NPs who don't bill

Specialties NP

Published

Hi All, i just wanted to get everyone's opinion regarding participating in a practice that does not allow me to bill. Heres the story...

So I work in an independent practice state. I work in an outpatient clinic for a specialty clinic at a hospital. There are 8 nurse practitioners who are inpatient only. The inpatient NPs do rounds/consults, as well as manage the patients on the service, and are the pre/post procedure NPs. None of them are allowed to bill for their services. They do the work, the MD signs off on their notes and drops the bill. Same for me, i see about 10 patient per day in the clinic, i do the H&P, prescribe Rx, help formulate plan of care, write the note...the MD comes in behind me signs off on the note, drops the bill. I am also responsible for typical outpatient NP duties, such as responding to patient phone calls.

I have a couple of qualms about this job (mostly because i feel like a glorified RN, i made anther post about it a month ago), but i am getting close to annual review time. It donned on me that not only am I under the hospital restrictions re: my pay increase, but i can't ask for an additional raise because i don't have proof of productivity because i don't bill. The docs here are bankrolling from the NPs while we are ALL getting paid the minimum by the hospital. While our director throws many a parties and talks often about how much the department makes, but the NPs never get a raise aside from the yearly 1-2% from the hospital. I understand that not all money made can be allocated to payroll, but does anybody see this as a little fishy? I previously worked at a practice where i did my own billing; i came to this job thinking i would have more support and eventually they would let me bill independently; but now im not so sure? Their reasoning for doing all the billing is that because they do procedures, the patient should always see the MD. Thoughts???

Specializes in Family Nurse Practitioner.
Im not sure i have a legal leg to stand on, just getting the short end of the salary stick

The good news is you and your colleagues are volunteers not victims and the compensation issues can be addressed.

I'm shocked it has been asserted that this is fraud. From what OP has posted and my interpretation of the billing codes they are meeting the criteria. Billing incident to is appropriate in full practice authority states especially in a specialty such as cardiology where, at least in my opinion, NPs shouldn't be doing much more than the very basics without physician oversight. Encouraging someone to report their practice for CMS fraud is a big deal and probably not appropriate to do based only on a few details posted on a message board.

The services are "rendered under the physician's immediate personal supervision", ie the doctor is standing right there in the room?

What would be the point of that?

In states where the physician is in a supervisory role over a mid-tier practitioner they have ruled the MD must be on premises. But different states vary.

In the case I was quoting from the MD wasnt even in the same country, and trying to bill medicare for his "supervisory" role.

Encouraging someone to report their practice for CMS fraud is a big deal and probably not appropriate to do based only on a few details posted on a message board.

I encouraged her to seek private counsel. Thats all. Because, as I stated previously, depending on the details it "could" be fraud.

As former law enforcement I try not to speak in absolutes without being party to all the facts.

One of the key factors is if MD's are including in the billing "incident to" that the NP was involved and what care they specifically provided, or if the MD is trying to pass it off as 100% their work.

The devil is in the details. But given its so rampant (both intentionally and unintentionally) its worth making sure when you are the mid-tier involved so you dont end up becoming an accessory.

Whistleblowing is definitely a big deal. OP, keep us posted.

Thank you all for a perspective i didn't know existed. I learned something new today.

In thinking about the practices of the four physicians I work with, i think they are skirting the medicare fraud line, as in doing just enough to prove that its not fraudulent. Two of them will see the patient, discuss what I've discussed and leave the room. Their billing looks like "seen with the nurse practitioner, i agree with the note as written, additional comments are (enter a shortened version of my H&P).

The other two are more of a "hi and bye" to the patient and then copy my assessment and plan with a few words changed....

Im not sure i have a legal leg to stand on, just getting the short end of the salary stick

There are a number of issues here. A number of people have mentioned incident to with varying interpretations. The first thing you need to figure out is what type of clinic you work in. The two types from a Medicare standpoint are freestanding clinics or provider based clinics (also know as hospital based outpatient clinics). From a hospital standpoint provider based clinics can charge higher fees for testing and add facility fees. The OP states they are working at an outpatient specialty clinic for a hospital so my suspicion is they are provider based but the OP would have to find out.

