Split/Shared Billing: Who Performed the Substantive Facility Visit?

Split shared billing fraud means knowingly putting the wrong practitioner on a Medicare claim for a shared facility visit: someone who did not perform the substantive portion. Billing under the physician’s name can mean a higher payment at taxpayers’ expense, but the work has to support that name. If you are the nurse practitioner who handled the visit, the physician asked to sign it or the coder told whose number to use, you may see the difference between the care delivered and the claim sent out.

Whose Work Does a Split/Shared Claim Represent?

A split/shared evaluation and management visit involves a physician and a nonphysician practitioner in the same group, each performing part of the visit in a facility setting. Each must qualify to bill the service if they performed it alone. Medicare pays the practitioner who performed the substantive portion.

The Centers for Medicare & Medicaid Services’ table covers eligible outpatient facility, inpatient, observation and emergency department visits, with a separate time rule for critical care. New and established patients, and initial and subsequent visits, can qualify when the shared-visit requirements are met.

The agency’s manual connects the setting, the practitioners and their work. For an insider, the submitted claim adds the service date and the national provider identifier used to bill. Those details let us compare the care with the payment rule that actually applied.

A signature is not the work. We follow that distinction through the original entries, the clinicians’ schedules and the claim. A name at the bottom of a note cannot supply work that never happened.

What Changed in 2022, 2023 and 2024?

In 2022 and 2023, the substantive portion of a qualifying noncritical facility visit could be established through history, examination, medical decision making or more than half of the combined time. That transitional choice matters when a concern involves older claims. A practice’s policy from that period must be read against the visits it governed.

Beginning January 1, 2024, the ordinary test became more than half of the practitioners’ total time or a substantive part of medical decision making. The agency’s update retains both alternatives. A claim attributed through medical decision making therefore calls for examination of that work, while a claim attributed through time calls for the qualifying minutes.

Critical care has used the more-than-half-time test since 2022. For prolonged services from 2024, the practitioner with more than half of the combined qualifying time, including prolonged time, bills both the primary visit and the prolonged service.

The service date belongs beside the policy, training materials and note template. If management continued using an earlier instruction after the rule changed, the relevant question is what that instruction caused staff to claim about later visits.

What Counts as the Substantive Portion?

Time and medical decision making test different contributions to the visit. A claim credited to the physician needs support for the contribution that put it under that physician’s name.

Time Counts Once, Even When Two Clinicians Are Present

Only distinct time counts toward the combined total. When the physician and nonphysician practitioner meet together or discuss the patient together, their overlapping minutes count once.

Qualifying time extends beyond the bedside. For noncritical visits, the Centers for Medicare & Medicaid Services includes reviewing tests, examining the patient and documenting clinical information, but excludes travel and separately reported services. A copied total leaves concrete questions for us to examine with you: who performed the work, what it involved and whether the same minutes appeared in both clinicians’ totals.

Medical Decision Making Has to Be Performed

Under the medical decision making alternative, each practitioner can perform aspects of the work, but the billing practitioner must perform the substantive part described in the evaluation and management coding guidelines. The clinical record has to support the work attributed to that physician.

The Centers for Medicare & Medicaid Services also requires one of the practitioners to have face-to-face contact with the patient. That person need not be the physician or the practitioner who bills. The bedside encounter and the work supporting billing attribution therefore belong in the same review.

If your concern is a repeated attestation added to another clinician’s note, we look at the decisions and treatment documented beneath it. The original entry, later amendments and identity of each author help show how the record came to describe the physician’s role.

Why the Setting and the Billing Identity Matter

Office incident-to billing and facility split/shared billing have different conditions. Incident-to billing requires qualifying services, appropriate supervision, an initial personal service and continuing physician involvement in the course of treatment. Facility split/shared billing instead turns on the shared visit and its substantive portion. A practice’s office workflow cannot answer who should bill its hospital visits.

Directly billed nurse practitioner and physician assistant services generally use an allowance of 85% of the physician fee schedule amount. The financial incentive sits in the billing identity as well as the code: the physician’s name claims the higher allowance. Same visit, bigger bill.

