Billing Under Another Provider’s Number Can Land Physicians in Hot Water

By Emma Cecil, JD, October 31, 2017

2018 Alliance sponsor feature article courtesy of MagMutual

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.

Key Takeaway

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.

Issue Spotlight: Proposed Changes to Medicare E&M Visits

Originally published in the July 18, 2018 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

The Centers for Medicare & Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule proposed rule that would affect Medicare physician reimbursement policies beginning in 2019. Among other changes, CMS proposes to:

  • Collapse evaluation and management (E&M) Levels 2-5 into one level for new patients and another for established patients. The average national payment would be $135 for new patients and $93 for established patients.
  • Allow clinicians to choose to document office and outpatient E&M visits using medical decision-making or time or continue using the current 1995 or 1997 E&M documentation guidelines.
  • Create a minimum documentation standard so clinicians would only need to meet requirements currently associated with a level 2 visit for history, exam, or medical-decision making (except when using time to document the service).

To help MGMA evaluate the impact of these proposed changes and advocate on behalf of medical group practices, please share your feedback on these proposals by filling out this brief comment form.

MLN Connects: Thursday, February 15, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 15, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • MIPS Reporting Deadlines Fast Approaching: 10 Things to Do and Know
  • Quality Payment Program: Performance Scores for 2017 Claims Data
  • Diabetic Self-Management Training Accreditation Program: New Webpage and Helpdesk
  • Measures of Hospital Harm: Comment by February 16
  • EHR Incentive Program: Accepting Proposals for New Measures by June 29
  • New Option for Submission of Medicare Cost Reports

Provider Compliance

  • Home Health Care: Proper Certification Required — Reminder

Claims, Pricers & Codes

  • January 2018 OPPS Pricer File

Upcoming Events

  • Improving Accessibility of Provider Settings Webinar — February 21
  • ESRD QIP: Final Rule for CY 2018 Call — February 22
  • 2018 QCDR Measures Workgroup Webinar — February 27
  • Serving Adults with Disabilities on the Autism Spectrum Webinar — February 28
  • MIPS Quality Data Submission Webinar — February 28
  • Palliative and Hospice Care for Adults with Disabilities Webinar — March 7
  • Low Volume Appeals Settlement Option Update Call — March 13
  • Open Payments: The Program and Your Role Call — March 14
  • MIPS Attestation for Advancing Care Information and Improvement Activities Webinar — March 14

Medicare Learning Network Publications & Multimedia

  • Medicare Enrollment Resources Educational Tool — Revised
  • PECOS FAQs Booklet — Revised
  • PECOS for DMEPOS Suppliers Booklet — Revised
  • Safeguard Your Identity and Privacy Using PECOS Booklet —Revised
  • PECOS for Provider and Supplier Organizations Booklet — Revised
  • PECOS Technical Assistance Contact Information Fact Sheet — Revised
  • Health Professional Shortage Area Physician Bonus Program Fact Sheet — Revised
  • Medicare Secondary Payer Booklet – Reminder
    Beneficiaries in Custody under a Penal Authority Fact Sheet — Reminder

MLN Connects: Thursday, February 1, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted February 1, 2018. Click on the header links for detailed information about each bullet item.

News & Announcements

  • Medicare Diabetes Prevention Program: Supplier Enrollment Open
  • Targeted Probe and Educate: New Resources
  • MIPS Clinicians: 2017 Extreme and Uncontrollable Circumstances Policy
  • Quality Payment Program: Patient-facing Encounters Resources
  • Eligible Hospitals and CAHs: Get Help with Attestation on QNet
  • Find Medicare FFS Payment Regulations
  • February is American Heart Month

Provider Compliance

  • Cochlear Devices Replaced Without Cost: Bill Correctly — Reminder

Upcoming Events

  • eCQM Reporting for Hospital IQR-EHR Incentive Program Webinar — February 6
  • Low Volume Appeals Settlement Option Call — February 13

Medicare Learning Network Publications & Multimedia

  • Next Generation Accountable Care Organization – Implementation MLN Matters® Article — Revised
  • DMEPOS Quality Standards Educational Tool — Revised
  • Home Oxygen Therapy Booklet — Revised
  • Looking for Educational Materials?

