highly illegal without fully understanding the situation. However, nearly every time I have encountered a situation like this the practice of one provider using their insurance credentialing to allow another provider to see clients/patients, and bill insurance for those services, constituted insurance fraud.
To get to the bottom of it, call the insurance companies in question and ask them! They will likely be very keen to know WHO the provider is who’s using his/her NPI number to obtain reimbursement for other providers’ services. To gauge whether your potential employer
a) has a super special arrangement with the insurance companies for medical billing,
b) is committing serious fraud and not realizing it, or
c) knows that he/she is committing fraud so serious that if (more like WHEN) insurance companies find out he/she will possibly lose his/her license and have huge penalties to pay,
I recommend telling the potential employer that you’re going to call the insurance companies and tell them what he’s doing–you know “just to check” and make sure it’s kosher. Then see how he/she responds 🙂
I feel your employer’s pain! The insurance credentialing process does take 3-4 months, and it is a real bummer for providers (and employers) to wait patiently through that lengthy process. Being able to legally do what your potential employer is describing would be awesome, and would really take the pressure of credentialing new providers for private practice. Personally, it would make life a lot easier at my practices!! 🙂
Good question! I hope my answer helped!
-Anthony
Dr. Anthony Centore is CEO of Thriveworks, is Private Practice Consultant for the American Counseling Association, and Author of “How to Thrive In Counseling Private Practice.” Learn more at https://twx.atlantacounseling.com/counseling-private-practice-book/
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Anthony Centore
I was wondering I had started a job back in August as a Centralized Biller for a company that provided PDN and SNV for longterm home health pediatric children. On the 3 day of employment, I noticed that the NPI numbers were being shared selectively for certain states and for different locations. The average mileage was over 333 miles. Obviously there was a variance with counties with that great distance. I wonder why would a company share or borrow a NPI and Provider ID from one location to the next? The services that were rendered-provided were not of that billing location. I was put in a compromising situation to change and transfer patients from one location to the next because the true location did not possess a NPI and provider license. Essentially I resigned. I did not want to contribute to this unethical illegal billing practice. I question why transfer a patient when their address and nothing changed. The person that was training was not merging chart transfers essentially resulting creating a duplicate patient chart. This made me wonder if this was a way to camaphlague what they were doing. Because the only way to identify a duplicate chart is by location. Otherwise it would not show up. I inquired about why they were borrowing and billing under same NPI number where services were clearly not rendered within that specified county and they tried to minimize my concern and justify that it was legal. This I thought was important for Medicaid and Medicare. I asked for supported documentation to see if they could provide me the material that says it is alright and ethical to bill like that and I got treated very rudely and bullied to resign. They would not provide the documentation. This company got in trouble for Federal fraud 3 months prior to that and clearly they are trying to get around the system in other ways.
It was my understanding that a NPI is an individual number and identifies location- provider specific. Medicaid and Medicare CMS guidelines I can’t seem to find it written that they need a number and that it can or can not be shared. I know some commercial insurances specifically say that you need an NPI number per location, what it is they don’t realize it is shared and mirrored. Something really doesn’t feel right about any of this. This has affected so many employees job and ethics that a lot of them resigned. The thing is they had 2 different departmental steps to billing processes when one would release a bill it would go to another department and then the billing would be manually changed before it was truly released. A centralized biller would intake the information, referral, POT point of care, audit, obtain authorization, release when everything is obtained and then it would go to another department to actually bill.
I appreciate your thoughts.
Hi,
I just started at a psychologists office as the practice manager. I am trying to reestablish rules/regulations etc as it was out of control before. We have 2 dr.s here who often do evals and such for bariatric procedures. 1 of them sees the patient for the eval and the other does thereport side. They also see patients for individual counseling. No matter which circumstance, ALL billing is ALWAYS done through only 1 of them. I am afraid that they are committing fraud unknowingly. Please advise so I can rectify the situation immediately!!!
I have been working with a PhD since I was gathering my hours for my license and have recently passed the EPPP. I want to continue working with the company but she wants to continue to bill under her Medicare number even though I have my own. Is this fraud and do I have anything to be concerned about?