Understand payer requirements for billing non-physician providers

By Madeline Hyden, Craig Wiberg
April 2, 2013
Body of Knowledge Domain(s): Human Resource Management

non-physician provider payer requirementsUsing non-physician providers (NPPs) is an effective way to balance provider workload and improve patient access as group practice professionals prepare for the influx of 30 million new patients with implementation of the Patient Protection and Affordable Care Act. However NPPs can put you at risk for noncompliance, as every health plan — including Medicare —has its own rules regarding NPP billing, and each state has its own laws for NPP licensing and scope of practice.

“After working in medical practices for 30 years, I’m no longer surprised when I hear situations where practices have been billing incorrectly for work performed by NPPs,” says Laura Palmer, FACMPE, senior industry analyst, MGMA, in her webinar, Using non-physician providers in your practice. Billing was one of three content areas covered in the webinar, which is available on-demand, and attracted hundreds of professionals.

Understanding your payers’ various billing policies for NPPs, outlined below, may help you avoid compliance issues:

“Incident to” billing

Medicare offers two options: “Incident to” billing or by independently credentialing them and directly billing Medicare with an NPP’s own Nation Provider Identifier (NPI) Many practices do a hybrid of both.

“Incident to” billing allows services provided by auxiliary personnel (such as NPPs) to be billed under the physician’s NPI. Services must be performed under a physician’s direct supervision or while a physician physically present in the same office suite.

Additionally, to qualify as “incident to,” services must be commonly furnished in the physician’s office or clinic, and must be an integral part of a Medicare patient’s normal course of treatment, during which a physician personally performed the initial service and remains actively involved in the course of treatment, according to the Centers for Medicare and Medicaid Services (CMS).

“Incident to” billing can provide reimbursement at a higher rate, since you’re billing under a physician and will receive the physician rate, but in some cases it can be difficult to do administratively. Get more specifics about this in the May/June issue of MGMA Connexion magazine.

Directly billing Medicare with NPI

Unless all services fall under the “incident to” definition, NPPs are required to complete appropriate Medicare enrollment forms, such as the CMS-855I application, to be paid for providing care to Medicare beneficiaries. Independently credentialing NPPs may be less administrative work, but you will receive a lower reimbursement because NPP services are reimbursed at a lower rate than the Medicare physician fee schedule rate. Medicare reimburses physician assistants and nurse practitioners at 85 percent of the physician fee schedule rate.

“We chose to fully credential our NPP,” says Barbara Tauscher, MGMA member, executive director, Gastroenterology Specialists of (Oregon City) Oregon. “The ‘incident to’ rules were too much of an administrative burden.”

Tauscher explains that if a physician was present at the group in the morning and the other “incident to” criteria were met, the NPP could bill for appointments under that physician’s NPI. However, oftentimes the physician would leave to see patients at the hospital in the middle of the day. The NPP would not be able to bill “incident to” using that physician’s NPI as the appropriate supervising physician was not physically present.

Private payer billing

Third party payers generally require their own credentialing of NPPs, and reimburse at a lower rate than physicians, Palmer says. The American College of Physicians recommends that practices understand the difference between payers that do not cover NPPs and those that do not enroll them as credentialed providers. Most payers will cover NPP services, but they may not enroll them. In this situation, a practice would bill under a physician’s NPI and follow the billing guidelines in the payer’s provider manual. Commercial payers will follow state laws and often require modifiers to correctly identify the provider and supervising physician providing care.

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Madeline Hyden, digital editor, Corporate Communications, MGMA

Craig Wiberg, Senior Industry Analyst, MGMA

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