For many physician employers, the subject of nonphysician practitioners (NPPs) and “incident-to” billing prompts more questions than answers.
A physician-led team allows for proper delegation to NPPs, including nurse practitioners and physician assistants. But doing so requires vigilance to comply with state scope-of-practice laws and to avoid costly billing mistakes.
So, it’s critical physicians get answers.
The Texas Medical Association’s Knowledge Center has general information on the following topics.
What is incident-to billing?
Under certain circumstances, supervising physicians can bill NPP visits under their own National Provider Identifier (NPI) number for full payment. The Centers for Medicare & Medicaid Services defines such services as “incident-to” because they are incidental to the physician’s diagnosis and treatment of an injury or illness.
What are the requirements for incident-to billing?
Carra Benson, TMA’s manager of reimbursement services, delved into the qualifications for incident-to billing during a September 2021 Ask the Expert event, “Delegation of Nonphysician Practitioners and Scope of Practice.”
To qualify under Medicare, she says, an NPP must see a patient for an existing problem and use a treatment plan developed by the physician in advance and under direct supervision – where a physician is present in the same office suite and available to intervene if needed – among other requirements.
Similarly, if an NPP sees a patient under general supervision – where a physician is only available by phone – the visit must be billed under the NPP’s NPI number, not the physician’s.
Physicians can find more information about incident-to billing, including a basic overview of Medicare, Texas Medicaid, and commercial plans’ respective requirements, in this TMA education sheet (log-in required).
What are the consequences of not meeting incident-to billing requirements?
Although physicians may have unanswered questions about NPPs and incident-to billing, they should take care to understand and heed the regulations around them.
Medicare and Texas Medicaid may consider practices with a pattern of violations to have committed fraud or abuse and as a result, the agencies may remove the practices from the programs. The rules vary across health plans. Commercial payers that follow Medicare’s lead on incident-to guidelines may request recoupment payments.
During the Ask the Expert event, Austin attorney Julian Rivera encouraged physicians to document any mistakes as well as any corrective actions taken to address them. If a mistake is substantial, he recommends hiring a lawyer who can help analyze the situation confidentially.
Emma Freer
Associate Editor
(512) 370-1383