| The Office of Inspector General (OIG) issued their November Work Plan. The update includes plans to evaluate incident to services to determine whether they complied with Medicare requirements.
Improper payments of incident to services continues to be the focus of numerous audits, overpayment and False Claims Act settlements.
Incident to is a Medicare specific billing concept and many payers actually prohibit incident to billing. The Medicare incident to provision allows non-physician services rendered in a physician office setting to be billed using a physician’s NPI under certain limited circumstances. The service is then reimbursed at 100% of the Medicare physician fee schedule rather than at the 85% APP rate.
The following criteria must be met to bill incident to:
- Rendered in a physician office (POS 11)
- For an established patient
- For an established problem(s)
- Under an established treatment plan
- Must be performed under direct supervision
- Physician must be in the office and immediately available
- Must be an employment relationship between the APP and physician
Incident to is a compliance risk for most organizations, especially those that bill high volumes of incident to services. The services billed under a physician NPI may skew data analysis and suggest over-utilization which may trigger an audit.
We recommend conducting audits of your APP services to ensure compliance with Medicare and other payer specific rules and requirements.
The HBE team of experts is available to assist you with utilization analysis, risk assessments, routine auditing and monitoring. as well as education and training for your clinical and administrative staff.
The OIG Work Plan can be found here: https://oig.hhs.gov/reports-and-publications/workplan/updates.asp
The CMS Incident to billing provisions are located here:
Medicare Benefit Policy Manual, Ch.15, section 60.1-60.3:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
Medicare Claims Processing Manual, Ch.12, section 30.6.4:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf |
