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Billing for NP practice

E

ecaissie

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Messages
26
Location
Somerset, NJ
Hi! I will be billing for an NP-owned practice, which is composed of two NP's and a physician. Aetna will not credential the NP's because they are not employees of the physician. (The physician is credentialed with Aetna.) If one of the NP's sees an Aetna patient and uses their NPI, will they be paid out-of-network, or will Aetna deny payment because they don't credential NP's except as physician employees?
 
Billling for NP Practice

Hi

Because AETNA does not crendential NP any claims submitted by an NP to AETNA would be denied. If the NP sees an AETNA patient, the visit can be billed under the Physician NPI number, however, the physician will need to co-sign the notes. In this case the physician would have to examined the patient and agreed with the NPs findings.
 
If this is an NP owned practice then I am assuming the physician the NP is collaborating with has his own practice and is not present when the patients are being treated and has not in all likelihood examined the patients prior to the NP visit, therefore if the NP cannot submit the claims as out of network then you cannot bill using the physician NPI. You should know the patient's payer prior to the encounter and if your provider is not credentialed then the patient needs to be notified at that time so they can cancel the visit if they desire.
 
This is directly from my Aetna Provider Contracting Rep in Florida. You may want to call yours.

[FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Payment for Mid-level Practitioners [/FONT][/FONT]
[FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Aetna pays mid-level practitioners at 85 percent of the recognized charge or contracted rates for covered professional services. This policy applies to nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists. [/FONT][/FONT]
[FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Effective 12/1/2013, when a mid-level practitioner performs more than one eligible surgical procedure on the same patient on the same date of service, the allowable benefit is calculated as follows:[/FONT][/FONT]

  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]85 percent for the first procedure with highest RVU+ [/FONT][/FONT]
  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]42.5 percent for the first procedure with the second highest RVU+ [/FONT][/FONT]
  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]21.25 percent for each subsequent procedure [/FONT][/FONT]
[FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Note: Clinical Nurse Specialists may be Nurse Practitioners (NPs) or Registered Nurses (RNs). If an RN is providing services as a Clinical Nurse Specialist the payment policy will apply. [/FONT][FONT=Times New Roman,serif]
[/FONT][FONT=Times New Roman,serif]
This policy does not apply to:[/FONT][/FONT]

  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Certified registered nurse anesthetists, registered nurse first assistants or behavioral health practitioners [/FONT][/FONT]
  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Claims billed with an Assistant Surgery modifier [/FONT][/FONT]
  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Covered DME, orthotics, prosthetics, supplies, drugs, laboratory, radiology services and immunizations billed by a Midlevel Practitioner [/FONT][/FONT]
  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Medicare Private Fee-for-Service (Non-network based) [/FONT][/FONT]
  • [FONT=Calibri,sans-serif][FONT=Times New Roman,serif]Providers contracted through a third party or vendor [/FONT][/FONT]
[FONT=Times New Roman,serif]Q: Is Aetna following the CMS ?incident to? and/or ?split/shared services? policy?A: Yes, Aetna is following the CMS ?incident to? and ?split/shared services? billing guidelines. When services rendered by the mid-level practitioner meet the ?incident to? or ?split/shared services? criteria, the claim must be submitted with the name of the supervising physician as the servicing provider. We also suggest billing with the SA modifier. The claim will then be paid at the physician rate. For more information on CMS?s payment policy refer to http://www.cms.hhs.gov/transmittals/downloads/R1764B3.pdf.
Q: How should claims be submitted when the services rendered are not ?incident to? or ?split/shared services? to the physician services?
A. The mid-level practitioner?s name must be listed as the servicing provider as follows:[/FONT]

  • [FONT=Calibri,sans-serif]For the paper CMS 1500 claim form, list the mid-level practitioner first name and last name in Box 31. [/FONT]
  • [FONT=Calibri,sans-serif]For electronic equivalent, the 837 health care claim transaction, the mid-level practitioner first name and last name should be formatted in the 2310B: NMI segment field. [/FONT]
[FONT=Calibri,sans-serif]We reserve the right to take appropriate action for any violation of policy.

[/FONT]
[FONT=Times New Roman,serif]Q. Will the claim reduction be applied if the billing name/address on the claim form (box 33) is that of a physician group, but the servicing provider is a mid-level practitioner?A: Yes.


Q: Does Aetna?s mid-level practitioner payment policy apply to hospital-based physicians (for example, hospitalists, emergency room, radiology physicians, etc.)?
A: Yes, this payment policy applies to all services provided by mid-level practitioners, regardless of what setting the services are provided in (with the exception of those services qualifying as ?incident to? or ?split/shared? as outlined in the CMS guidelines).
Q: When is credentialing required? A: Credentialing is required for mid-level practitioners when:[/FONT]

  • [FONT=Calibri,sans-serif]Contracted by Aetna as individuals/independently practicing when permitted by the state [/FONT]
  • [FONT=Calibri,sans-serif]Available for member selection as a primary care provider (nurse practitioners only) [/FONT]
[FONT=Times New Roman,serif][/FONT]
 
Having a similar issue with a PA and Aetna.

The PA has his own practice and assists in emergency room surgical procedures for different doctors.

We got a letter back from Aetna that the PAs claim is denied with the explanation "These expenses are not covered because this provider does not meet the plan of a "physician".

We can't bill this under the physicians NPI because it does not fit into 'incident-to" billing.

We have not had trouble with other insurances.

Any ideas?
 
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