Wiki Incident-To in PBB

neecen

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Good day everyone! Can anyone tell me if incident-to billing is permitted in a provider based billing office? I have read numerous articles on incident-to billing and numerous articles on provider based billing. In all of the articles I have read, none of them discuss the combination of the two and if they are allowed.

Thank you in advance on insight you can provide!
 
Incident-to billing is an office billing concept. In a provider based clinic, you have to follow outpatient hospital rules.... the supervision rules are based on the CPT, there has to be a physician's treatment plan of care in place, and in some cases, an order or referral for services. CMS is murky about PBB, so the outpatient facility guidance in CMS and 42CFR needs to be followed.
 
Incident-to billing is an office billing concept. In a provider based clinic, you have to follow outpatient hospital rules.... the supervision rules are based on the CPT, there has to be a physician's treatment plan of care in place, and in some cases, an order or referral for services. CMS is murky about PBB, so the outpatient facility guidance in CMS and 42CFR needs to be followed.
Thank you so much. This makes perfect sense to me however, I couldn't find any resources to show to my committee. I will definitely go in and print this rule.
 
do all insurance companies follow incident -to billing?
No. It is a CMS policy. Each insurance company may decide to follow or not follow incident-to.
Historically, commercial carriers did not credential NPPs, and advised to bill under the supervising physicians. Insurance companies later realized if they credential NPPs and then require incident-to billing, they could potentially pay less money. That is what many carriers do now, but not all.
 
I appreciate your feedback
How can we identify insurance carriers who follow incident to billing? It's difficult to find a direct answer with insurance companies

Most major insurance companies have provider manuals available online. Those are a great resource for information.

I always try to have a copy of the provider contract, any amendments or documents referenced in a contract, and also a provider manual for at least the major payers. Depending on who does the contracting in your organization, insurance contracts may be harder to come by, but provider manuals are generally accessible to anyone.
 
Most major insurance companies have provider manuals available online. Those are a great resource for information.

I always try to have a copy of the provider contract, any amendments or documents referenced in a contract, and also a provider manual for at least the major payers. Depending on who does the contracting in your organization, insurance contracts may be harder to come by, but provider manuals are generally accessible to anyone.
I appreciate your feedback. Believe it or not, most contracts do not state incident-to billing. I have all contracts/ amendments per insurance...
Do you have any direct link for the major payers?
 
I appreciate your feedback. Believe it or not, most contracts do not state incident-to billing. I have all contracts/ amendments per insurance...
Do you have any direct link for the major payers?

If you go to the website for your major payers, you should be able to find the provider manuals on the menu for providers.

For example, the Aetna menu for healthcare professionals has all the manuals, past provider newsletters, state specific regulations, etc: https://www.aetna.com/health-care-professionals.html
 
By the way, what you're looking for may not specifically be titled "Incident-To Billing." That's a CMS term - if the commercial payer doesn't follow Incident-To, they're probably not going to have a subsection in a contract labeled as "Incident-To."

I'd also look for sections that address how Midlevel Practitioners/Nonphysician Providers are expected to bill and how they will be reimbursed. For example, there could be a commercial payer policy that clearly states that NP/PA are expected to bill for all services rendered under their own NPI.

My current employer doesn't bill incident-to, so I don't have a list of the current payer policies offhand. (I think they decided there were too many compliance risks involved in tracking incident-to billing, so we just don't do it across the board. Not sure - the decision was made long before I started here.)

I used to work in contract management with a different organization, which is where I got used to navigating the provider manuals & resources to find information. But I haven't had to stay current on commercial incident-to policies since I moved to my current employer.
 
By the way, what you're looking for may not specifically be titled "Incident-To Billing." That's a CMS term - if the commercial payer doesn't follow Incident-To, they're probably not going to have a subsection in a contract labeled as "Incident-To."

I'd also look for sections that address how Midlevel Practitioners/Nonphysician Providers are expected to bill and how they will be reimbursed. For example, there could be a commercial payer policy that clearly states that NP/PA are expected to bill for all services rendered under their own NPI.

My current employer doesn't bill incident-to, so I don't have a list of the current payer policies offhand. (I think they decided there were too many compliance risks involved in tracking incident-to billing, so we just don't do it across the board. Not sure - the decision was made long before I started here.)

I used to work in contract management with a different organization, which is where I got used to navigating the provider manuals & resources to find information. But I haven't had to stay current on commercial incident-to policies since I moved to my current employer.
thank you for your reply, very helpful!
if you don't bill incident to, how do you bill under Nurse Practitioners/Physician Assistants?
Are Nurse Practitioners/Physician Assistant credentialed with insurance companies?

