Insurance reimbursement

core0 · Jun 11, 2008

Hi,
I'm a new NP working in Kansas. I was wondering if anyone knows if an NP working in a satellite office with the supervising physician 50miles away can still bill "incident to?" Also does blue cross and blue shield allow billing "incident to?" I am having a difficult time finding websites thats answers my questions.
thanks

You can only bill incident to if the physician is present in the same suite of offices and did the initial encounter for that particular problem.

Here is an article that discusses it (registration required):

http://www.medscape.com/viewarticle/408391_5

As for blue cross and blue shield, generally incident to only applies to medicare patients that meet the guidelines. Commercial insurance usually only recognizes credentialled providers. Either they credential NPPs and you bill under your NPI or they do not credential NPPs then you bill under the physician or practice NPI at the contracted rate.

David Carpenter, PA-C

T9458 · Jun 11, 2008

thanks for the quick reply coreo,

i do agree with you on the case of the satellite office, but a classmate of mine insisted that she would still be able to bill "incident to" even if her physician is not present.

It seems that all the NP/PA's that i know bill "incident to" for both medicare and private insurance just because it is not cost effective for the practice if they bill under their NPI.

core0 · Jun 11, 2008

thanks for the quick reply coreo,
i do agree with you on the case of the satellite office, but a classmate of mine insisted that she would still be able to bill "incident to" even if her physician is not present.
It seems that all the NP/PA's that i know bill "incident to" for both medicare and private insurance just because it is not cost effective for the practice if they bill under their NPI.

There is a guy named Michael Powe who is the director of health systems and reimbursement policy for the AAPA. He maintains that if he does nothing else, he can continue to be gainfully employed just answering questions about incident to.

The rules are pretty simple, but people still don't seem to understand them. If you look at the Medicare Payor data there is less billing under incident to each year. Part of this is because it is rarely cost effective to have the physician evaluate every new problem. Especially if the problem is brought to light in the middle of the encounter. Part of this is because Medicare can fine a practice more than $11,000 dollars for each "fraudulent" incident to billing.

If they are billing incident to fraudulently then that is really not cost effective. The penalties are severe and one potential penalty is to bar a provider from Medicare services. Effectively ending employment in the medical field. If they thing that it is "cost effective" to not bill under their NPI they are wrong. Medicare is spending 5x the amount spent last year to prove them wrong though increased enforcement.

As far as billing incident to for private insurance, I'm not even sure how you would go about this. Medicare has a very specific way to fill out the electronic claims for incident to that really don't apply to commercial insurance. In my previous practice we chose not to use it. Medicare/caid was billed under my UPIN and commercial insurance was billed under the physician at 100% (per the insurance company instructions).

There is a lot of discussion that not that the NPI is out there it makes NPPs more visible, but I haven't seen any evidence that commercial insurance companies are any more likely to credential NPPs. There was one attempt by Blue cross in the midwest to pay NPPs a percentage of the physician payment but I believe it was withdrawn. One advantage of commercial insurance is that you contract with them and anything is fair game. That is why it is important to ensure that the contract specifically addresses services by NPPs and how they are paid for.

David Carpenter, PA-C

forpath · Jun 11, 2008

thanks for the quick reply coreo,
i do agree with you on the case of the satellite office, but a classmate of mine insisted that she would still be able to bill "incident to" even if her physician is not present.
It seems that all the NP/PA's that i know bill "incident to" for both medicare and private insurance just because it is not cost effective for the practice if they bill under their NPI.

coreo,

Is it also fraud to NOT report someone you know is billing Medicare fraudulently?

core0 · Jun 12, 2008

coreo,
Is it also fraud to NOT report someone you know is billing Medicare fraudulently?

Interesting question. Short answer is that from my understanding fraud has to either have active participation or complicity. So merely hearing that someone is billing Medicare fraudulently would not be fraud.

The long answer is more complicated. There are some states where it is a crime not to report medicaid fraud if you know about it. As far as I know it is not a crime to not report Medicare fraud.

The other thing that you have to consider is do you really know that someone is committing fraud? People say things all the time that aren't really true. Without seeing how they are billing its really impossible to know what is happening.

David Carpenter, PA-C

DaisyRN, ACNP · Jun 13, 2008

here's another medscape article that i have printed... it has good info!

http://www.medscape.com/viewarticle/562664_4 (this is the incident to page)...