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