Starting April 1, Aetna will pay physician practices only 85% of the Medicare Physician Fee Schedule’s allowed amounts for services provided by non-physician practitioners (NPPs) – regardless of whether they bill Medicare directly or “incident-to” physician supervision.
Both direct and incident-to claims will still be required to include modifiers SA or SB to indicate what type of NPP rendered the service, such as a nurse practitioner or certified nurse midwife.
Whether billing incident-to or directly, NPPs are still required to be employed by supervising physicians and registered with the Texas Medical Board as having delegated prescriptive authority.
“This is essentially [Aetna] getting rid of incident-to billing,” the Texas Medical Association’s Director of Physician Payment Services Carra Benson told Texas Medicine Today.
Aetna previously paid 100% of the fee schedule for services given by NPPs if they billed incident to under a supervising physician’s name and National Provider Identifier (NPI) – so long as those services were incidental to the physician’s diagnosis and treatment of an injury or illness and conducted in the same office suite where the physician was present and available to intervene if needed.
Under that model, NPPs who billed directly under their own name and NPI received payment at only 85% of the fee schedule, which Ms. Benson says incentivized incident-to billing.
Aetna also will require NPPs to credential with the payer to continue to bill for services. The change will apply to both commercial and Medicare patients and follow similar moves by Blue Cross Blue Shield last year.
Ms. Benson encourages supervising physicians to have their NPPs credentialed by individual payers. Doing so avoids disruptions in billing or coverage and provides a safety net against lost revenue if an NPP visit billed under the physician’s NPI number is disqualified for any reason, she says.
Credentialing involves collecting and verifying information about an NPP’s professional qualifications. This includes, but is not limited to:
- Relevant training;
- Licensure;
- Certification or registration to practice in a health care field; and
- Academic background.
To speak directly with TMA billing and coding staff, visit
TMA’s comprehensive Physician Payment Resource Center. For payer updates, visit
TMA’s Health Plan News page.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469