While the “silver tsunami” of baby boomers first hit the health care industry a decade ago, demand for health care services remained high going into 2020. Add to the equation a global pandemic and a surge in the burnout rate of health care professionals, and you are left with a health care industry in search of a way to bridge the ever-widening gap.

Many providers are turning to midlevel practitioners to fill the void and keep pace with demand; however, properly billing for these non-physician practitioners (NPPs) is not always an easy task. Improperly billing for NPP services can quickly turn into an overpayment nightmare.

Background

The simplest way to bill for NPP’s services is under the NPP’s NPI. Many payors, including Medicare and Medicaid, credential certain midlevel NPPs (physician assistants, nurse practitioners, nurse specialists, etc.); yet, reimbursement rates for services provided and billed by NPPs are typically lower than the same services when provided by a physician (85% of the Physician Fee Schedule (PFS) for Medicare). While billing under an NPPs NPI is fairly straight forward, there are certain instances when an NPP’s services may qualify to be billed through a physician’s NPI as “incident-to.”

The immediate draw to incident-to billing is a higher reimbursement rate for the NPP’s services (100% of the PFS),but nothing comes easy in the health care industry. While each payor is free to develop its own incident-to rules, for simplicity,  this article focuses only on Medicare’s incident-to rules. Providers should always verify each payors’ rules prior to submitting incident-to claims. Improperly billing for incident-to services can result in overpayments audits and recoupments. The following are a few (not all) of the pitfalls providers face when billing incident-to.

Common Pitfalls

1. The patient presents for the first time to the NPP or with a new medical condition

As the term suggests, incident-to services provided by NPPs must be made in conjunction with the billing physician’s professional services. Meaning the physician must initiate the patient’s care, including arriving at a diagnosis and developing a plan of care for the patient, in order for a physician to bill for an NPPs services. An NPP may provide additional care “incident-to” the physician’s services, such as follow-up encounters for the same medical condition.

Where the patient presents for the first time to the NPP, without first seeing a Medicare credentialed physician, the NPP’s services should be billed under the NPP’s enrollment, and not as incident-to services. Similarly, if an existing patient presents to the NPP with a new or worsening medical condition, a physician must evaluate the new or worsening condition before an NPP’s services related to the new or worsening condition can be billed as incident-to. If the physician does not see the patient for the new or worsening medical condition, the NPP’s services should be billed under the NPPs enrollment.

2. Physician fails to remain active in the management of patient’s care

In addition to the initial encounter, Medicare incident-to rules require the physician to actively participate in, and manage, the patient’s plan or care. Although Medicare has not set a specific minimum frequency for physician involvement, state laws and regulations governing physician oversight of NPPs may offer a good baseline. Physician involvement should be noted in the patient’s medical record. The physician should also see the patient face-to-face at a frequency that reflects his or her active involvement in the patient’s care. This frequency will vary based on the diagnosis and plan of care. The failure to meet the incident-to requirements, including they physician’s ongoing involvement, may result in overpayments and recoupment efforts.

3. Billing an NPP’s services as incident-to without proper physician supervision

Medicare requires direct physician supervision in order to bill for NPP services as incident-to,. “Direct supervision” means that a physician must be on-site, in the office-suite, but not necessarily in the same room as the NPP who is providing the incident-to services. The supervising physician also must be immediately available to assist the NPP, if needed.

If the NPP is providing services incident-to a physician’s services and the physician is a member of a group practice, any physician in the group may supervise the NPP during the incident-to services. In other words, it does not have to be the billing physician that provides the direct supervision required under Medicare regulations. If the billing physician is a solo practitioner, then he or she must directly supervise the NPP when billing incident-to.

As a result of the pandemic, Medicare has expanded its definition of “direct supervision” to include supervision via certain telecommunication methods. The telecommunication must occur through real-time, interactive audio-visual technology, as  audio-only telephonic communication does not satisfy the requirement. If a supervising physician is not on-site in the office suite, and not available via real-time audio-visual telecommunication technology, an NPP’s services should not be billed as incident-to, but rather under the NPP’s credentials.

Conclusion

If you or your group is contemplating adding NPPs to your practice and would like to take advantage of the higher reimbursement rates offered under incident-to billing, please be sure to review each payors’ rules and regulations carefully before submitting any claims. Additional rules regarding Medicare’s incident-to billing requirements can be found in the Medicare Benefit Policy Manual.

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