Orlando Harmon
Incident-to billing is a billing structure that allows non-physician practitioners (NPPs) to provide follow-up services under the direction of a supervising physician and bill under the doctor's national provider identifier (NPI) number. This results in a greater Medicare reimbursement rate. Commercial payers may or may not allow incident-to billing, and it is important to confirm their policies. Commercial insurers recognize the services provided by NPPs in most settings and have developed their own policies, which vary from state to state and region to region.
| Characteristics | Values |
|---|---|
| Incident-to billing | Allows NPPs to provide follow-up services under the direction of a supervising physician and bill under the doctor's national provider identifier (NPI) number |
| Commercial insurance incident-to billing | Commercial insurances may or may not allow incident-to billing |
| Commercial insurance recognition | Commercial insurers recognize the services PAs provide in most settings |
| Commercial insurance billing | Most commercial insurers request that the bill be submitted under the name and identifier of the “contracted” physician |
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What You'll Learn
Commercial insurance and Medicare billing rules
Commercial insurance is typically provided by private issuers, in contrast to government-sponsored health insurance, which is provided by federal agencies. Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) are examples of government-sponsored insurance. Commercial insurance can be purchased by individuals or sponsored by employers, and it is regulated by both federal and state governments.
When it comes to Medicare and billing rules, there are a few things to keep in mind. If a patient has Medicare and other health insurance, each type of coverage is called a "payer." The "primary payer" pays up to its coverage limit and then sends the remaining balance to the "secondary payer." If the secondary payer doesn't cover the remaining balance, the patient may be responsible for the remaining costs.
Incident-to billing is a specific billing practice that allows NPPs (Nurse Practitioners) to provide follow-up services under the direction of a supervising physician and bill under the doctor's National Provider Identifier (NPI) number, resulting in a greater Medicare reimbursement rate. Medicare has specific rules for incident-to billing, such as requiring the supervising physician to be present at the clinic when the NPP renders services. Practices should also be aware that regulations vary from payer to payer and should confirm if their commercial payers allow incident-to billing, adhering to the applicable payer rules.
To streamline billing practices and ensure compliance with regulations, practices can utilise electronic health record (EHR) systems, such as ModMed's EMA®, which suggests codes based on national coding guidelines. Proper training in billing practices and understanding the guidelines for all payers can help mitigate the risk of audits, legal challenges, or fines.
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Commercial insurance and incident-to billing
Incident-to billing is a way of billing outpatient services rendered in a non-institutional setting by a non-physician practitioner. This kind of billing is tricky because there are Medicare guidelines that dictate how incident-to billing is supposed to work, and then each commercial insurance company has its own tweaks to the process. The guidelines for incident-to billing services for Medicare and Medicaid are well-documented and public knowledge. However, the guidelines and rules of commercial insurance companies around incident-to billing are not public knowledge and are not required to be published.
Each commercial insurance company has its own set of guidelines and rules that must be followed in order to secure payment for incident-to billing services. Therefore, it is important to research your contract for the guidelines around incident-to billing. Some contracts state that providers cannot provide incident-to billing services, while others outline specific guidelines for these services. As such, there is no universal rule around the guidelines for incident-to billing services when it comes to commercial insurance companies.
Incident-to billing allows non-physician practitioners to provide follow-up services under the direction of a supervising physician and bill under the doctor's national provider identifier (NPI) number, resulting in a greater Medicare reimbursement rate. Properly training your team about the ins and outs of incident-to billing can help your practice bill services in compliance with these complex regulations. Furthermore, understanding the guidelines for all payers may help mitigate the risk of audits, legal challenges, or fines.
Practices should confirm if their commercial payers allow incident-to billing and follow the applicable payer rules. It is important to ensure compliance and adhere to the regulations set forward, especially when working with government or commercial insurance companies.
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Commercial insurance and NPP billing
Commercial insurance companies may bill directly under the Physician assistants and nurse practitioners (NPPs) or under the supervising M.D.s. It is generally safer to bill under the provider who performed the services. However, billing under the supervising physician is possible if the payer allows for 'incident to' billing and the documentation meets all the requirements.
'Incident-to' billing allows NPPs to provide follow-up services under the direction of a supervising physician and bill under the doctor's national provider identifier (NPI) number, resulting in a greater Medicare reimbursement rate. The NPP fee schedule is typically 85% of the physician fee schedule. However, by adhering to incident-to guidelines, follow-up services provided by a credentialed NPP can receive 100% of the physician fee schedule for Medicare.
