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Medical Staffing and Services Company Settles NPI Case For $475,000

31 Jul, 2023 F.J. Thomas

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Sarasota, FL ( – A National Provider Identification Number (NPI) is a 10-digit identification number that is issued by CMS Medicare to healthcare providers and is unique to them. NPI numbers are issued as individual provider numbers, but are also issued as Group NPIs for provider groups, and Location NPIs for locations where healthcare services are provided. All three types of NPI numbers are required when billing for healthcare services, regardless of payer type. 

Additionally, large healthcare groups with hundreds of providers use NPI numbers as a way to organize and track their providers internally. Often the credentialing software that is used to keep track of employed physicians is completely separate from the software used to bill out claims. When a provider is termed, that information is input in the credentialing software first. Frequently, practice management software where claims are billed, often do not have the capability of including a term date. Usually a record is just inactivated.  

One of the basic requirements in billing healthcare claims is that the rendering physician NPI listed on the claim must be the physician that provided the services. The exception is “Incident To” billing, when services or supplies are furnished in the office or a skilled nursing facility, as a part pf the physician’s course of treatment. Services may be performed by a non-physician provider, under a physician’s supervision. In this case, the claims are billed as if the physician personally rendered the services. 

Incident To billing only applies to office and skilled nursing facilities. It does not apply to “facility settings”, which would include emergency services. Over the years, provider groups have struggled with the complexity of the Incident To requirements. 

Earlier this month, the Department Of Justice for the Southern District of New York announced a settlement with a large medical staffing and billing services company group for their inappropriate use of NPI numbers on their claims. However, in this case it does not appear to be a genuine misunderstanding of the Incident To rules. 

Advanced Health Partners, Medexcel Emergency Physician Services of Yonkers, and Tri-State Emergency Physicians agreed to pay out $475,000 to resolve a lawsuit filed under the False Claims Act alleging misuse of NPI numbers in billing claims for emergency services. 

Advanced Health Partners provided billing and coding services. Medexcel, at least in some instances, directed which NPI should be used on claims for certain services. According to the complaint, from 2007 to 2017 Advance Health Partners billed claims with rendering provider NPIs that did not belong to the provider that actually provided the services performed. 

In the examples given in the complaint, claims were billed under the physician’s NPI number for two or more years after they were no longer employed by the group. In fact, thousands of claims were filed to federal payers using the NPI numbers of over a dozen providers that were no longer employed by the group.

If the employed providers that actually performed the services had a valid NPI number with Medicare, this case begs the question of why their NPI was not used. While the answer to that is not identified in the complaint itself, with the group being large and complex, it is easy to wonder if the manner of NPI tracking on software could have been a contributor.  

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    About The Author

    • F.J. Thomas

      F.J. Thomas has worked in healthcare business for more than fifteen years in Tennessee. Her experience as a contract appeals analyst has given her an intimate grasp of the inner workings of both the provider and insurance world. Knowing first hand that the industry is constantly changing, she strives to find resources and information you can use.

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