Medicare services performed by a physician assistant or nurse practitioner are reimbursed at 85% of the physician fee schedule. However, there is one way, in the outpatient setting, that you can get reimbursed at 100%. “Incident-to” billing refers to services that have been rendered in lieu of the physician.
To qualify for incident-to billing and receive 100% payment for services rendered, the following requirements must be met:
- A physician must have treated the patient before for the original problem (it is not possible to bill incident-to for a new patient or consultation).
- Supervising physicians must be on-site. This does not have to be the original physician who saw the patient but rather any of your supervising physicians. The physician does not need to see the patient that day.
- The service must be one that is typically performed in an office setting.
- The service performed must be within the scope of practice and in accordance with state law.
Here is an example:
Joe sees Dr. Smith. The patient is diagnosed with hypertension, started on a diet and exercise routine, and asked to follow up in six weeks with the PA or NP. At the follow-up appointment, the PA or NP starts him on a medication for hypertension and tells him to return in another six weeks. During that time, Dr. Smith is in the office but never gets that chance to follow up with the patient personally. That visit would be billed as incident-to (under the physician’s National Provider Identifier) and therefore reimbursed at 100% of the physician fee schedule. It this case, it is important that you have a bonus or production-based compensation program that will allow you to get “credit” for the payment when it comes in.
So where does it get complicated? Imagine that during that follow-up visit you are on the way out the door and the patient says “Oh, can you examine this lesion on my nose?” Once you look, you are no longer dealing with a problem Dr. Smith saw. Your options are to bill the entire visit (and potential biopsy) under the PA or NP provider number and get reimbursed at 85%, or go get the physician to see the patient.
Only you can decide if it is worth it to you to bill incident-to at all. You want to avoid having all Medicare patients automatically billed incident-to regardless of whether you meet the criteria or not. That would be insurance fraud (punishable with fines, being barred from participating with Medicare and other insurances, loss of medical license, and criminal charges). Remember, this concept only applies to Medicare.