Hi i have a question and any help would be greatly appreciated :)
If a patient sees a dr who is not in network with their insurance company is it okay to bill the insurance using another dr's name who is in network?
Hi i have a question and any help would be greatly appreciated :)
If a patient sees a dr who is not in network with their insurance company is it okay to bill the insurance using another dr's name who is in network?
Only if you want to be charged with fraud.
Thats what i thought but the dr's here said there is a way to code and use both dr's names and it wouldn't be illegal
Who ya gonna listen to your doctor or the District Attorney? If you get caught who will have to put on the pink jump suit and do the perp walk.
yeah i'm refusing to do it. i just wanted to make sure i'm right
There have got to be some more details to this scenario that would be helpful. From your original question, it only sounds fraudulent. From those few details, there is no relevance then to "in" or "out" of network. Is there any other info you could provide?
When something is questionable, cover yourself and just don't do it. If the doctor wants to bill it, let them, and they can take the hit.
I constantly see questionable things and when I'm asked to do it I say "My livelyhood isn't worth it, sorry!!!"
Why did this pt see the Dr. that was out of network when you said there is one there that was in network or am I just missing something.
There are 3 dr's and they're all in network with different insurance companies. Sometimes an employee will schedule a patient with a dr who isnt in network with the patients insurance.
Sorry I missed this thread earlier. I have been working a lot in this area, so can shed some light.
This will vary depending up the plan. Many of the VCPs, including Eyemed and VSP have it stated in their contracts that any member seen in your office must be seen by a plan credentialed doctor, even on a fill in basis.
On the plans that will allow you to have fill in (Medicaid/Medicare) you can use the Q6 modifier to signify a locum tenens. This means there is a reciprocal agreement between the rendering provider and the credentialed provider. All monies will be paid to the credentialed provider, and it is the credentialed provider's information that is on the CMS 1500 form. This also means that the credentialed provider is accepting liability for the services performed and the claim.
There are a few plans (and you can do Medicare this way as well) that will allow you to enter the rendering providers information in Box 24J, and then use the BILL AS, (Box 33) to put the credentialed provider's information. You see this more with group settings, where they want the monies to be paid to the clinic, and not the individual provider.
"Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland
I have seen some contracts limit the number of exams by a "fill-in Dr." to 2 weeks a year.
Yes each plan can have its own specific rules. For state/federal insurances, such as Medicare, 60 consecutive days is the rule.
"Some believe in destiny, and some believe in fate. But I believe that happiness is something we create."-Something More by Sugarland
Jubilee, I anoint you our resident expert on such things.
Thanks :) It wasn't a specialty I desired, but one I acquired out of need and happy to share.
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