Q&A: Billing for physicians in other groups

September 19, 2008

Medical practices must credential outside physicians to their insurance plans before they can bill for services.

My group has contracted with another group to have one of its physicians provide interpretations for the various testing we do. It is not necessarily the same physician who interprets each time. In addition, everything is done in the other group's office, and we simply bill for his/her services as part of our group. Our claims have been rejected for these services, and someone suggested we need to contract with a specific physician. Are they correct?

To bill the services of a physician as part of your group, you need to credential that physician to the insurance plans you are on. In addition, according to Centers for Medicare & Medicaid Services policy, in order to meet the definition of "physician in the group practice" (defined in 42 C.F.R. §411.351), an independent contractor-physician must furnish patient care service for the group practice under a contractual arrangement directly with the group practice to provide services to the group practice's patients in the group practice's facilities. The specific contractor-physician must have a written contract with the outside group, or his/her group must have a signed contract with the group requesting the services. If he/she signs the contract between groups, the contract must identify the individual physician and the services that will be specifically provided, and should indicate where the services will be rendered. We suggest having your malpractice insurer and health-care attorney, familiar with Stark and anti-kickback regulations, review your arrangement and contract to ensure it does not create a liability situation for your practice.