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The DOJ Settles “Incident to” False Claims Case

The DOJ Settles “Incident to” False Claims Case February 6, 2020

The Department of Justice (DOJ) recently announced a False Claims Act settlement with a family practice physician who improperly billed “incident to” services.  Specifically, the physician billed for services rendered by nurse practitioners which did not meet the direct supervision requirements.  Consequently, the services were reimbursed at the higher physician billing rate resulting in a settlement of $285,000.  

Improper “incident to” billing has been the subject of numerous audits and over-payment settlements. The most recent MedPAC report included recommendations to eliminate the Medicare “incident to” provisions.

Currently, many payers do not recognize “incident to” billing and prohibit the billing for services rendered by a nurse practitioner or physician assistant using a physician’s NPI.  The Medicare “incident to” billing provisions allow non-physician services rendered in an outpatient office to be billed using a physician’s NPI in the following limited circumstances:  

  • Established patient
  • Established condition
  • Established treatment plan
  • Must be directly supervised (physician must be in the office suite and immediately available to provide direction and assistance)
  • Services must be rendered by an employee of the physician practice acting within their state scope of license.

Improper reporting of “incident to” services is a compliance risk for most organizations.  Additionally, practices who bill high volumes of “incident to” services face additional risks.  Most, if not all, payers and enforcement agencies employ data analysis to identify unusual and aberrant billing practices.  Billing a high volume of “incident to” services creates data anomalies suggestive of over-utilization and is likely to trigger an audit.

We recommend conducting routine auditing and monitoring of your nurse practitioner and physician assistant services to ensure compliance with payer specific billing and reimbursement rules.  The HBE team has expertise in “incident to” billing and is available to assist you with conducting data documentation, coding, and billing audits.  We also offer customized education and training for your physicians, coders and executive leadership.

The Medicare “incident to” billing provisions are located at:

Medicare Benefits Policy Manual, chapter 15, section 60.1-60.3: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

 Medicare Claims Processing Manual, chapter 12, section 30.6.1: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

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