Practices must follow specific criteria and understand the rules for each case and payer. Regulations vary from payer to payer. For example, with Medicare, the supervising physician must be present at the clinic when the NPP renders services billable as incident-to. Practices should confirm if their commercial payers allow incident-to billing and follow the applicable payer rules.
Electronic Health Record (EHR) systems, such as ModMed's EMA®, can streamline clinical documentation and suggest codes based on a provider's notes and choices. This can help reduce errors and save time by configuring the system to handle claims following documentation guidelines, including whether or not a specific payer allows incident-to billing.
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Commercial insurance and reimbursement
Commercial insurance is a complicated process, and it is important to seek the guidance of a licensed broker-agent to navigate the various options available. The broker-agent will present different coverage options based on the individual risk characteristics of the business. Commercial health insurance is regulated at the state level, and each state has its own insurance commissioner or equivalent agency to oversee the insurance plans operating within its jurisdiction.
When it comes to reimbursement, healthcare reimbursement, in particular, is a complex and lengthy process that can take months. Providers are typically paid after services are rendered, and the reimbursement process involves multiple steps, each of which carries the risk of errors or delays. Healthcare reimbursement in full is not guaranteed, and some independent physicians choose to avoid insurance altogether, billing patients directly.
For those who do accept insurance, there are several steps to ensure timely reimbursement. Proper documentation is critical, and providers must log important patient details, exam information, and their thought process in establishing a diagnosis and treatment plan. Reimbursement is often a shared responsibility between payers and patients, with patients owing a copayment, coinsurance, or deductible amount, which varies depending on their insurance plan.
UnitedHealthcare, for example, offers commercial reimbursement policies that are based on national reimbursement determinations, as well as state government program reimbursement policies and requirements. They utilize a customized claims editing system to process claims in accordance with their reimbursement policies.
Incident-to billing is another aspect of reimbursement, where NPPs can provide follow-up services under the direction of a supervising physician and bill under the physician's national provider identifier (NPI) number, resulting in a higher Medicare reimbursement rate. Practices must understand the specific criteria and rules for each case and payer, as regulations vary. Medicare, for instance, requires the supervising physician to be present at the clinic when the NPP renders services billable as incident-to.
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Commercial insurance and EHR
Electronic Health Records (EHRs) are regularly shared and updated between multiple healthcare providers, giving medical professionals more information to provide better care. They are comprised of various records from multiple providers, hospitals, and physicians, among others. EHRs are a novel approach to help track coverage and support vulnerable patients in gaining and maintaining coverage. They are also used to identify each patient's insurance status and measure healthcare utilization.
Insurance companies have started underwriting EHR systems, hospitals, IPAs, and non-profit organizations. These entities then select "appropriate" Electronic Health Records to "donate". This could become very expensive for the recipient. Third-party payers use templates and structured language to manage and control the practices they work with. Templates can be set up to limit choices and provide intimidating warnings.
ModMed's EHR, EMA, streamlines clinical documentation and suggests codes based on a provider's notes and choices. It can be configured to handle claims following documentation guidelines, including whether a specific payer allows incident-to billing. Practices must confirm if their commercial payers allow incident-to billing and follow the applicable payer rules. Incident-to billing allows non-physician practitioners (NPPs) to provide follow-up services under the direction of a supervising physician and bill under the doctor's national provider identifier (NPI) number.
Physicians must be careful of template software that can be used to manipulate levels of service. Medicare, for example, audits template EHRs to look for cloning or inappropriate descriptors.
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Frequently asked questions
Incident-to billing allows non-credentialed NPPs or PTs to provide follow-up services under the direction of a supervising physician and bill under the doctor’s national provider identifier (NPI) number, resulting in a greater Medicare reimbursement rate.
The guidelines for incident-to billing vary from payer to payer. For example, Medicare requires the supervising physician to be present at the clinic when the NPP renders services billable as incident-to. Practices should confirm if their commercial payers allow incident-to billing and follow the applicable payer rules.
Commercial insurances may or may not allow incident-to billing. Commercial insurance companies have developed their own policies, which may differ in each state and region. It is recommended to contact individual payers directly to confirm their policies.
