NPs who don't bill

  1. 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???
  2. Visit britt_possible profile page

    About britt_possible, MSN, NP

    Joined: Nov '13; Posts: 20; Likes: 27

    29 Comments

  3. by   Oldmahubbard
    If the MD bills without personally evaluating the patient, it is fraud.

    Personally, I would be looking for another position.
  4. by   britt_possible
    Quote from Oldmahubbard
    If the MD bills without personally evaluating the patient, it is fraud.

    Personally, I would be looking for another position.


    Well, i can't speak for the inpatient side of things, but the MDs see the patient after me in the outpatient setting. I have 90% committed to leaving after my one year is up in September, but being that I am still novice NP, would like to know if this inability to bill is truly a red flag or not....
  5. by   core0
    Quote from britt_possible
    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???
    The exact situation depends on how the clinic is structured but most likely this represents fraud at least of Medicare/caid.

    There are two situations where the attending can bill for work done by an APP.
    If the clinic is a hospital based clinic then they can use what is called shared billing. In this case the physician must see every patient and document participation in one part of the encounter (History, PE or Assessment and plan). The documentation has to be meaningful (ie it can't be seen and agreed). For the assessment and plan they have to document their plan in full (it can be the same as yours but it has to be written out by the physician). If they are just signing the note by Medicare standards they are committing fraud.

    The second situation is for non hospital based clinics.
    This is called incident to. In this case they have to see the patient, perform all the elements of the encounter and lay out a plan. Then if you see the patient to carry out the plan they can bill under incident to as long as they are in the suite when the patient is seen. If there is any change in condition or new problems need to be addressed then they have to seen the patient again and document the complete new encounter.

    Most commercial payers (non Medicare) don't credential APPs and have the organization bill under the physician.

    If you work for a large system there should be a compliance department that is well versed in these rules. I would have a talk with them about what's going on. The bigger problem from an organizational standpoint is you are invisible from a revenue standpoint. If the revenue from these encounters was attributed to you it would be much easier to justify a raise. In our system even if the encounter is billed under the physician the revenue is attributed to the provider who performed the services. When one of our departments switched to this system it became apparent that physicians that looked like star performers weren't covering their salaries and the APPs were doing the bulk of the billing.
  6. by   Oldmahubbard
    Most of the private insurers I am familiar with do credential NPs
  7. by   Jules A
    Nothing sketchy if they are seeing the patients to maximize billing. Not billing yourself is only problematic because you don't have a concrete way to indicate your value but that doesn't mean you should accept such a low rate. You can estimate the amount you would be billing and use that to some extent or as loose data if you look for another job. The big issue here and I just commented in your other thread is not that your group is working you like glorified RNs but that they are paying you as glorified RNs. I made over $80,000 a year as ADN in DC years ago so it is unfortunate your colleagues are willing to work for such low pay especially in such a high COL area. That you work for the hospital is no excuse as they can increase rates specialty specific as needed or your physician's group could add bonuses.
  8. by   broughden
    Quote from britt_possible
    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???

    Based on your description your hospital and this clinic are likely practicing insurance fraud. I would discuss this with your own private legal counsel, before talking to ANYONE on the employer side.
    Possibilities exist for whistleblower lawsuits, if this involves medicare/medicaid at all, where you could collect a large settlement.

    In the case of medicare the MD's have to make sure they are meeting the "incident to" criteria in providing treatment to the patient. Otherwise its fraudulent billing.

    Billing Under Another Provider's Number Can Be Risky | MagMutual

    Example of medicare whistleblower lawsuit involving billing:
    Del. whistleblower could get $2.9M in Medicare fraud case
    Last edit by broughden on Jul 23
  9. by   Oldmahubbard
    Apparently there is a legal way for the NP to see the pt, then the MD, and the MD bills at the higher rate. I have heard of it, I just don't understand the logistics, and how it pays off financially.

    What I suspect really happens is that the NP does 99% of the work and the doctor pops his or her head in the door.

    Fraud. Please let me know if I am wrong
  10. by   broughden
    Quote from Oldmahubbard
    Apparently there is a legal way for the NP to see the pt, then the MD, and the MD bills at the higher rate. I have heard of it, I just don't understand the logistics, and how it pays off financially.

    What I suspect really happens is that the NP does 99% of the work and the doctor pops his or her head in the door.

    Fraud. Please let me know if I am wrong
    That's the "incident to" I was referring to above.
    Under the medicare guidelines a PA/NP can provide treatment to a patient "incident to" a physician's care or supervision, which is billed at a higher rate than if the PA/NP directly provided the care which is typically billed at a 15% lower rate.

    From the 11th Circuit Court of Appeals:
    Each HCFA 1500 form states:

    SIGNATURE OF PHYSICIAN OR SUPPLIER

    (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)

    I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnished incident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUS regulations.

    For services to be considered "incident" to a physician's professional service, 1) they must be rendered under the physician's immediate personal supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician's service, 3) they must be of kinds commonly furnished in physician's offices, and 4) the services of nonphysicians must be included on the physician's bills.

    Healthcare providers may bill Medicare Part B for the services of physician assistants and nurse practitioners in one of two ways; the amount of reimbursement the providers receive is dependent on the billing method. Physician assistant or nurse practitioner services may be billed as services "incident to the service of a physician." 42 CFR §§ 410.10, 410.26. To be correctly billed in this manner, the physician assistant or nurse practitioner services must have been provided under certain circumstances.1 When physician assistant or nurse practitioner services are billed as "incident to the service of a physician," the physician's Unique Provider Identification Number (UPIN) is used on the bill submitted to the FI. Alternatively, a provider may bill Medicare for physician assistant and nurse practitioner services under the physician assistant's or nurse practitioner's own UPIN. Billing Medicare in this second way indicates that the physician assistant or nurse practitioner has performed the service under some level of supervision by a physician, but the requirements of 42 CFR § 410.26 have not necessarily been met. For services billed under a physician assistant's or nurse practitioner's UPIN, the FI pays 85% of what it would pay for the same services billed under a physician's UPIN.
    "Incident to" mostly happens in states like Florida where PA's and NP's must practice under the supervision of a physician, but even then there are very strict guidelines as to how much interaction the physician has with the patient to allow them to bill at this higher rate.

    In independent practice states, like the OP's, where the NP is providing the entire care, they are most likely knowingly or unknowingly committing billing fraud.

    Which is why I said she needs to seek independent legal counsel immediately. Many of these cases run into the millions of dollars and the whistleblower can receive a substantial cut of the judgement.
  11. by   Oldmahubbard
    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?

    They must be an" incidental, but integral" part of the physician's services.

    I doubt what the OP does could be construed as "incidental." It sounds like she does the work and the MD rubber stamps it.

    These regs are a bunch of bs rhetoric and an exercise in semantics.

    They are thinking they will get away with it, because nobody has ever complained.

    I am surprised Medicare even allows anything like this anymore.
  12. by   britt_possible
    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
  13. by   Oldmahubbard
    The doctors look at the patient with their eyeballs, but they don't repeat your physical exam to verify it, do they?

    I thought not.

    Now you have to decide whether to whistleblow the fraud, which goes on all over the country. Your facility is far from unique.

    This system will not change as long as people turn a blind eye, and someone is making money off it.

    Or just look for another job.
  14. by   Jules A
    Quote from britt_possible
    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.

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