Wiki Billing under P.A.'s and N.P.'s

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lgirouard14

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Just looking for some general guidance. We are wondering if for commercial insurance companies we should be billing directly under the Physician assistants and nurse practitioners or if we bill directly under the M.D.'s who are supervising them? Thank you for any and all help!
 
You should be billing under the rendering physician. If the PA renders the services this should be the provider you bill under.
 
pedihc said:
Just looking for some general guidance. We are wondering if for commercial insurance companies we should be billing directly under the Physician assistants and nurse practitioners or if we bill directly under the M.D.'s who are supervising them? Thank you for any and all help!
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It's always safest to bill under the provider who actually performed the services. But if your payer allows for 'incident to' billing and the documentation of the encounter meets all of the requirements for this, then you can bill under the supervising physician. Because these rules are complex, many offices simply opt to just bill under the PA or NP to avoid the potential of putting the practice at risk of an unfavorable audit.
 
100% agree with the above. Unless it's Medicare, we don't even consider whether or not the visit meets incident to. For my specific practice, I bill incident to like 10 times a year with 5 PAs. Even if the carrier does follow incident to, the way our practice runs, the incident to requirements are rarely met.
If many of your payors do follow incident to and many of your visits would meet incident to requirements, I would suggest making a chart for yourself of which carriers allow incident to, and if they require any specific modifier on incident to. I recall some wanting -SA.
 
Is this a new change? When I started P.A.'s could not be credentialed with Commercial insurances?? Or am I mistaken? So we would have to credential all of our P.A.'s with commercial insurances in order to bill under them, correct? Thank you for all of the feedback! Much appreciated!
 
It is a change, but dependent on your definition of "new".
When I started in billing (~25 years ago), you are correct that insurances would not credential NPPs. The billing went out under the supervising physician. Over the past 20 years, commercial insurances have realized that if they do credential mid-levels, and billing is submitted under them, they could pay less money for those services. I am only aware of 1 small carrier now that does not credential NPPs. For all other carriers (commercial, Medicare, Medicaid), our NPPs are credentialed.
 
Agree with all of the advice above. While it "could" be billed incident-to provided the requirements are met, the risk vs. reward is so high that most practices don't do it. And, as advised above, many payers don't recognize it at all so you couldn't do it anyway. It's definitely a high risk and oft audited issue. In my experience, it was too time consuming and too risky to try and figure out if incident to was met on the visit and if the payer allowed it. Further, the NPPs were used to reduce the burden on the physicians and took on their own schedules independently so incident-to was rarely met.
 
klapetri@ilovemygyn.com said:
OBGYN NY private practice- can someone explain in simple terms "incident to" vs "spilt shared services" If the payor does not allow to credential NP/PA's how is claim billed?
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VERY generalized-
Split/shared apply to facility visits. Both providers see and participate in the care of the patient that day. May bill under physician if physician performed substantive portion of visit or >50% of the total time. (Note starting 2023, will be based on >50% of time only.)
Incident-to applies to office visits. May bill under physician if physician is onsite, established problem and established plan of care.

Not all commercial carriers follow CMS's incident-to rules. If the payor does not allow NPPs to credential, they should have a guideline which would usually be to bill under the physician. You must follow whatever the payor guidance is.
 
I appreciate your reply
Does incident to apply to physician assistances or only nurse practitioners?
If physician (MD/DO) in office and est.pt not a new problem we can bill under PA/NP? If commercial insurance allows?
I can't seem to find a guidelines for commercial carriers in NY if they follow incident to or not
 
Both incident to and split shared are used for PA, NP and CNM (among others). I call these NPP (non-physician practioners). There are also a variety of other abbreviations in common use. Incident to can also be used for other employees, like an RN billing 99211.
Basically, you can always bill under NPP. You WANT to bill under the physician when permitted as you will receive a higher payment. NPP fee schedule is typically 85% of the physician fee schedule.
Each commercial carrier will set their own rules regarding whether or not they follow incident to. Almost all of my contracts specify we will be following Medicare guidelines, so incident to would apply. Your contracts could differ.
For carriers that do not follow incident to, they might credential NPPs and all services should be billed under the NPP (even if it does meet incident to), or might not credential NPPs and instruct you to bill all services under the supervising physician (even if it does not meet incident to).
IF the carrier follows incident to, AND NPP sees patient for ESTABLISHED problem with a documented PLAN of care and the physician is ONSITE, then you may bill NPP services under the physician to receive full reimbursement. Some carriers require using modifier -SA on incident to claims.
I will note for my practice, it is rare that my NPPs are seeing patients when a physician is onsite, and even then it's even more rare that there's no new problem addressed and a documented plan of care. Basically, it's so rare that my billers and coders don't even really look to see if it could possibly be incident to. My NPP services are billed under the NPP.
Here are some references to start your research on incident to billing:
 
The practice I work for is owned by the actual physician. He has hired an NP to help. When claims are going out, the billing provider listed would be the doctor and rendering provider should be listed as the NP? Or should it both be listed with the NP's information.. She has been credentialed with a number of payers already
 
csperoni said:
Both incident to and split shared are used for PA, NP and CNM (among others). I call these NPP (non-physician practioners). There are also a variety of other abbreviations in common use. Incident to can also be used for other employees, like an RN billing 99211.
Basically, you can always bill under NPP. You WANT to bill under the physician when permitted as you will receive a higher payment. NPP fee schedule is typically 85% of the physician fee schedule.
Each commercial carrier will set their own rules regarding whether or not they follow incident to. Almost all of my contracts specify we will be following Medicare guidelines, so incident to would apply. Your contracts could differ.
For carriers that do not follow incident to, they might credential NPPs and all services should be billed under the NPP (even if it does meet incident to), or might not credential NPPs and instruct you to bill all services under the supervising physician (even if it does not meet incident to).
IF the carrier follows incident to, AND NPP sees patient for ESTABLISHED problem with a documented PLAN of care and the physician is ONSITE, then you may bill NPP services under the physician to receive full reimbursement. Some carriers require using modifier -SA on incident to claims.
I will note for my practice, it is rare that my NPPs are seeing patients when a physician is onsite, and even then it's even more rare that there's no new problem addressed and a documented plan of care. Basically, it's so rare that my billers and coders don't even really look to see if it could possibly be incident to. My NPP services are billed under the NPP.
Here are some references to start your research on incident to billing:
Click to expand...
The practice I work for is owned by the actual physician. He has hired an NP to help. When claims are going out, the billing provider listed would be the doctor and rendering provider should be listed as the NP? Or should it both be listed with the NP's information.. She has been credentialed with a number of payers already
 
cgarciamck87@gmail.com said:
The practice I work for is owned by the actual physician. He has hired an NP to help. When claims are going out, the billing provider listed would be the doctor and rendering provider should be listed as the NP? Or should it both be listed with the NP's information.. She has been credentialed with a number of payers already
Click to expand...
It depends on whether you are billing under the NPP or under the physician due to incident to (or other payor guidance).
I am assuming that "billing provider" is the name going on the claim based on your software.
 
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