Sparrow Medical Group settled allegations that it billed advanced-practice-provider services as physicians’ incident-to services without meeting the conditions. The Justice Department alleged that the claims used 100% of the physician rate instead of the lower practitioner rate. That case concerned incident-to billing, but it shows why the name on the claim matters to government spending.

Inside the business, compensation can also depend on productivity. The American Medical Association’s compensation-method report describes salary, productivity and bonus arrangements, often in combination. We examine the actual compensation instructions alongside the claim: whose work received credit, whose name carried the bill and what staff were told to document.

The same encounter can raise separate questions about an inflated visit level or the medical need for the service. Practitioner attribution asks whose contribution supports the bill. The code, the clinical need and the billing identity each have to connect to the care that occurred.

Can Nursing-Facility Visits Be Billed as Split/Shared?

The Centers for Medicare & Medicaid Services’ manual permits qualifying skilled nursing facility visits in its settings paragraph, but its table footnote broadly excludes nursing-facility visits. The settings paragraph also excludes visits required to be performed entirely by a physician. Its April 2022 FAQ repeats the broad exclusion, as does the table footnote in its later update.

We examine the exact facility, visit and billing policy with you. If your organization used a blanket instruction for every nursing-facility claim, the care you saw and the claims it produced give us the starting point.

What Evidence Does a Whistleblower Need?

Useful evidence connects the submitted claim to each practitioner’s actual contribution and the instructions behind the billing choice. The original clinical entries and schedules help explain whose work the claim represents, while the claim shows whose billing identity the practice used.

The Centers for Medicare & Medicaid Services requires the medical record to identify both practitioners. The practitioner who performed the substantive portion and bills the visit must sign and date the record. Modifier FS must appear on the split/shared claim to identify the service as shared.

For a time-based attribution, the useful comparison includes the activities, distinct minutes and overlapping time. For medical decision making, it includes each clinician’s contribution and the resulting management decisions. Group affiliation and the practitioners’ eligibility belong beside those clinical facts because they determine whether the shared-visit framework applies at all.

The Journal of AHIMA’s 2017 article, Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, connects treatment dates, treatment descriptions and signatures with the people who can explain them. Its point reaches beyond the finished note:

You may know who supplied the attestation, who selected the billing practitioner or who raised a concern about the policy. That account gives meaning to the entries and claims. We work with you to connect what happened in the clinical workflow with what Medicare was asked to pay.

What Happened After Someone Raised the Billing Problem?

Internal warnings and the claims submitted afterward can connect management’s knowledge to a repeated billing practice. The inquiry follows who controlled the billing decisions, including people who set policies or responded to audits. The physician named on the claim may be only part of that account.

The chapter Implementing a Physician Practice Compliance Program, in Jones and Bartlett Publishers’ 2011 Health Care Administration, puts medical records, billing reports, computer records and interviews into the same investigation. It also calls for documented operational changes after wrongdoing is identified. For an insider, that makes the response to an audit worth examining alongside the policy that existed on paper.

A hospitalist upcoding case shows why that response matters. TeamHealth, as successor to IPC, agreed to pay $60 million in 2017 to resolve allegations involving Medicare and Medicaid services billed above the care furnished. A former IPC hospitalist brought the whistleblower case and was awarded approximately $11.4 million from the settlement. The government joined the case, and its complaint alleged that management pressed hospitalists to increase their billing and disregarded audit warnings.

The complaint described the alleged response to Medicare contractor TrailBlazer’s education and audit work:

We see an audit warning treated as an obstacle to the revenue target. In a split/shared inquiry, the corresponding questions concern who chose the billing identity, what they learned about the missing contribution and what continued to reach Medicare. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When Your Work and the Claim Tell Different Stories

If you know who performed the visit and why someone else’s number reached Medicare, speak with our whistleblower experts about the billing practice you have seen. We build the connection between the clinical record, the health care payment and the people directing the claims, and bring in healthcare billing whistleblower lawyers who understand physician-practice cases. We stay beside you as that inside knowledge becomes the foundation of your strongest split shared billing whistleblower case.