MLN Connects: Thursday, January 18, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN).  Below is the latest news from Thursday, January 18th:

News & Announcements

  • 2018 Value Modifier Results and Payment Adjustment Factor
  • Final DMEPOS Quality Standards for Therapeutic Shoe Inserts
  • Glaucoma Awareness Month: Make a Resolution for Healthy Vision

Provider Compliance

  • CMS Provider Minute Video: CT Scans – Reminder

Upcoming Events

  • New Medicare Card Project Special Open Door Forum – January 23
  • ESRD QIP: Final Rule for CY 2018 Call – January 23
  • MIPS Annual Call for Measures and Activities Webinar – February 5
  • Comparative Billing Report on Opioid Prescribers Webinar – February 21

Medicare Learning Network Publications & Multimedia

  • QRUR Video Presentation – New
  • Low Volume Appeals Settlement Call: Audio Recording and Transcript – New
  • Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians Web-based Training – Revised
  • How to Use the Medicare Coverage Database Booklet – Revised
  • Behavioral Health Integration Services Fact Sheet – Revised

Value-Based Coding in a Changing Environment


With ICD-10-CM comes a new dawn in physician documentation and a much more transparent clinical footprint.  Government payers, insurers, hospitals, health systems, medical groups and others will use ICD-10’s granular data to determine accurate, fair physician compensation and reimbursement.

Diagnosis Coding is Vital to Fair Provider Compensation.   Medical groups are signing payer contracts that adjust payment for a contract year based on quality measures, outcomes, utilization and the acuity of care for a patient population. The payor measures acuity of care by reviewing the patient’s age, gender and medical conditions. Where does the payor get the list of medical conditions? Diagnosis codes on claims!  Medicare Advantage Plans base incentive payment on Risk Adjustment Factor (RAF) Scores.

Diagnosis Coding is Vital to Fair Funding to Insurance Plans. The purpose of a Risk Adjustment model is to predict the future health care costs for enrollees in Medicare Advantage plans. CMS is then able to provide capitation payments to these plans. Additional funding to the plans in the form of Capitation payments help the health plans to enroll not only healthier individuals but those with chronic conditions or who are more seriously ill.

HHS Payment Goals are to help drive the health care system towards greater value-based purchasing. Rather than continuing to reward volume regardless of quality of care delivered CMS is focused in improving outcomes and reducing cost. Alternative payment models include Accountable Care Organizations (ACOs), bundled payments, and advanced primary care medical homes. Specifically, they want to:

  • move 50% of Medicare payments into alternative payment models by the end of 2018.
  • move 90% of Medicare payments to a model tied to quality or value by 2018.

Under MACRA (Medicare Access and Chip Reauthorization Act) there is a merge of previously introduced payment incentive programs, including: 

  • Merit-Based Incentive Program (MIPS)
  • Physician Quality Reporting System (PQRS)
  • Value-Based Payment Modifier (VBM)

Clinical Practice Improvement Programs have included Meaningful use of certified EHR technology and Alternative Payment Models (APMs). From 2019-2024, some providers will receive a lump-sum payment for Increased transparency of physician-focused payment models. Starting in 2026, CMS will offer some providers higher annual payments.  APM Criteria includes coordinating care; improving quality, reducing costs.

Hierarchical Condition Category Model (HCC) affects Medicare Advantage Plans (aka Medicare Part C) which have been paid under an HCC model since 2004. HCC is a risk adjustment model which identifies patients with serious acute or chronic illnesses and assigns a risk factor score to the beneficiary based on the patient’s demographics and medical history.  The government contracts with for-profit insurers to manage health care for these patients, and pays insurers a yearly fee for each member they enroll. The higher the risk score, the higher the annual fee.

Hierarchical Condition Category Model (HCC) Calculations

Each patient is assigned a Risk Adjustment Factor (RAF) score. RAF scores are based on:

  • Patient’s age and sex
  • Medicaid or disability status
  • Total of all chronic conditions and disease interactions

RAF scores identify the patient’s health status. Lower RAF scores indicate a healthier patient and higher RAF scores indicate a sicker patient.  The Average FFS patient has a score of 1.00.

How does HCC Affect Payment? RAF scores are additive. All qualifying diagnoses are included in the RAF score. Risk factors are added to achieve total RAF scores for each patient. RAF scores are predictive, and ICD-10 codes reported this year determine payments for next year.  Remember, the payment for the RAF score is from CMS to the Medicare Advantage Plan. Then Plan distributes the incentive bonus to all providers participating in the care of the patient.  This payment is in addition to the contractual fee-for-service payments and is paid annually.

It is important to remember that the health status is re-determined each year, therefore codes must be submitted every year to be counted.  Past data is not carried forward, and the RAF for each patient is reset every year.  Also, payment is made per HCC category (not per diagnosis code). A patient with 4 ICD-10 codes from category E11 for Type II Diabetes Mellitus with complications will only receive credit once for complicated Diabetes Mellitus (HCC 18), and not 4 times that value in the RAF score.

How to Achieve Accurate RAF Payment

The Annual Health Assessment is very important. Consider implementing a program to have a staff member call all Medicare Advantage members to schedule their Annual Wellness Visit and be sure the Risk Assessment, required screenings, and status of all chronic conditions is addressed and documented to qualify as a “reportable” diagnosis.  The claim should include accurate and specific diagnosis coding.

