Ensure your NPs, PAs are being used optimally, legally

June 1, 2012

Healthcare issues are heating up. Take, for example, recovery audit contractors (RACs), Z-Picks (bounty hunters for the commercial carriers), Obamacare being challenged in the U.S. Supreme Court, the Office of Inspector General (OIG) "hit list" targeting providers for overpayments, fraud and abuse allegations, and 5010 playing havoc with our claims processing system. What else can go wrong?

Key Points

Things aren't getting better, but they can be controlled if your practice becomes more proactive rather than reactive. Keeping up with the RAC websites and the Centers for Medicare and Medicaid Services' publications is step one.

Getting your proverbial heads out of the sand with respect to your second-level providers is also a step in the right direction to avoid allegations of submitting false claims under the Federal False Claims Action. That is punishable by prison, exclusion to the Medicare program, revocation of one's medical license and huge, exorbitant fines.

For the commercial carriers, it is less straightforward and requires much more research to get the correct answers. I recommend hiring a professional credentialing consultant. In absence of that, do your homework.

First, contact the carrier's contract representative - not provider representative. The contract rep is harder to locate and talk to, but he or she is the person who can give you the most appropriate advice.

Go through the process, no matter how long it takes. Get detailed instructions on the following:

Don't be afraid to talk to the carrier because you have been billing incorrectly for years - fix it now. You may have to disclose and refund some monies, but that is better than serving jail time.