The reason this matters is the Medicare billing rules are different for provider based clinics than free standing clinics.

Free standing clinics can bill under incident to. Despite what is written above, incident to does not require personal physician supervision. Instead it requires direct supervision which mean the physician must be in the office suite when the service is provided. There is no requirement for the physician to see the patient after the first visit but they must demonstrate continued involvement (poorly defined) in the care of the patient. The physician must do the entirety of the initial encounter (HPI PE A/P) then the APP can perform follow on care as long as they follow the plan originally formulated by the physician. If the plan changes or a new problem develops the physician must again see the patient and perform the entire encounter.

For provider based clinics the rules are similar to inpatient encounters and providers can use shared billing. In this case the APP sees the patient and documents the entire encounter. The physician then sees the patient and documents one part of the encounter. The key here is the physician must document that they saw the patient and document one element of the encounter. Seen and agreed does not work.

Given the OPs statements its not possible to determine if fraud exists or not but its extremely likely. If this is a freestanding clinic it doesn't matter if the physician sees the patient or not as long as the initial encounter was performed by the physician. The OP does not say whether they are following a plan done by the physician or not. If this is provider based clinic then at least some of the physicians are not meeting Medicare requirements for shared billing as the OP describes it.

One thing to remember is that there is relatively little risk from the OPs side. If they are not submitting billing under the OPs name then there is little fraud risk. Instead the risk devolves to the physicians who are submitting the fraudulent billing. Finally when discussing whistle blowing Medicare requires at least an attempt to deal with this at an institutional level. Medicare requires every Medicare billing entity have an effective compliance program. Any hospital will have a compliance department. My recommendation to the OP is to start there. Discuss your concerns with the compliance department in a non accusatory manner (ie I am concerned that the department is billing for my Medicare encounters under the physicians NPI). This makes it their problem not yours.

There are a number of issues here. A number of people have mentioned incident to with varying interpretations. The first thing you need to figure out is what type of clinic you work in. The two types from a Medicare standpoint are freestanding clinics or provider based clinics (also know as hospital based outpatient clinics). From a hospital standpoint provider based clinics can charge higher fees for testing and add facility fees. The OP states they are working at an outpatient specialty clinic for a hospital so my suspicion is they are provider based but the OP would have to find out.

The reason this matters is the Medicare billing rules are different for provider based clinics than free standing clinics.

Free standing clinics can bill under incident to. Despite what is written above, incident to does not require personal physician supervision. Instead it requires direct supervision which mean the physician must be in the office suite when the service is provided. There is no requirement for the physician to see the patient after the first visit but they must demonstrate continued involvement (poorly defined) in the care of the patient. The physician must do the entirety of the initial encounter (HPI PE A/P) then the APP can perform follow on care as long as they follow the plan originally formulated by the physician. If the plan changes or a new problem develops the physician must again see the patient and perform the entire encounter.

For provider based clinics the rules are similar to inpatient encounters and providers can use shared billing. In this case the APP sees the patient and documents the entire encounter. The physician then sees the patient and documents one part of the encounter. The key here is the physician must document that they saw the patient and document one element of the encounter. Seen and agreed does not work.

Given the OPs statements its not possible to determine if fraud exists or not but its extremely likely. If this is a freestanding clinic it doesn't matter if the physician sees the patient or not as long as the initial encounter was performed by the physician. The OP does not say whether they are following a plan done by the physician or not. If this is provider based clinic then at least some of the physicians are not meeting Medicare requirements for shared billing as the OP describes it.

