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.