Certified vs. Uncertified Staff: Understanding the Difference
When it comes to billing Medicaid, one of the fundamental distinctions that healthcare providers need to understand is the difference between certified and uncertified staff. This distinction has significant implications for how and under whose name Medicaid services can be billed.
Certified Staff
Certified staff refers to healthcare professionals who have received certification or licensure in their respective fields. This includes, but is not limited to, physicians, nurse practitioners (NPs), physician assistants (PAs), licensed practical nurses (LPNs), and registered nurses (RNs). Certification typically involves completing an accredited educational program, passing a certification exam, and meeting ongoing continuing education requirements.
Certified staff are generally authorized to provide a wide range of medical services, and they can bill Medicaid directly for the services they render, provided those services fall within their scope of practice. For example, a certified nurse practitioner can bill Medicaid for a patient visit, as long as the service provided is within their legal scope of practice and complies with state Medicaid rules.
Uncertified Staff
Uncertified staff, on the other hand, are individuals who work in healthcare settings but do not hold certification or licensure to perform medical procedures independently. This group may include medical assistants, aides, receptionists, and other support staff. While these individuals play crucial roles in the healthcare delivery system, they are not authorized to provide medical care independently or bill Medicaid for services under their own names.
Uncertified staff can assist in providing care under the supervision of certified healthcare providers. For example, a medical assistant may take vital signs, prepare patients for exams, or assist with administrative tasks. However, the actual medical services must be performed or directly supervised by a certified provider to be eligible for Medicaid billing.
When Is It Permissible to Bill Under a Practice Name?
In certain situations, it is permissible to bill Medicaid under a practice name rather than under the individual provider’s name. This practice is common in group practices, clinics, and healthcare organizations where multiple providers work together to deliver care. However, specific rules govern when and how billing under a practice name can be done legally and ethically.
Group Practices and Clinics
In a group practice or clinic setting, Medicaid billing can be done under the practice’s name if the services are provided by or under the direct supervision of a certified provider. The practice must be properly enrolled with Medicaid, and the billing should reflect the provider who actually rendered the service or supervised the uncertified staff who assisted.
For instance, if a certified physician supervises a medical assistant who is taking patient histories and preparing the patient for the physician’s examination, the service can be billed under the practice’s name as long as the physician is listed as the supervising provider. The key factor is that the certified provider must be actively involved in the patient’s care and directly oversee any tasks performed by uncertified staff.
Incident-To Billing
Another scenario where billing under a practice name may be appropriate is under the “incident-to” billing provision. This provision allows services provided by uncertified staff to be billed under the supervising physician’s or certified provider’s name, as long as certain criteria are met.
To qualify for incident-to billing:
- The service must be an integral part of the patient’s normal course of treatment.
- The physician or certified provider must have initially seen the patient and established the treatment plan.
- The service provided by the uncertified staff must be part of this treatment plan and be performed under the direct supervision of the certified provider.
- The certified provider must be physically present in the office suite when the service is provided.
Incident-to billing allows practices to maximize efficiency by utilizing uncertified staff for routine follow-up care, as long as the certified provider maintains overall responsibility for the patient’s care and is available to intervene if necessary. However, it’s crucial to understand that incorrect use of incident-to billing can lead to compliance issues and potential fraud allegations.
Telehealth Services
With the rise of telehealth, questions about billing under a practice name have become increasingly relevant. For telehealth services, Medicaid billing rules vary by state, but generally, the same principles apply: certified providers must render the services or supervise them, and the billing must accurately reflect who provided the care.
For example, if a nurse practitioner provides telehealth services from a clinic, the service can be billed under the clinic’s name as long as the nurse practitioner is listed as the rendering provider and the clinic is properly enrolled with Medicaid to provide telehealth services.
The Risks of Improper Billing
Improper billing, whether intentional or accidental, can have severe consequences for healthcare providers. Billing Medicaid under someone’s name when that person did not provide or supervise the service is considered fraudulent and can lead to serious legal and financial penalties, including fines, repayment of funds, exclusion from Medicaid, and even criminal charges.
To avoid these risks, healthcare providers must ensure that their billing practices are transparent, accurate, and fully compliant with Medicaid regulations. This includes:
- Training Staff: Ensuring that all staff, both certified and uncertified, understand the rules regarding Medicaid billing and the limitations of their roles.
- Accurate Documentation: Keeping detailed records of who provided or supervised each service and ensuring that the documentation supports the billing claims.
- Regular Audits: Conducting internal audits to review billing practices and identify any potential issues before they escalate.
Conclusion: Protecting Your Practice
Billing Medicaid under someone’s name requires careful consideration of the provider’s certification status and the specific circumstances of the care provided. By understanding the rules surrounding certified versus uncertified staff and the conditions under which billing under a practice name is permissible, healthcare providers can avoid the pitfalls of improper billing.
If you are uncertain about your Medicaid billing practices or need guidance to ensure compliance, it’s essential to consult with legal experts who specialize in healthcare law. The Norman Spencer Law Group can provide the expertise and support you need to navigate the complexities of Medicaid billing and protect your practice from potential legal issues. By seeking professional advice, you can ensure that your billing practices are both ethical and compliant, safeguarding your practice’s future.
Whether you’re dealing with issues related to certified versus uncertified staff, incident-to billing, or general compliance with Medicaid regulations, the attorneys at Norman Spencer Law Group are here to help. With their deep understanding of healthcare law and experience in defending against Medicaid fraud allegations, they are the right partner to guide you through any challenges you face. Don’t leave your practice vulnerable—contact Norman Spencer Law Group today to ensure your Medicaid billing practices are secure and compliant.