The Physician Who Never Sleeps

Years ago, I worked with an Orthopedist who needed hours less sleep than I or the average person needed.  While it would be incorrect to say he never slept, he woke up early, did his administrative tasks before his wife and kids were awake and arrived for work on time and ready to go.  But, he’s not the subject of this article.


No, my concern is the doctor whose claims look like she never sleeps, who reports such a high volume of services in a 24 period, day in and day out, week in and week out, that a payer might wonder if the doctor ever sleeps or rather, if other professionals are performing services that are being reported under her National Provider Identification  (NPI).


Medicare and private payers have rules about reporting services performed by someone else (Physician Assistant, Nurse Practitioner, other clinical staff members) under the NPI of the physician.   The Office of Inspector General has telegrammed their interest in this topic by putting enrollment and assignment, incident to billing and high cumulative Part B payments on the 2013 Work Plan.  In 2009, CMS dramatically decreased the period of time that a group could bill retroactively after enrolling a physician from 27 months to 30 days. 


This is a risk area that every practice can and should review.  It is simple and cheap.  Verify that the correct NPI is on a claim form.  In general:


  • Use the NPI of the physician who performed the service.  Do not use another physician’s NPI ever for Medicare or without written permission for a commercial payer.  This means, if a physician is not enrolled in Medicare, the medical practice may not submit a claim for the services.
  • If billing Medicare for services provided by staff members under the physician’s NPI, be sure that the requirements for incident to are met.
  • If reporting services provided by a non-physician practitioner to Medicare under the physician’s NPI, be sure the requirements for either incident to or shared services are met.
  • Medicare allows billing for locum tenens physicians (not non-physician practitioners) when the regular physician is absent due to vacation, illness or has left the practice.  A locum physician may only report services for 60 days (counting the first day as day 1, and including days off in the 60 day count) when the physician being replaced is not available. 
  • If providing services jointly with a resident, be sure that the attending sees and examines the patient and documents her participation in the care. 


All of the rules I’ve outlined above are for Medicare, but many private payers have similar rules.  Not all private payers enroll non-physician practitioners, however, and in that case, report the service under the physician’s NPI. 

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s