Ask An Expert- NPI Billing: What You Need to Know to Avoid Liability in your Eyecare Practice

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Amanda Whitener has extensive revenue cycle expertise dating back nearly a decade, ranging from ambulatory surgery centers to optometry. As HELIX's RCM Account Manager, she focuses on helping ODs experience financial freedom by ensuring claims are worked quickly and correctly, as she has robust knowledge of operations for various areas of the practice. Amanda's primary role is helping offices reduce billing burden and labor costs while maximizing cash coming through the door. 

Insights and Best Practices from Industry Professionals for Safer Billing Practices

The question of whether one can bill under another healthcare provider's NPI has become a common topic of discussion. In most cases, the answer to this question is no. Billing under another provider's NPI is generally only permissible in rare circumstances. Oftentimes, healthcare providers mistakenly believe they can bill under another's NPI, while unknowingly risking liability under the False Claims Act. 

Scenario #1: Can I Bill Under a Another doctor's NPI if I am in training and the supervising credentialled doctor is present in the exam room? 

The answer is no. In a training situation, the only way to bill under the credentialled doctors NPI is if that doctor is the one performing while the trainee watches. The provider must be present in the room with the trainee, document the patient’s visit and sign the medical record as the rendering provider. 

Scenario #2: Can I Bill Under a Another doctor's NPI if the supervising credentialled doctor signs off on the chart? 

The answer is no. A non-credentialled doctor, is a non-credentialled doctor, even if a credentialled doctor signs off on the chart. It would be better to not get paid, than to have a massive takeback unexpectedly if an audit is performed. Industry standard is to hold the providers claims until they are fully credentialed.  

Scenario #3: Can I Bill Under a Another doctor's NPI if I am brand new to an office and in the process of getting credentialled? 

The answer is no. A good rule of thumb is to submit the claim under the NPI of the doctor who performed the services, regardless of credentialling status. Keep in mind that there are payers, including Medicare, who typically will allow the effective date of the enrollment of the provider back to the application date. This allows claims on hold to be sent, processed, and paid within the timely filing period for most insurance payers.   

Essentially, the only time a provider is authorized by Medicare to bill under another provider’s NPI is in a Fee-for-Time (formerly known as Locum Tenens) or in Reciprocal Billing. Both options have quite specific qualifications, rules, regulations, and even modifiers surrounding them.  

Fee-for-Time is basically when a doc brings in a substitute doctor as an independent contractor, who is not an employee of the practice and typically does not have their own practice, to cover while the doctor is absent for various reasons. In this situation, the covering provider can bill under the credentialled/absent provider’s NPI, using the Q6 modifier, up to a continuous period of 60 days. After the 60 days, many payers including Medicare require the covering provider to file under their own NPI. In fee-for-time, the substitute provider is reimbursed by the regular provider on a per diem basis, hence the name fee-for-time. Reciprocal Billing is similar, having specific guidelines and restrictions. That said, it is imperative that providers familiarize themselves with the process prior to billing in this capacity. 

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