Provider misidentification

Using another physician’s PIN could result in severe penalties.

In anticipation of one provider’s approaching retirement, a group of two ophthalmologists added another ophthalmologist to their practice. She previously practiced in Canada. She also has a license to practice in the United States. Since establishing residency in the United States, she has not practiced ophthalmology. Once hired by this group practice, she immediately began to see patients in the office and referred all surgical cases to the other ophthalmologists. For the purpose of reimbursement, no one in the practice bothered to enroll her as a member of the group in any insurance plans. An ophthalmologist within the group evaluated all of her charts and countersigned them as acceptable. The group then used that ophthalmologist’s name and personal identification number for billing all insurance companies even though the ophthalmologist did not render the service.

Is this process acceptable to Medicare and other payers?

This process is not acceptable under Medicare requirements or those of any other insurance company. Each practitioner (ophthalmologist or optometrist) in a group practice must apply for and maintain his or her own identification number, and that number must be reflected on the claim form to identify who provided the service.

By way of example, one Medicare carrier addresses the issue of improper use of another physician’s PIN as follows:

“Connecticut Medicare is also aware that some groups or entities are submitting claims for the new physicians or non-physician practitioners using one of the other physician’s Medicare Provider Identification numbers while waiting for the new PIN to be issued. This is not acceptable practice. Before these services can be billed to Medicare, each provider must obtain his or her own PIN. The claims for that provider should be held until Medicare issues a PIN number.”

It is important to recognize that the delay in obtaining a PIN will not likely impact the ability of the physician or practice to be paid for the services. The Medicare program, and most insurers, will accept claims for services rendered as of the date the request for a PIN has been submitted. Thus, while waiting the issuance of a PIN may create temporary cash flow problems, it should not adversely affect payment. On the other hand, to use an incorrect PIN to obtain payment could result in allegations that an improper claim was submitted with potentially severe penalties.