Is this legal or illegal?

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  1. Is this legal or illegal?

    • 7
      Legal
    • 1
      Illegal
    • 2
      Not sure

10 members have participated

Specializes in Adult/Geriatric.

Is this legal or illegal? What would you do in this situation?

Company A that you work for says that you have to see your nursing home patients a minimum of twice a month (including the monthly visit) even if there is no medical necessity for the second visit. Medicare guidelines say that nursing home patients should be seen for required monthly visits…. And other medically necessary visits.” Company A says there is no legal problem here because it does not get paid from Medicare. They say it has a contract with Insurance company B that pays them a set amount per patient each month regardless of number of visits.

What would you do?

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Specializes in Critical Care.

I'm not really sure why you think it might be illegal. Your employer wants you to see patients more than the minimum required for reimbursement, and they aren't seeking additional reimbursement for these extra visits. There's no false billing occurring or billing for unnecessary visits?

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It sounds like you are seeing them more than what the minimum $$$$$$ wants you to. Logically, that seems like a great idea...more frequent reassessment! Are you concerned that by having 2 nursing assessments per month instead of 1, you are causing them increased financial hardship without due cause? Because their insurance will not cover a second visit without a proper reason?

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Specializes in Nephrology, Cardiology, ER, ICU.

Hi there - I work in nephrology and we are required to see our dialysis pts a total of 4 times/month (usually MD sees 1/4 of these visits)

Is your reimbursement "bundled" - meaning the company receives a set amt for these visits? Or do you bill for each visit separately?

Also - I moved thread to APRN forum

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Specializes in Adult/Geriatric.

Thank you for your answers. Im not talking about my employer.

Company A wants the NP to bill for 2 visits even if one of the visits is not medically necessary. They get paid a set amount per head regardless of number of visits made.

How is it legal if Medicare rules don't allow for medically unnecessary visits? Does it become legal because the company gets paid from the insurance company and not directly from Medicare? Very confusing 🤔

What's the difference between an NP Forum and an APRN forum?

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Thank you for your answers. Im not talking about my employer.

Company A wants the NP to bill for 2 visits even if one of the visits is not medically necessary. They get paid a set amount per head regardless of number of visits made.

How is it legal if Medicare rules don't allow for medically unnecessary visits? Does it become legal because the company gets paid from the insurance company and not directly from Medicare? Very confusing í ¾í´”

What's the difference between an NP Forum and an APRN forum?

Each insurer has their own rules. It sounds like you are in some kind of captitated plan. You get paid no matter how many times you see the patient. Medical necessity has nothing to do with it. Usually you do extensive modeling to make sure you don't lose money on these plans. Lets say you get paid $200 per patient per month but don't don't get paid anything if they end up in the hospital. Lets say you decrease your admissions by 50% by seeing the patient twice a month instead of once. Then most likely it save (makes the company) money seeing the patients more often. If its not medicare then the rules are per the insurance company. If they don't pay per then their nothing against it.

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Specializes in Hospice, corrections, psychiatry, rehab, LTC.

Company A is paid a flat monthly fee per patient, so there is no profit motive for the second visit. They are not defrauding Medicare, because they aren't paid by them. I see no issue with it.

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Specializes in DHSc, PA-C.

If they are in a nursing home and have medical conditions, then a visit twice a month can certainly be deemed necessary and good care. Seeing a patient every single day that is stable, now that would be a different story.

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Specializes in Pediatric Critical Care.

The legalities surrounding medicare only apply if a company receives money from medicare/medicaid. If they are working with a private insurance company, those laws aren't applied because they are only for medicare/medicaid. In the absence of the government regulation, the insurance companies and health care companies can do whatever they want, and their priorities aren't necessarily cost-saving or patient centered.

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Specializes in Nephrology, Cardiology, ER, ICU.

Difference between APRN forum and NP forum:

APRN forum - all APRN issues: NP, CRNA, CNM, CNS

NP forum - NPs

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Specializes in Critical Care.
Thank you for your answers. Im not talking about my employer.

Company A wants the NP to bill for 2 visits even if one of the visits is not medically necessary. They get paid a set amount per head regardless of number of visits made.

How is it legal if Medicare rules don't allow for medically unnecessary visits? Does it become legal because the company gets paid from the insurance company and not directly from Medicare? Very confusing í ¾í´”

What's the difference between an NP Forum and an APRN forum?

Why is company A wanting you to bill for a visit when they already have an agreement that they don't get paid on a per visit basis? What type of company is "company A"?

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