If I Could Turn Back Time. . . Provider Certification Lapse Fatal to Surgery Bills

So for those of you old enough to recall Sonny and Cher, and then later just Cher, imagine the title above being bellowed out by that strong magnificent voice. Actually, perhaps “wail” would be the more appropriate term in this case.  Followed by a riddle: “When is a medical charge owed by the carrier not owed by the carrier?”

Answer:  “ When the physician’s provider certification lapses.”   Ouch!!

Further clarification from my partner Gary Baker, the real owner of the bragging rights:

I had a case where Dr. Bose performed surgery.  Ultimately our doctor conceded after reviewing the op report and agreed the surgery was reasonable and necessary.  But during Dr. Bose’s deposition I questioned him about his certification status as he was not a certified provider on the DOL site.  Turns out his certification lapsed on 8/31/19 and was not revived until 3/29/21 (just days prior to his depo).  More significantly it was lapsed at the time of surgery.  The Board found the bills not compensable based on the lack of certification since no pre-authorization was given.  It is always advisable to check a doctor’s provider certification status.

The case in question is Joseph Wilson v Gingerich Concrete, IAB Hr’g No. 1215102 (May 6, 2021). 

So this is kind of a beautiful thing, in the humorous vein of how often does a doctor do something for free? And for those physicians who do not regard Provider Certification status as a real thing, the joke’s on you. Now as for that DME doc who folded, that is no laughing matter. ☺

Irreverently Yours,

Cassandra Roberts