Carolyn Buppert, NP, JD

Disclosures

June 17, 2003

Question

In my office, there has been a great deal of debate over billing the nurse practitioners' (NP) services. Who is ultimately responsible for correct billing in our office if we were ever audited -- the NPs, the physicians, or the office manager who does all the billing for all of us?

Response from Carolyn Buppert, NP, JD

Response from Carolyn Buppert, CRNP, JD

Nurse practitioner and attorney who specializes in the legal issues affecting medical practices and nurse practitioners. Buppert is the author of Nurse Practitioner's Business Practice and Legal Guide (1999) and The Primary Care Provider's Guide to Compensation and Quality (2000). She lectures extensively on avoiding malpractice, reimbursement issues, and negotiating contracts. Buppert can be reached at http://www.buppert.com

The answer is all of you, possibly. In your case, however, it sounds like the physician owners and practice manager are most at risk. If audited, the investigators and, later, a judge or jury, would decide which individuals' activities met the definition of "fraud." The definition of "fraud" is "an intentional deception or misrepresentation which the individual knows to be false or does not believe to be true, and the individual is aware that the deception could result in some unauthorized benefit to him/herself or some other person."[1]

For example, if a physician bills a NP's office visits under his or her own number, without following the rules on "incident to" billing, the local Medicare Carrier may notice that there is unusually high billing activity on the part of that physician. The Carrier may report the unusual billing pattern to the local office of the Federal Bureau of Investigation (FBI). FBI agents conduct interviews, data analyses, and legal research to gather evidence on who was responsible for the office's billing and whether that individual had access to and opportunity to learn and follow the rules, but chose not to. Because NPs often have little control over a practice's billing and usually do not benefit from abusive billing practices, NPs are not often the focus of investigation. NPs are interviewed as witnesses, however. And, if a NP does have control over the billing operation or does benefit from fraudulent billing, then the NP can expect to be charged along with other involved parties.

Here are some questions the NPs working for such a physician may expect to be asked:

 

  • Did your employer provide you with any training on billing?

  • Was there an office policy regarding the circumstances under which procedures would be billed under your number and/or under your employer's number?

  • Have you heard of the "incident to" billing rules?

  • Do you read professional journals? Have you read articles on billing nurse practitioner services?

  • Did you ever ask your employer how your services were being billed?

  • Do you have a Medicare number? If not, did you ever ask you employer about getting a Medicare provider number? If not, was the physician in the same office suite, every time you saw a patient covered by Medicare?

  • How would you know which insurance your patient have, and so on.

If a NP has a Medicare provider number, that NP signed a statement on the last page of the form CMS 855 promising to follow Medicare's rules. If a NP does not have a Medicare number and signed no such statement, the NP may be asked whether he or she was taught the billing rules in school, or whether the NP has seen articles in the professional literature about billing NP services. If the investigators believe that the NP knew the rules and knew the rules were not being followed but participated in the improper billing to receive some personal benefit from the deception, then the NP might be charged with fraud, along with the physician and billing personnel. At a trial, a judge or jury would decide which defendants had the requisite intent to deceive the government.

The rules on incident-to billing are found in the Medicare Carriers Manual[2]

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