Unqualified Incident To Billing Danger!

Is your nurse providing physical therapy services such as lymphatic drainage, orthotic fitting and exercises for lymphedema patients and billing under the physicians name? Is your nurse providing wound care services such as selective debridement and billing under the physician's name? What other services are your medical staff performing and billing under the physician? Have you reviewed your nurses, medical assistants, and other physician extenders scope of practice for your state to ensure you are in compliance? The OIG has found that nurses and medical assistants (and other staff) lack the necessary training, certification, and/or licensure, pursuant to State laws, State regulations, and Medicare regulations to perform the functions that you are billing for. According to KZA consultants, these scenarios are more common than you might think. We help practices sort out who can bill for what, documentation requirements, and review scopes of practice.

Read on to see what the OIG had to say......

The Office of Inspector General (OIG) for the Department of Health & Human Services recently released a report titled “Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services,” examining Medicare billing by physicians but are performed by nonphysicians.

The OIG reports concludes that unqualified nonphysicians performed 21 percent of the services that physicians did not perform personally.

As a result of the findings, the OIG made three recommendations to the Centers for Medicare & Medicaid Services (CMS):

1. Seek revisions to the “incident to” rule. The rule should require that physicians who do not personally perform the services they bill to Medicare ensure that no persons except:
   
   a. licensed physicians personally perform the services or
   
   b. nonphysicians who have the necessary training, certification, and/or licensure,
   pursuant to State laws, State regulations, and Medicare regulations personally
   perform the services under the direct supervision of a licensed physician
   
   
2. Require physicians who bill services to Medicare that they do not personally perform to identify the services on their Medicare claims by using a service code modifier. The modifier would allow CMS to monitor claims to ensure that physicians are billing for services performed by nonphysicians with appropriate qualifications.
   
   
3. Take appropriate action to address the claims for services that we detected that:
   
   a. were billed by physicians and performed by nonphysicians that were, by
   definition, not “incident to” services and
   
   b. were for rehabilitation therapy services performed by nonphysicians who did
   not have the training of a therapist.

Click here to read the OIG Report: “Prevalence and Qualifications of Nonphysicians Who Performed Medicare Physician Services.”

For more information visit www.karenzupko.com or call (312) 642-5616.