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Discussion

Is this Fraud?

I work in a Podiatry practice. They bill every visit on the physicians number. I do have an NPI number as does the other NP that works with me. We work independently, physician not on site, she works opposite days. So we are seeing new patients, follow ups everything and they only bill on the physician. I know about "incident to" billing and it seems like this practice is not following those rules

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    Seems like that to me too. It's my understanding that this is only allowable if the physician has also seen the patient face to face the same day.

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    Seems like that to me too. It's my understanding that this is only allowable if the physician has also seen the patient face to face the same day.

    This is not correct. Incident-to billing allows for billing under the physician NPI at a higher rate as long as the NP/PA is following the alread-established diagnosis. Adding something new requires billing under your own number. Here is an article listing the rules for incident-to: Incident-to billing: Clearing up the confusion | Medical Economics

    Fortunately, you won't go to jail for doing this, and many practices do it. Usually, an audit, warning and fine come first. Some practices get away with it for years before being caught.

    You can, however, lose your NP license depending on the scope of practice in your state.

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    Good article. It may be obvious that I don't deal with billing, but: the author seems to indicate that this does not apply the to vast majority of insurance companies in their experience.

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    • Author

    I think it is only Medicare. Which is the majority of our elderly clients in the practice

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    The physician does not necessarily have to see the patient on the same day, but should see at least once a year...BUT...to bill under the MD/DO/DPM license, they must be on site otherwise the billing should be under you. Same goes if you see the patient for a new complaint...if you are initiating the visit...it should be under your NPI unless you have the physician see the patient on the same visit. Real tricky. Is it abused? I am sure it is!

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    • Author

    So we are being asked to change to provider to the physician when we do the superbill in our charting. I'm feeling uncomfortable. Yesterday for instance I saw 3 brand new patients. How can that be billed under the physician if she is not on site?

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    • Experts

    It depends on the insurance. If this is private insurance then its per the contract. Since many private insurance companies don't credential NPs they instruct the office to bill under the physicians NPI. On the other hand, for Medicare, new patients must be billed under the NPs NPI. For incident to the patient must be seen first by the physician and then the physician must be present in the suite of offices to bill for incident to. So if everything is being billed under the podiatrist as you describe, then its fraud.

    The other question is scope of practice. In a collaboration state does the nursing or medical board allow a collaborating podiatrist? On the PA side only 5 states specifically allow this (one allows PAs to work with podiatrists but the SP must be an MD/DO). In independent states, what training program encompasses podiatry? I think this would be hard to back up in court.

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    • Author

    I was told by the nursing board here in Massachusetts I do not need a collaborating physician at all if I am not prescribing. I was told it is only needed for prescriptive practice. I do not have my DEA I do not prescribe everything goes thru her for prescriptions. I see the patient and write the plan which may include a script but it goes thru her dea. She did it want to pay the extra fees to have other providers writing scripts.

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    • Experts
    I was told by the nursing board here in Massachusetts I do not need a collaborating physician at all if I am not prescribing. I was told it is only needed for prescriptive practice. I do not have my DEA I do not prescribe everything goes thru her for prescriptions. I see the patient and write the plan which may include a script but it goes thru her dea. She did it want to pay the extra fees to have other providers writing scripts.

    I hope you have that in writing from the Board of Nursing as in my state when the guard changes the rules sometimes change and I would think monitoring the diagnoses a NP assigns would be as important as prescribing in states that require supervision.

    Also how much is she paying you? Podiatry from what I've heard is one of the biggies as far as income. That is very odd that she doesn't want you to prescribe. I haven't ever heard there are fees other than the licenses which are not significant. Our value is usually in our ability to prescribe.

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    • Author

    She said the fee for additional prescribers for electronic prescribing is too much and she doesn't want to pay it. I feel I am UNDER paid for sure $50 an hour.

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    • Experts
    She said the fee for additional prescribers for electronic prescribing is too much and she doesn't want to pay it. I feel I am UNDER paid for sure $50 an hour.

    Although you are underpaid for a NP she isn't allowing you to work as a NP so I guess not a bad rate for a glorified RN? My guess is its more about controlling the practice than the money and since she is billing the full boat no loss of income for her either way. :(

    Have you thought about how this experience is going to translate into your next job? Without prescribing experience any future employers will probably attempt to pigeon hole you as a newbie unless you have experience prescribing from other jobs. This sounds like a great deal for your doc and a cruddy deal for you.

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    • Author

    I have prescribing experience as I worked in internal medicine for years and I also have a psych job right now that I do 1 day a week and I prescribe there. I only do 1 day a week in Podiatry. It is not in my long term plans to be working as an NP in this capacity. I have an essential oil business and Teach alternative health classes. I plan to leave podiatry in about 2 months and just keep my psych job along with my essential oil business. I have a few companies I work with to help them utilize the oils in practice.

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