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Dermatology Practice Today

Q&A with Dr. Debra #2

Published June 19, 2014 11:18 AM by Debra Shelby
Here is another question sent to me on the NADNP website @ www.NADNP.net

"I am an ARNP with FNP-C certification and 10 years experience in dermatology. Recently, a new office manager was hired and has changed the billing for midlevel providers to direct billing with insurance carriers. Prior to this we all billed under the supervising MD who was onsite. BCBS of MA is denying some of the procedure codes including excisions with complex repair, ED&C, and others stating that they do not reimburse "this type of provider" for these codes. The solution at the office is for the NPs to not perform these procedures and refer to the MDs in the office.

I am reaching out to your organization, the Mass Board of Nursing, and the Mass Coalition of NPs to inquire as to the legality of this situation. I believe BCBS has no right to limit my scope of practice and am seeking advice as to what my options are and if your organization's scope of practice lists these procedures."

Technically, they are not restricting your scope of practice, but your reimbursement. Insurance companies do not have any authority over practice acts or scope of practice. However, they can financially impact your practice by not reimbursing for the services you provide. That could fall under a "restriction of trade". NPs and PAs had this situation with Medicare years ago, but they changed some of the rules. I would suggest writing to BCBS and show them the Medicare guidelines that support the reimbursement for these procedures. Be prepared to provide data that supports the reduction of wait times and the cost effectiveness of NPs and PAs providing these services. Do research on insurance companies, including BCBS, in other states that reimburse for these procedures. All states differ, even different regions may differ within the state.

With this discussion, I need to bring up an important point. There are many physicians who bill under their Medicare number erroneously thinking because they are on site that it qualifies them to bill "incident to" services (billing under your supervising physician's Medicare number in order to get 100% reimbursement). The physician must see the patient and prepare a care plan. The NP or PA may follow up with that patient for that specific problem and bill "incident to" if the physician is on site. If the patient presents with a different problem, the physician must first see that patient if they want to bill this way.

I recently met a dermatology NP who worked for a physician that had been billing under his or another physician's Medicare number in order to get the 100% reimbursement. This NP never realized that she did not have a Medicare number! She "trusted" them to do the right thing, but her lack of billing knowledge won't save her from a Medicare complaint or audit.

I caution each of you to make sure your billing is done correctly. You are responsible for ALL of your billing. This includes using the correct codes, office level visit and supporting documentation. Make sure they are using your Medicare number, not theirs. Take billing classes or seek professional billing advice. If you don't, you may find yourself in a qui tam suit and possibly have your Medicare number revoked. There are people, even other providers, who are looking to make money off of "whistle blowing". I know of a physician who has turned in multiple colleagues and has made millions. While I don't condone fraud in any form, it would be nice if we would reach out and educate our colleagues prior to filing a fraud complaint. The provider may be innocently unaware of wrong doing and could correct the error. Please see the attached link for further information.

http://www.cms.gov/site-search/search-results.html?q=incident%20to%20billing

http://www.medicarefraudcenter.org/

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    Occupation: Physician assistant and nurse practitioners
    Setting: Various dermatology settings
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