If it is easier for you, please email me directly!
 
thank you for your reply, very helpful!
if you don't bill incident to, how do you bill under Nurse Practitioners/Physician Assistants?
Are Nurse Practitioners/Physician Assistant credentialed with insurance companies?

If it is easier for you, please email me directly!

Yes, our Nurse Practitioners and Physician Assistants are directly credentialed with all of our payers. Whatever services they provide are billed under their NPI.
 
For my practice, all of my NPPs are separately credentialed. Almost all of our contracts specify to follow CMS guidelines, which does allow incident-to.
That being said, we RARELY bill incident-to for a variety of reasons. In my opinion, you are severely limiting the care NPPs may bill if only providing incident-to services. We also have a logistics hurdle. Incident to requires (among other things) for the MD to be onsite and immediately available. We have 3 exam rooms at our main location. My NPPs have office hours when my MDs don't. We also have multiple locations and an MD may be at one location and NPP at another.
Here are SOME of the highlights of incident-to requirements:
1) MD onsite and immediately available.
2) Established patient with an established problem.
3) Plan of care already determined and initiated by physician that NPP is carrying out.
A known issue (monitoring stable fibroid) or patient being seen for birth control renewal is definitely possible incident to (if you don't have the logistics issue).
Urinary frequency and burning, likely UTI? Cannot be incident-to unless the MD previously saw the patient already for that problem and initiated a plan of care.
New patient? Never incident to.
Established problem but now worsening or improving and the clinician needs to change the plan? Likely not incident to depending how the plan of care was written.
Well woman exam and PAP screening? Not incident to.

Your NPPs should be credentialed with every carrier that does so. If your carrier permits incident-to and you are able to provide some services incident-to, that is clearly the best reimbursement scenario. Some carriers don't permit incident-to and all services must be billed by the clinician providing them. Some carriers don't permit incident-to and instruct all services to be billed by the supervising clinician. This last situation is more and more rare as carriers have realized they can pay less for NPP services.

If you don't credential your NPPs and/or don't meet incident-to requirements, you will wind up with your NPPs either seeing very few patients, or seeing patients for services you can't bill for.
 
For my practice, all of my NPPs are separately credentialed. Almost all of our contracts specify to follow CMS guidelines, which does allow incident-to.
That being said, we RARELY bill incident-to for a variety of reasons. In my opinion, you are severely limiting the care NPPs may bill if only providing incident-to services. We also have a logistics hurdle. Incident to requires (among other things) for the MD to be onsite and immediately available. We have 3 exam rooms at our main location. My NPPs have office hours when my MDs don't. We also have multiple locations and an MD may be at one location and NPP at another.
Here are SOME of the highlights of incident-to requirements:
1) MD onsite and immediately available.
2) Established patient with an established problem.
3) Plan of care already determined and initiated by physician that NPP is carrying out.
A known issue (monitoring stable fibroid) or patient being seen for birth control renewal is definitely possible incident to (if you don't have the logistics issue).
Urinary frequency and burning, likely UTI? Cannot be incident-to unless the MD previously saw the patient already for that problem and initiated a plan of care.
New patient? Never incident to.
Established problem but now worsening or improving and the clinician needs to change the plan? Likely not incident to depending how the plan of care was written.
Well woman exam and PAP screening? Not incident to.

Your NPPs should be credentialed with every carrier that does so. If your carrier permits incident-to and you are able to provide some services incident-to, that is clearly the best reimbursement scenario. Some carriers don't permit incident-to and all services must be billed by the clinician providing them. Some carriers don't permit incident-to and instruct all services to be billed by the supervising clinician. This last situation is more and more rare as carriers have realized they can pay less for NPP services.

If you don't credential your NPPs and/or don't meet incident-to requirements, you will wind up with your NPPs either seeing very few patients, or seeing patients for services you can't bill for.
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!
 
My orthopedic practice has contracted with a physical therapist to perform EMG/NCS. He comes to our office and performs the test. The test is ordered by our physicians in our practice. We bill these incident to. We have a different supervising physician assigned each day and whomever is supervising that day we list as the supervising physician for the EMG/NCS, unless the ordering physician is in the office, in that case we list that physician as supervising. I get a signature from the supervising and the physician that has seen the patient and ordered the test. The claim is billed under the physician that seen and ordered the test. Is there anything I am missing??
 
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.
 
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.
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.
Thank you, @ csperoni !!! I appreciate your help!
 
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