LANSING, Mich. (WILX) - Sparrow has agreed to pay $671,310 to resolve allegations that they violated the False Claims Act by misusing “incident-to” billing, announced U.S. Attorney Mark Totten Wednesday.
The United States alleged that Sparrow improperly billed services under a physician’s name and reimbursement rate where the services were rendered by mid-level providers at Sparrow’s locations where the “incident-to” billing criteria were not met.
An “incident-to” billing provision allows an Advanced Practice Provider (APP), including nurse practitioners and physician assistants, to treat a patient but bill the encounter under the physician’s name and reimbursement rate if specific criteria are met. Those criteria include the presence of an on-site doctor, that the physician performs the initial visit for the patient, and that the physician establishes the patient’s diagnosis and treatment plan during the initial visit.
If an APP appropriately performs a service “incident to” a physician’s oversight, the physician or their healthcare practice may submit a claim for 100 percent reimbursement for the patient encounter instead of the 85 percent reimbursement rate if the APP billed services under their own billing number.
“Truthful and accurate billing is crucial to our Medicare system,” said Totten. “This settlement reflects the commitment of my office in working with our investigative agencies to protect the Medicare population and maintain the system of trust and...
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