NPI Numbers and How to Handle Them
Common Questions and Issues Surrounding NPI Numbers and How to Handle Them
By Jeff Cottle, Associate Attorney at Irvine Legal
A National Provider Identifier (NPI) can be very confusing for physicians and medical providers. The basic idea behind an NPI seems simple enough: They are used to identify a provider during the billing process, rather than using an individual provider’s actual name or social security number. However, in the real word, navigating the regulations and uses of an NPI can be very tricky. Here, we try to identify a few of the common questions, and provide guidance on how handle these scenarios.
1- Can one physician bill under another physician’s NPI number?
The general answer is no, a physician cannot bill under another physician’s NPI number, with very rare and limited exceptions (to be discussed later in the article).
An NPI number is a unique identifier for individual physicians who practice medicine and bill under HIPAA. An NPI must be used by a physician as an identifier when submitting HIPAA standard transaction claims to private insurance companies or to Medicare and Medicaid.[1] When one physician bills under another physician’s NPI number, it can constitute fraud under the False Claims Act. The penalties for fraud under the False Claims Act can be enormous (which will also be discussed later).[2]
2- What are the two types of NPI numbers? How can you get a clinic or medical group NPI number?
Under the applicable regulations put forth by the Centers for Medicare and Medicaid Services (CMS), an individual physician or provider is considered an Entity Type 1, and an organization health care provider is considered an Entity Type 2. [3] A typical claim for payment for a standard procedure will have both the Entity Type 1 and the Entity Type 2 identified, with the Type 2 providing information on the entity doing the billing, and the Type 1 identifying which individual provider actually treated the patient.[4]
There are two primary options to apply for an NPI. The first is to simply access the CMS website, create a username and password, and use that new account to apply for an NPI through the National Plan and Provider Enumeration System (NPPES) here: https://nppes.cms.hhs.gov/NPPES/Welcome.do.
The second option is to give permission to an Electronic File Interchange Organization (EFIO) to submit application data through bulk enumeration. This bulk enumeration process is referred to as an Electronic File Interchange (EFI). This option is convenient for larger medical industry groups who would like to streamline the process of applying for several NPIs at once. More information regarding the filing and process of using an EFI can be found here: https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/efi.
3- If I am covering for a provider out of town by treating a patient who is not my normal patient, which NPI number do I use? Are there any other scenarios when an individual can bill under a different NPI?
The answer is, unfortunately, the old attorney cop out answer: it depends.
If a physician goes out of town, or for some reason is unavailable, then the substitute physician can be billed under the regular physician’s NPI number under certain very specific circumstances for the purposes of Medicare billing. These circumstances are generally referred to as Locum Tenens or Reciprocal Billing arrangements. In order to bill under the NPI of the regular physician, these requirements must be met:
1. The regular physician is unavailable to provide the visit services
2. The Medicare beneficiary has arranged or seeks to receive the visit services from the regular 3. physician
3. The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis
4. The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days subject to the exception noted below
5. The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6 (service furnished by a locum tenens physician) after the procedure code. When Form CMS-1500 is next revised, provision will be made to identify the substitute physician by entering his/her unique physician identification number (UPIN) or NPI when required to the carrier upon request.[5]
If the above-named requirements are not met, then the bill must be submitted under the treating physician’s NPI number, and not the regular but unavailable physician’s NPI number. As well, keep in mind that these requirements are for Medicare billing only. For Locum Tenens, or other similar arrangements, that are not billed under Medicare, then an individual must ask the Medicaid or commercial payers what their rules are.[6]
As a side note: an auxiliary employee can use a supervising physician’s NPI number for billing if the supervising physician originally saw the patient, created the treatment plan, directly and personally supervised the auxiliary employee, and continued to take an active part in the treatment of the patient.[7]
4- If I do this wrong, what are the risks?
The consequences of misusing an NPI number, or of billing improperly, can be drastic. Submitting a claim under the wrong NPI number can constitute fraud under the False Claims Act. Penalties under the False Claims Act can result in large payouts to the government, sometimes reaching several hundreds of thousands of dollars.[8] On top of that, there can be local state board and licensing consequences associated with inappropriate billing procedures. Truly, the best way to handle these issues is to bill properly in the first place.
Conclusion
At Irvine Legal, we can help you to navigate the labyrinth of billing requirements and regulations, as well help you to deal with a myriad of other healthcare regulation related questions. If you have questions related to your NPI number, billing, or anything else that you and your practice may be dealing with, please do not hesitate to reach out to us.
[1] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/NPI-What-You-Need-To-Know.pdf
[2] https://www.magmutual.com/learning/article/billing-under-another-providers-number-can-land-physicians-hot-water/
[3] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/NPI-What-You-Need-To-Know.pdf
[4] Id. See also, for example, https://www.deltadentalins.com/about/legal/understanding-npi.html
[5] https://comphealth.com/resources/bill-locum-tenens-services/. See also: https://www.locumtenens.com/resource-center/articles/billing-tips/
[6] Id.
[7]https://journals.lww.com/jwocnonline/FullText/2012/03001/Understanding_Medicare_Part_B_Incident_To_Billing_.5.aspx
[8] https://www.magmutual.com/learning/article/billing-under-another-providers-number-can-land-physicians-hot-water/