One thing to remember is that there is relatively little risk from the OPs side. If they are not submitting billing under the OPs name then there is little fraud risk. Instead the risk devolves to the physicians who are submitting the fraudulent billing. Finally when discussing whistle blowing Medicare requires at least an attempt to deal with this at an institutional level. Medicare requires every Medicare billing entity have an effective compliance program. Any hospital will have a compliance department. My recommendation to the OP is to start there. Discuss your concerns with the compliance department in a non accusatory manner (ie I am concerned that the department is billing for my Medicare encounters under the physicians NPI). This makes it their problem not yours.

Great answer.

This is why I decided long ago, that if I want to move my practice forward I'm going to medical school.

You're complaining about NPs, but I see the same thing with CRNAs. As a CRNA you have to take very similar classes to pre-med pre-requisites, you pay nearly 40k a year for 2-3 years, and when you're done you do receive the full payment from the insurance companies the way an MD does. Yes, you'll make 200k, but you're doing the same amount of work, going into the same amount of debt, for less money.

You see, Medicare + Medicaid bills by points. A CRNA gets lets points, and the doctor gets more. Also, you'll still be subject to hearing crap from some hotshot 22-year-old doctor who doesn't know more than you. If you ask me, not worth it! Just go to medical school.

Nurses really need to make sure they do their research before they spend money to go into these "advanced practice" programs. They are selling you something... and the opportunity costs might not be worth it. Also, attrition rates are much higher than medical school, and you know what nursing programs do???? THEY BRAG ABOUT IT!!!

Specializes in Cardiology.
This is why I decided long ago, that if I want to move my practice forward I'm going to medical school.

You're complaining about NPs, but I see the same thing with CRNAs. As a CRNA you have to take very similar classes to pre-med pre-requisites, you pay nearly 40k a year for 2-3 years, and when you're done you do receive the full payment from the insurance companies the way an MD does. Yes, you'll make 200k, but you're doing the same amount of work, going into the same amount of debt, for less money.

You see, Medicare + Medicaid bills by points. A CRNA gets lets points, and the doctor gets more. Also, you'll still be subject to hearing crap from some hotshot 22-year-old doctor who doesn't know more than you. If you ask me, not worth it! Just go to medical school.

Nurses really need to make sure they do their research before they spend money to go into these "advanced practice" programs. They are selling you something... and the opportunity costs might not be worth it. Also, attrition rates are much higher than medical school, and you know what nursing programs do???? THEY BRAG ABOUT IT!!!

I am not sure how this commentary fits into my original question or fits into the narrative that follows.

Specializes in Cardiology.

One thing to remember is that there is relatively little risk from the OPs side. If they are not submitting billing under the OPs name then there is little fraud risk. Instead the risk devolves to the physicians who are submitting the fraudulent billing. Finally when discussing whistle blowing Medicare requires at least an attempt to deal with this at an institutional level. Medicare requires every Medicare billing entity have an effective compliance program. Any hospital will have a compliance department. My recommendation to the OP is to start there. Discuss your concerns with the compliance department in a non accusatory manner (ie I am concerned that the department is billing for my Medicare encounters under the physicians NPI). This makes it their problem not yours.

Thank you.

I agree, the fraud complaint will not fall on the OP. Extremely unlikely.

Honestly, I think the best option is to look for another job, and then make the very major decision about whether to file a CMS complaint.

Because if you start making noise within your organization about the discrepancies of this practice model, I guarantee, it will suddenly be found that your work is not of sufficient quality for continued employment.

Because if you start making noise within your organization about the discrepancies of this practice model, I guarantee, it will suddenly be found that your work is not of sufficient quality for continued employment.

I agree with you and therefore disagree with Core0.

The OP needs to seek private counsel and document, document, document. Do NOT walk blindly into your employer's compliance or HR department seeking answers. They work for and represent your employer, not you.

They will discredit and dump an employee in a heartbeat rather than admit wrongdoing. To believe otherwise is ridiculously naive.

My docs make all the money and I get my salary which is pennys compareed to what I make for them I see 30 patients a day average bill is 200 thats 120000 a month and I get paid 11800 a month and thats if I made my bonus.

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