Incident-To Billing: Unraveling The Insurance Allowance Mystery

Incident-to billing is a way of billing outpatient services provided in a non-institutional setting by a non-physician practitioner. This type of billing is complex, as it is subject to Medicare guidelines and each commercial insurance company's own variation of the process. Medicare is the nation's largest health insurance program, covering over 40 million people who are aged 65 or older or disabled. It allows for incident to billing for services provided by certain medical professionals, such as physician assistants (PAs) and non-physician providers (NPPs). However, there are significant restrictions and confusion surrounding this billing method, and it is important to ensure compliance with all regulations to avoid insurance fraud.

Medicare may allow 'incident-to' billing

Medicare may allow incident-to billing, but it is important to note that this is a complex process with strict guidelines that must be followed to avoid insurance fraud. Incident-to billing is a way of billing for outpatient services provided in a non-institutional setting by a non-physician practitioner.

Medicare, the nation's largest health insurance program, has set the standard for many billing practices, with other companies often adopting Medicare's rules and regulations. However, it is crucial to understand that Medicare has specific requirements for incident-to billing that must be met to receive reimbursement.

• Non-Institutional Setting: Incident-to billing under Medicare is only applicable when services are provided in a non-institutional setting, typically an office or clinic. It does not apply to hospital or skilled nursing facility settings.
• Initiation of Care: A Medicare-credentialed physician must initiate the patient's care. They must treat the patient during the initial visit, establish a diagnosis, and create a treatment plan.
• Follow-up Care: After the initial encounter, a non-physician provider may provide follow-up care under the direct supervision of a qualified provider.
• Physician's Role: A physician must be actively involved in the patient's course of treatment and must be present in the office suite to provide assistance and direction.
• Employment Status: Both the credentialed physician and the non-physician provider must be employed by the group entity billing for the service. They cannot be contracted clinicians.
• Type of Service: The service provided must typically be performed in an office setting and must be part of the normal course of treatment for the patient's diagnosis or illness.

It is important to note that there may be slight variations in the interpretation and application of these guidelines by different Medicare contractors and local coverage decisions. Therefore, it is crucial to refer to the specific guidelines provided by the relevant Medicare contractor for your jurisdiction.

Additionally, while Medicare may allow incident-to billing, private and commercial plans, such as Blue Cross and Optum, may not. It is essential to review the insurance contract and ensure that incident-to billing is permitted and that your clinical supervision documentation meets the requirements.

Private insurance companies may not allow it

Private insurance companies may not allow incident-to billing, and it is important to check with each carrier before billing services in this way. Medicare has set the standard for many aspects of healthcare insurance, and its guidelines dictate how incident-to billing is supposed to work. However, each commercial insurance company has its own tweaks to the process.

For example, in one region of the US, Anthem has not adopted Medicare's incident-to guidelines and has instead implemented a guideline that requires all practitioners to bill under their own PIN. There is only one other payer in this region, besides Medicare, that has adopted incident-to guidelines.

TherapyAppointment, a service that helps create 'incident-to' claims, warns that the practice of billing 'incident-to' may not be allowed by all insurance companies and that doing so could be considered a fraudulent practice punishable by hefty fines.

Medicare may allow 'incident-to' billing, but private and commercial plans such as Blue Cross, Optum, and others may not. It is critical to check with insurance companies to avoid any issues.

Additionally, it is important to note that incident-to billing is a way of billing outpatient services rendered in a non-institutional setting by a non-physician practitioner. This type of billing can be confusing, and it is essential to understand how it works to avoid insurance fraud and increase productivity in one's practice.

To bill incident-to, the following requirements must be met:

• The service must take place in a non-institutional setting, such as an office or another non-institutional location.
• A Medicare-credentialed provider must initiate the patient's care.
• After the initial encounter, a non-physician provider may provide follow-up care.
• A physician must actively participate in and manage the patient's course of treatment.
• Both the credentialed clinician and the qualified non-physician provider must be employed by the group entity billing for the service.
• The incident-to service must be the type of service usually performed in an office setting and must be part of the normal course of treatment for a diagnosis or illness.

