Regulation of Medicine
Billing Under Another Provider's Number Can Land Physicians in Hot Water
By Emma Cecil, JD
October 31, 2017
An Oklahoma physician agreed last August to pay the government $580,000 to resolve allegations that he violated the False Claims Act (“FCA”) by causing false claims to be submitted to Medicare for services he did not provide or supervise. According to the government, the physician allowed a company that employed him and in which he had an ownership interest to use his national provider identification (NPI) numbers to bill Medicare for physical therapy evaluation and management services furnished by other providers.
This case is merely another example of government enforcement action against providers who submit or cause to be submitted claims for services using the name and NPI of a physician who did not personally furnish the services. Back in 2011, the University of North Texas Health Science Center paid the government $859,500 to resolve allegations it had for submitted claims for physicians’ services provided to Medicare and Medicaid beneficiaries using the NPI numbers of physicians who neither provided nor personally supervised the services rendered. Other examples include Towson University Speech Language & Hearing Center, which paid $10,000 for submitting claims for audiology services with an NPI that did not correctly identify the provider who actually rendered those services; a family practice physician who paid $133,880 for submitting claims to Medicare for nurse practitioner services as though he had personally performed the services; a hospital that paid $706,090 in penalties for submitting claims for physicians’ services provided by a doctor to Medicare beneficiaries using the provider identification numbers of another doctor who did not furnish the services; and a medical school practice that paid $138,321 after it submitted claims for services provided by physicians to Medicare beneficiaries using the provider identification numbers of two physicians who did not furnish the services.
As a reminder, services generally must be billed under the name and NPI of the provider who actually performed the services. Billing under one provider’s name and NPI for services that are furnished by another provider may be fraudulent if the identity of the person performing the service would be material to the government’s decision to pay the claim.
The government does, however, permit the services of one provider to be billed under the name and NPI of another provider in certain limited circumstances, including where the services of auxiliary personnel (including both physicians and non-physician practitioners) are billed “incident-to” the professional services of a physician, and where the services of a substitute physician are billed under the regular, but unavailable, physician’s name and NPI on a temporary basis (“locum tenens” and “reciprocal billing” arrangements). These billing practices have very specific and stringent requirements, and failure to strictly comply with those requirements could subject providers to significant liability under the False Claims Act.
Importantly, the incident to, locum tenens, and reciprocal billing rules are Medicare rules and may not apply in the context of private payor billing. Many commercial plans specifically prohibit billing the services of one provider under the name and NPI of another provider and explicitly require that all services be billed under the name of the rendering provider. Providers billing private payors must therefore review their provider contracts and health plan rules to determine whether billing the services of one provider under the name and NPI of another provider is ever allowed, and if so, under what circumstances. If prohibited, knowingly billing under another provider’s name and NPI could potentially lead to criminal liability under the federal health care fraud statute, which makes it a crime to knowingly and willfully obtain by means of false or fraudulent representations money or property owned by any health care benefit program in connection with the delivery of or payment for health care services.
Before submitting bills for services furnished by one provider under the name and NPI of another provider, practices must be intimately familiar with the rules under which such billing is appropriate and allowed. Although practices that are under pressure to pay non-credentialed physicians may be able to bill the non-credentialed physician’s services under a credentialed physician’s NPI pursuant to Medicare incident to rules, such billing may be prohibited by commercial payors. Commercial payors also may not recognize locum tenens or reciprocal billing arrangements. In sum, billing under another provider’s name and NPI without strictly complying with CMS’s stringent incident-to or reciprocal billing rules, or in violation of private payor contracts, can spell big trouble, including treble damages under False Claims Act where claims are submitted to the government, and even criminal liability under the federal health care fraud statute.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.