Pitfalls with Non-Physician Providers
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Pitfalls with Non-Physician Providers

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Review of reimbursement issues related to mid-level providers.

Review of reimbursement issues related to mid-level providers.

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  • 1. Compliance Challenges Mid-level providers
  • 2. Overview of Program
    • Governing laws and regulations
      • Federal and state self-referral law and regulations (“Stark”)
      • Federal anti-kickback law and regulations
  • 3. Overview of Program
    • Primer on billing and coding
      • Physician relationships
      • “Incident to” billing
      • Billable v. non-billable work
      • CPT codes
      • Global Billing
  • 4. Overview of Program
    • Permissible use of mid-level providers
    • Impermissible use of mid-level providers
  • 5. Overview of Program
    • Issues related to scope of practice and other rules and regulations under the Education Law are beyond the scope of this program.
  • 6. Anti-kickback law and regulations
    • Anti-kickback statute prohibits physicians and hospitals from asking for or receiving or offering or paying any type of remuneration (including any kickback, bribe, inducement, or rebate) directly or indirectly, overtly or covertly, in cash or in kind in return for referring an individual to a person [physician or hospital] for any item or service.
  • 7. Anti-kickback law and regulations
      • The penalty for knowing and willfully doing so is up to $25,000 or 5 years imprisonment, or both.
  • 8. Anti-kickback law and regulations
      • In a nutshell – nothing may be offered or accepted that would impermissibly induce or entice physicians to bring their patients to our hospital to provide services reimbursed by state or federal funds
  • 9. Anti-kickback law and regulations
        • Permissible:
          • quality of care,
          • excellent staffing,
          • up to date equipment,
          • case management,
          • separately billable services billed by NP,
          • non-billable services,
  • 10. Anti-kickback law and regulations
        • Not permissible:
          • free space,
          • free supplies,
          • free staff,
          • bill for services furnished by other providers,
          • furnish services another provider is obligated to furnish
  • 11. Primer on billing and coding
        • "Incident to" billing:  not applicable to KH billing since we credential all of our providers and they submit their own billing
  • 12. Primer on billing and coding
        • Billable Services: Those services with an identifiable CPT code such as E/M services (initial inpatient, subsequent inpatient, discharge services & consults) and procedures (PICC line insertions, ABG etc) are all billable services. 
  • 13.
        • Non-billable Services: Case management, Home Health set up are examples of non-billable services.
  • 14. Primer on billing and coding
        • CPT Codes and Evaluation and Management (“E/M”) code assignment.
  • 15. Primer on billing and coding
        • Global Billing –
          • All services associated with a surgery including those 24 hours prior and 90 days after a surgical procedure, including the post operative care normally associated with the procedure (e.g. wound care, pain management, etc.
          • only those conditions not normally associated with the procedure may be separately billable (e.g., tachycardia 2 days after an amputation).
  • 16. Use of midlevel providers
      • Permissible use
        • Billable services - NPs and PAs may provide billable services if they:
          • are payor credentialed and have a billing number (NPI),
          • perform the billable work,
          • are working with a physician who has a billing number linked to Kaleida Health,
          • are not furnishing services someone else is required to perform, and
          • no one else bills for the billable services they performed.
        • Non-billable services - examples
          • discharge planning
          • case management
          • throughput
  • 17. Use of midlevel providers
    • Impermissible use
        • Billable services – NPs and PAs may not provide billable services if:
          • another provider bills and collects for those services,
          • another provider is required to furnish those services,
          • doing so violates any state or federal law or regulation or third party payor rules
  • 18. Putting it altogether
    • Vignette #1
    • Susan Jones, PA, is employed by Metropolis Memorial Hospital to follow orthopedic surgical patients during their inpatient stays. Susan’s supervising physician is the Chief of Orthopedics, a university faculty practice plan physician who is not an employee of the hospital. Susan regularly rounds on the orthopedic patients to be sure their pain is managed well; complications are avoided or addressed as early as possible; and a discharge plan is in place, constantly reevaluated, and updated as needed.
        • May Susan provide these services or do they impermissibly induce physicians to send their patients to MMH?
        • May Susan perform the admitting history and physical? If so, who may bill and collect for it?
        • May Susan write pain management orders? If so, who may bill for the pain management services she provides?
        • May Susan put in a PICC line if the patient develops an infection? If so, who may bill and collect for it?
        • May Susan discharge the patient? If so, who may bill and collect for it?
  • 19. Putting it altogether
      • Vignette #2
    • Brittany Sticks, NP, is employed by David Community Hospital to cover emergent needs of inpatients during the night. Her collaborating physician is an employee of the hospital as its Chief Medical Officer. She is called to see patients when their attendings and hospitalists are not available. Typically she evaluates patients with new onset of chest pain, fever and chills, hypotension, injuries from falls, and performs procedures such as arterial blood gas collections or replacing PICC lines.
        • May the hospital bill and collect for the procedures that Susan performs such as inserting PICC lines? If not, who may?
        • May the hospital bill for the consultations Susan does? If not, who may?
        • May Susan provide services if the hospital cannot bill for them?
  • 20. Putting it altogether
      • Vignette #3
    • John Garrison is an employee of Mt. Olive Medical Center and an RPA-C with special training and experience in neurology. Typically he cares for in-patients on a special neurology floor for epilepsy patients by rounding twice a day, ordering and interpreting diagnostic tests, writing medication orders after conferring with attending physicians, and assuring discharge plans are developed. The physicians who admit patients to the special unit come to the floor every day.
        • May the hospital bill for John’s services when he rounds on the patients twice a day? If so, what may it bill? If not, who may bill for the services he has provided?
        • If John writes progress notes each time he rounds to evaluate the patients and if he discusses the findings with the attendings, may the attendings bill and collect for the services if they document that they have “Reviewed and concur with above.”?
  • 21. Putting it altogether
      • Vignette #4
    • Palms of Pasadena Hospital is trying hard to attract a pulmonology group to provide specialist services. Being located in a depressed area with one of the highest rates of heart and lung disease in the country, the hospital desperately needs pulmonologists to care for its inpatients. The hospital has hired nurse practitioners to help the pulmonologists it has because there just “aren’t enough of them to go around.”
        • What functions could the NPs provide?
        • What functions would be impermissible?