It is crucial to follow these rules precisely to realize the benefits of incident-to billing.

Commercial insurance companies have their own rules

For example, while Medicare requires that incident-to billing takes place in a non-institutional setting, this is not always the case for commercial insurance companies. Outpatient therapeutic services in a hospital setting may be covered by some commercial insurance companies, but not by Medicare. Additionally, while Medicare requires that a credentialed physician initiates a patient's care, this may not be the case for all commercial insurance companies. Some companies may allow non-physician providers, such as nurse practitioners or physician assistants, to initiate care and bill under incident-to.

It is important for providers to be aware of the specific rules and regulations of each commercial insurance company they work with. Failing to comply with incident-to billing requirements can result in massive settlements and penalties for fraud. Commercial insurance companies typically request that bills are submitted under the name and identifier of the "contracted" physician, but this may vary depending on the company. Additionally, most commercial insurers do not "credential" non-physician providers, as they are not the "contracted provider" with the insurance company. This may change in the future, but for now, it is an important distinction to note.

To navigate the complex world of incident-to billing with commercial insurance companies, providers should study their contracts thoroughly and be familiar with the provider manual for each company. Building a relationship with a contact person at the insurance company can also help to ensure compliance and avoid issues with billing. Ultimately, it is the responsibility of the provider to understand and follow the rules set forth by each commercial insurance company to avoid penalties and ensure proper reimbursement.

Incident-to billing is a way of billing outpatient services

Medicare Part B allows physicians and certain other non-physician practitioners to receive reimbursement for certain services furnished by "auxiliary personnel" on an "incident-to" basis. This means that non-physician providers can report services as if they were performed by a physician, and be reimbursed at the full pro fee schedule value. This is in contrast to services provided by non-physician providers that are not billed incident-to, which are typically reimbursed at 85% of the pro fee schedule amount.

There are several requirements that must be met to bill incident-to. Firstly, it only applies to professional services billed to Medicare and not to services with their own benefit category, such as diagnostic tests. Secondly, the service must take place in a non-institutional setting. Thirdly, incident-to services cannot be rendered on a patient's first visit, or if there is a change to the plan of care. A Medicare-credentialed physician must initiate the patient's care and establish the diagnosis and plan of care. Fourthly, subsequent to the initial encounter, a non-physician provider may provide follow-up care under the direct supervision of a qualified provider. Fifthly, a physician must actively participate in and manage the patient's course of treatment. Sixthly, both the credentialed physician and the qualified non-physician provider must be employed by the group entity billing for the service. Finally, the incident-to service must be of a type usually performed in the office setting and must be part of the normal course of treatment of a diagnosis or illness.

It is important to note that not all insurance companies allow incident-to billing. For example, Medicare may allow it, but private and commercial plans such as Blue Cross and Optum may not. Therefore, it is crucial to check with each insurance carrier before billing services incident-to.

There are six basic requirements for Medicare payment

There are six basic requirements that must be met to fully satisfy the guidelines for Medicare payment. These requirements are particularly important as failing to adhere to them could result in accidental insurance fraud.

• The service must take place in a non-institutional setting. This is a crucial factor in the incident-to billing process. Medicare will not pay for a claim that is incident-to if the place of service is any institutional setting.
• A Medicare credentialed provider must initiate a patient's care. This means that the first session must be conducted by a Medicare credentialed clinician.
• After the initial encounter with the Medicare credentialed provider, a non-physician provider may provide follow-up care. Once the initial session has been completed and there is a treatment plan in place, a non-physician provider can conduct follow-up care with the client.
• A physician must actively participate in and manage the patient's course of treatment. This is another critical element in the process that is belaboured by clinicians because it requires a physician to be actively involved in the treatment of the client.
• Both the credentialed clinician and the qualified non-physician provider providing the incident-to service must be employed by the group entity billing for the service. This is an important compliance regulation.
• The incident-to service must be the type of service usually performed in the office setting and must be part of the normal course of treatment of a diagnosis or illness. The service must be performed in the office setting and must be a part of the normal course of treatment of the diagnosis or illness.

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