Thank you for breaking this down, and explaining I appreciate it-
Just to be clear, I'm inquiring about the major insurance companies like Aetna BCBS, Cigna, Emblem Health, Healthfirst UHC/Oxford The Empire Plan(NYSHIP)
if you do not bill as incident-to, your NPP's are credentialed with insurance and reimbursed at 85%? Billing under there own NPI (or group if have group contracted?)
What if insurance does not allow NPP's to be credentialed, how do you bill?
If insurance allows NPP's to be credentialed, it is not necessary to bill incident to?
Incident to allows NPP's to be reimbursed at 100%? but service they provide are limited? and documentation needs to indicate incident to
I truly appreciate all your help! Thank you! Thank you!
Our corporate offices handle credentialing, but I am 99% certain that the the major commercial carriers listed all credential NPPs. Also, because we are such a large healthcare organization, we sometimes have separate agreements/policies than private practices.
Regarding your specific questions:
if you do not bill as incident-to, your NPP's are credentialed with insurance and reimbursed at 85%? Billing under there own NPI (or group if have group contracted?)
Yes, our NPPs are credentialed with every plan our physicians are. Since our services do not typically meet incident-to requirements, we bill under the NPP and most carriers reimburse at 85%.
What if insurance does not allow NPP's to be credentialed, how do you bill?
I am not aware of any insurance that does not permit our health system's NPPs to be credentialed. When we were private practice, if a carrier did not allow NPPs to be credentialed, the carrier provided guidance to bill under the supervising physician, even if it did not meet incident-to. But you should double check this with any payor who does not credential NPPs.
If insurance allows NPP's to be credentialed, it is not necessary to bill incident to?
Incident-to billing is never "necessary" or required. It's like a bonus or extra credit. It's a way to receive 100% reimbursement even if services are provided by NPPs, IF certain requirements are met. Some carriers credential NPPs and still permit incident-to (again, assuming requirements are met). Some carriers credential NPPs and do not permit incident-to.
Incident to allows NPP's to be reimbursed at 100%? but service they provide are limited? and documentation needs to indicate incident to
Yes, incident-to billing is reimbursed at 100%. Many services provided by NPPs in regular every day patient care simply do not meet the incident-to requirements. As long as they are providing services within their scope, they are absolutely allowed to provide the service. It is just not allowed to be billed incident-to the physician, and must be billed under the NPP. I know a lot of administrators who confuse incident-to (which is a BILLING policy) with scope of practice. Incident-to simply explains how to potentially bill a service for 100% reimbursement, and not whether or not the NPP can/should/may provide the service.
Bottom line. Each carrier sets their own policy and guidelines about NPP services and how to bill them.
1) Your NPPs should be credentialed with all payors that your physicians participate with.
2) If the payor does not credential NPPs (this is very rare), then follow their policy which would most likely be to bill under the supervising physician even if not incident-to. 100% payment
3) IF the payor permits incident-to billing AND the services provided meet all the incident-to requirements, then bill incident to. 100% payment
4) If the carrier does NOT permit incident-to OR you are not meeting all the requirements, bill under the NPP. 85% payment
For item #4 above, if you do not credential NPPs, there will be many times you receive 0 payment (denied, or applied to the deductible.) You would also be required to notify the patient they are seeing an out of network provider before services and follow the No Surprises Act guidelines.
If you do not credential your NPPs and expect to be able to bill all their services under the physician, it is almost impossible.