Example of How Diagnosis Codes Affect Payment

Table1A patient is seen in your office.  Patient is a 64-year-old disabled female.  She has Type II diabetes and Diabetic Chronic Kidney Disease. The patient also has congestive heart failure and Stage IV CKD (GFR 24 ml/min Filtration).  The patient is obese with a BMI of 56, is on insulin and is paraplegic.  (see table)

Common HCC Categories

Chronic Kidney Disease
Diabetes Mellitus
Peripheral Arterial Disease (PAD)
Major Depressive Disorders
Stroke and Late effects of prior Stroke
Chronic Conditions
History of Heart Attack
Renal Dialysis Status
Tracheostomy Status
Respirator Dependence
Lower Limb Amputee
Organ Transplant Status
Asymptomatic HIV Status
Protein Calorie Malnutrition
Alcohol Dependence & Drug Dependence

What supports coding for HCC?

Use Current ICD-10 Codes. Effective October 1, 2017 the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) added or updated approximately 620 diagnosis codes in the 2018 ICD-10-CM coding classification.

  • 360 new codes added
  • 226 code descriptions revised
  • 34 codes changed from valid to invalid
    • Validity changes are the result of new codes being added to the classification, changing a previously valid code to an invalid code, creating a new subcategory
    • Example: a valid 4-character code now requires 5 characters
  • There are also updates to the 2018 ICD-10-CM Official Guidelines for Coding and Reporting that impact medical record documentation, code selection and sequencing.

Adherence to the Guidelines when assigning ICD-10-CM diagnosis codes is required under HIPAA in all healthcare settings.

ICD-10-CM and Documentation – Use the MEAT Acronym.  A condition is reportable when the condition was Monitored, Evaluated, Assessed or Treated.  Do not report a diagnosis code that was not addressed during the encounter or documented in the note.  Our auditors have found errors when the main note does not mention a problem, but ancillary documentation such as medication lists and referrals contains orders for those conditions. The medication list may include Prednisone 5mb PO daily for asthma, but asthma is not mentioned in the history, exam or assessment portion of the note.  Referrals for consultations and tests can be found in the note (Ex: chest x-ray confirms pneumonia) without mentioning pneumonia in the assessment portion of the note.

Steps to take in your Practice: Identify HCC Categories that are clinically meaningful. What chronic diseases do your sickest patients have?  The HCC diagnosis categories are well defined. Meet with your clinicians and decide which specific diseases/conditions are common. The ICD-10 codes are grouped to each HCC category.  There are more than 9,000 ICD-10-CM codes map to 79 HCCs in the current risk adjustment model.  Diagnosis codes are excluded from mapping when they do not predict future cost or are vague or variable in diagnosis, coding or treatment. An example is symptom codes or osteoarthritis.

Risk Adjustment Data Validation (RADV) are a reality when participating in an incentive program.  CMS audits Medicare Advantage (MA) plans for accuracy of risk-adjustment payments and compares accuracy of coding to medical record. Medicare Advantage (MA) plans can be audited annually.  MA plans audit provider records to ensure compliance.  If you are selected, you will be required to submit medical records to substantiate coding. Audits may include the entire note to verify that it supports the level of service billed, medical necessity, and all codes reported.  Common errors from RADV audits show that electronic medical record was not authenticated, or medical record does not have legible signature or appropriate credentials

Parting Thoughts.  Does your practice have a compliance program? Make it stronger by Including risk adjustment audits to validate clinical documentation. Use audit results to provide education to all clinicians and coders, and continue to audit CPT coding documentation. Continue to monitor patient visits to ensure annual reporting.

About the Author: 

Nancy M Enos, FACMPE, CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group.   Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer.  In July 2008 Nancy established an independent consulting practice.

As an Approved PMCC Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses and consultative services.  Nancy frequently speaks on coding, compliance and reimbursement issues.  Nancy is a Fellow of the American College of Medical Practice Executives. She is a Past President of MA/RI MGMA.  EMAIL:

MLN Connects: Thursday, January 11, 2018

MLN Connects is the official news source of the Medicare Learning Network (MLN). Here is the latest news, posted January 11, 2018.  Click on the header links for detailed information about each bullet item.

News & Announcements

  • New Payment Model to Improve Quality, Coordination, and Cost-effectiveness for Both Inpatient and Outpatient Care
  • SNF Quality Reporting Program Confidential Feedback Reports
  • Hospital Quality Reporting: Updated CY 2018 QRDA I Schematron
  • January is Cervical Health Awareness Month

Provider Compliance

  • Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims – Reminder

Upcoming Events

  • New Medicare Card Project Special Open Door Forum – January 23
  • ESRD QIP: Final Rule for CY 2018 Call – January 23

Medicare Learning Network Publications & Multimedia

  • Major Joint Replacement (Hip or Knee) Booklet – New
  • Medicare-Required SNF PPS Assessments Educational Tool – Revised