January 2023
Fighting Fraud, Waste and Abuse Reminder: Inaccurate Identification of Rendering Providers May Lead to Improperly Paid Claims
Blue Cross and Blue Shield of Illinois (BCBSIL) is aware of several cases involving providers/groups filing claims under the rendering National Provider Identifier (NPI) of a physician or medical doctor; however, these services were actually performed by a mid-level provider, resulting in claims being inaccurately paid at inflated reimbursement rates.
As a reminder, reimbursement is based on the type of rendering provider indicated on the claim. The provider types listed below will have the differentials applied to the Schedule of Maximum Allowances (SMA) as noted:
100% of the SMA
- Physician
85% of the SMA
- Licensed Clinical Psychologist
- Certified Nurse Specialist
- Certified Nurse Practitioner
- Certified Registered Nurse Anesthetist
- Licensed Physician Assistant
85% of 20% of the SMA
- Licensed Surgical Assistant
- Registered Nurse First Assistants
70% of the SMA
- Licensed Clinical Social Worker
- Master Social Worker
- Licensed Clinical Professional Counselor
- Licensed Professional Counselor
- Licensed Marriage and Family Therapist
- Board Certified Behavioral Analyst
- Board Certified Assistant Behavioral Analyst
- Certified Early Intervention Specialist
- Developmental Therapist
Please take an opportunity to review your billing practices and ensure claims submitted to BCBSIL are in compliance with requirements specified in the BCBSIL Provider Manual and your BCBSIL Provider Agreement.
If you’re aware of an instance of potential fraud, waste and/or abuse, we encourage you to file a report online or call the BCBSIL Fraud Hotline at 877-272-9741 to create a report. All online reports and calls are confidential, and you may remain anonymous. For more information, visit our Fraud and Abuse page.
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.