Compliant Use of Non-Physician Practitioners
Medicare allows coverage for services provided by Non Physician Practitioners (NPP’s) such as Nurse Practitioners (NPs) and Physician Assistants (PAs), per the following key principles.
To furnish covered services to a Medicare program beneficiary, Medicare requires that NPs:
- Be a registered professional nurse authorized by the State in which services are furnished to practice as a nurse practitioner in accordance with State law;and
- Be certified as a nurse practitioner by a recognized national certifying body that maintains established standards for advanced practice nursing; or
- Be a registered professional nurse authorized by State law to practice as a nurse practitioner and been granted a Medicare billing number as an NP by December 31, 2000.
Medicare also establishes minimum qualifications for PAs:
- The PA must have graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
- The PA must have passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA); and
- The PA must be licensed by the state to practice as a physician assistant.
Medicare limits coverage to the services that a nurse practitioner or physician assistant is legally authorized to perform, in accordance with regulations and state law for the state in which he/she is licensed. Reimbursement under Medicare Part B also requires that NP and PA services meet all of the following conditions:
- The services furnished by the NPP are the types of services that are considered to be physician’s services if furnished by a doctor of medicine or osteopathy (MD/DO);
- The services are furnished by a person who meets the qualifications for NPs and PAs, as outlined, above;
- The NP or PA is legally authorized to furnish the services in the state in which the services are performed;
- If an NP, the services are performed in collaboration with an MD/DO. If a PA, the services are performed under the general supervision of an MD/DO; and
- The services are not otherwise precluded from coverage due to statutory exclusions.
NP and PA services within state scope of practice laws may not be paid if they are otherwise excluded from Medicare coverage due to medical necessity provisions. NPs and PAs should evaluate local and national coverage determinations, and Medicare coverage provisions, to ensure accurate reimbursement.
Medicare defines “collaboration” as a process in which an NP works with one or more physicians to deliver health care services, with medical direction and appropriate supervision as required by the law of the state in which the services are furnished. Where a state does not have laws governing collaboration, collaboration is supported for Medicare by the NP documenting his/her scope of practice and the relationships that he/she has with physicians to deal with issues that go beyond the nurse practitioner’s scope of practice.
“Collaboration,” as defined in these circumstances, does not require the collaborating physician to be present with the nurse practitioner when the services are furnished, or to make a separately independent evaluation of the patient. Rather, collaboration requirements are set by state law, and vary from state to state.
The supervising physician is responsible to oversee and direct a PA’s professional services. The supervising physician does not need to be present while the PA is performing services, unless such physical presence is otherwise required by the state law in which the PA practices. Medicare does require that the supervising physician be immediately available to the PA for consultation by telephone, if necessary, unless State laws or regulations require otherwise. Evaluate your state law requirements to be sure that the PA is complying with applicable state and Medicare rules and regulations.
Payment for PA and NP services is 80 percent of the actual charge, or 85 percent of the Medicare Physician’s Fee Schedule amount. The physician or group practice may bill for the services of an NP who is an employee or independent contractor. Medicare also permits NPs to bill the Medicare program, directly.
PAs may not bill their services directly to Medicare. Although the PA has the option of selecting employment relationships (i.e., 1099 vs. W-2), payment for his/her professional services may be made only to the PA’s “actual qualified employer.” If the PA’s employer is a professional corporation or other duly qualified legal entity (i.e., a limited liability corporation or limited liability partnership), properly formed, authorized, and licensed under State laws, and permits PA ownership in the corporation or entity as a stockholder or member, the corporation or entity as the PA’s employer must still bill for the PA’s services, even if the PA is a stockholder or officer of the corporation or entity.
NPP Services Furnished “Incident To” Physician Services
In some circumstances, the services of NPs and PAs may be billed “incident to” a physician’s professional service. To be covered incident to the physician’s care, services, and supplies furnished by the PA and NP must:
- Be an integral, although incidental, part of the physician’s professional service;
- Be commonly rendered without charge or included in the physician’s bills;
- Be of a type that is commonly furnished in physician’s offices or clinics; and
- Be furnished by the physician or by auxiliary personnel under the physician’s direct supervision.
When pursuing reimbursement under the incident to provisions, practices must be careful to follow the requirements, including—but not limited to—the requirement of “direct supervision.” That is, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time that the NP or PA is performing an incident to service.
The PA or NP may not render incident to services on the patient’s first visit. Additionally, incident to services may not be billed for services rendered to hospital patients, or for patients in a skilled nursing facility who are in a Medicare-covered stay.
If the incident-to requirements are met, the services are paid as if the physician provided them, at 100 percent of the Medicare fee schedule. Examples of services rendered under this scenario generally include high volume, low acute services, including minor surgery, setting casts or simple fractures, reading X-rays, and other activities to evaluate and treat a patient’s condition.
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