In general, the services of residents and ABMS Fellows (i.e., physicians in ACGME- or ABMS-approved training programs) are not billable.  However, when services are furnished by a Fellow (as defined below) outside of the scope of the Fellow’s training program under a “moonlighting” arrangement, such services may be billed under the Fellow’s name and NPI number pursuant to the following standard:

A.            Definitions

1. Formal Fellowship Training Program – A training program following completion of a program leading to a General Specialty Certificate that (a) is designed to lead to a Subspecialty Certificate or (b) is otherwise characterized by a formal didactic program of defined length and articulated goals and standards for training in a subspecialty area.
   1. American Board of Medical Specialties (ABMS) Fellow – A physician who is: (i) engaged in a formal fellowship training program; (ii) has an unrestricted license to practice medicine in California; and (iii) is in an Accreditation Council for Graduate Medical Education (ACGME) or ABMS-approved training program leading to a specialty certificate.  For these purposes, an unrestricted license means a physician’s and surgeon’s certificate issued by the Medical Board of California pursuant to Business & Professions Code § 2050 without any restrictions imposed by the Board.  An unrestricted license shall not include any exemption from licensure or special permit, including, but not limited to, exemption under Business & Professions Code § 2111, 2112 or 2115 or a certificate of registration under Business & Professions Code § 2113.
   2. Non-ABMS Fellow – A physician who is: (i) engaged in a formal fellowship training program that is not ACGME- or ABMS-approved; and (ii) has an unrestricted license to practice medicine in California.

2. Moonlighting
   1. Internal Moonlighting – Furnishing of services by a Fellow outside of the scope of the Fellow’s training program, but within a practice location where the Fellow rotates as part of the training program.
   2. External Moonlighting – Furnishing of services by a Fellow outside of the scope of the Fellow’s training program at a practice location that is not part of the Fellow’s training program.
   3. Moonlighting Agreement – Written agreement setting forth the scope of services that may be separately billed under Fellow’s name and NPI, as more particularly described below in Section B.4.

B.           Approval of Moonlighting Arrangement for ABMS Fellows

1. For Internal Moonlighting, the Fellow must be credentialed for the proposed services through USC Care and the hospital where services will be furnished.
2. The scope of services to be provided by the Fellow under any Internal Moonlighting arrangement must be reviewed and approved by USC Care, Risk Management and the Integrated Credentialing Committee.
3. If the Fellow is in a training program that is supported by non-USC funding (including county funding), USC Care must ensure that the terms and conditions of funding permit moonlighting and that all funder-specific requirements regarding moonlighting are satisfied prior to the fellow engaging in any Internal or External Moonlighting activity.
4. Prior to engaging in any Moonlighting activity, the Fellow must have a written Moonlighting Agreement approved by USC Care and Fellowship Program Director.  The Moonlighting Agreement must include, at a minimum, the following:
   1. The scope of services to be provided by completing Moonlighting Request Form (Appendix B.)
   2. A statement that such services are outside of the scope of the Fellow’s training program
   3. If Internal Moonlighting
      1. Fellow will be covered under the USC Malpractice policy;
      2. Services will be billed by USC;
      3. Separate compensation will be provided to the Fellow for the services
   4. If External Moonlighting
      1. Fellow will not be covered under the USC Malpractice policy for services furnished under the moonlighting arrangement
      2. Services are not billable by USC

C.           Billing of ABMS Fellows

Internal Moonlighting services of an ABMS Fellow may only be separately billed under the Fellow’s name and NPI if:

1. The services are furnished in an outpatient setting;
2. All requirements for Moonlighting arrangements are satisfied;
3. The services to be billed are within the scope of services set forth in a Moonlighting Agreement approved by USC Care;
4. The Fellow has completed training and is board eligible for the services to be billed;
5. Fellow has a faculty appointment and is credentialed as a billing fellow;
6. Fellow practices under the rules of the USC Care and USC Compliance program;
7. The Fellow has not treated the patient in the course of the Fellow’s training program for the same or a related diagnosis or treatment plan as that for which the Fellow is rendering moonlighting services.

D.           Billing of Non-ABMS Fellows

1. Fellows who are not in an ACGME- or ABMS-approved training program are considered “regular” physicians under Medicare billing rules.  Services of these Fellows may only be separately billed under the Fellow’s name and NPI if:
   1. All requirements for Moonlighting arrangements are satisfied;
   2. The services to be billed are within the scope of services set forth in a Moonlighting Agreement approved by USC Care;
   3. The Fellow has completed training and is board eligible for the services to be billed;
   4. Fellow has a faculty appointment and is credentialed at the hospital where services will be rendered and is credentialed as a billing fellow through USC  Care;
   5. Fellow practices under the rules of the USC Care and USC Compliance program;
   6. The Fellow has not treated the patient in the course of the Fellow’s training program for the same or a related diagnosis or treatment plan as that for which the Fellow is rendering moonlighting services.
   7. If the Fellow is in a training program that is supported by non-USC funding (including county funding), USC Care must ensure that the terms and conditions of funding permit separate billing of the Fellow’s services.

STANDARD ATTACHMENTS

Appendix A – Flowchart for Separately Billable Services of Fellows

Appendix B – Moonlighting Request Form

REFERENCES AND DEFINITIONS

Medicare General Information, Eligibility and Entitlement Manual, Pub. 100-01, Ch. 5, Sec. 70.7.

Medicare Benefits Policy Manual, Pub. 100-02, Ch. 15, Sec. 30.3.

Medicare Claims Processing Manual, Pub. 100-04, Ch. 12, Sec. 100.

Association of American Medical Colleges, Advisory, “Billing for Clinical Fellows in Their Own Name,” Memorandum #96-12, March 10, 1996.

 

Any questions related to billing of fellow services should be directed to the USC Office of Culture, Ethics and Compliance or the Office of General Counsel for clarification.