Wiki NP/PA billing under MD

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midnight1995

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Looking for help from all different states - I know the incident to guidelines and most commercial insurance may or may not follow Medicares guideline. Here iss the million dollar question -
1.) if the NP/PA is credentialed with Medicare/Medicaid and commercial insurance can you always bill under the MD (outside the incident to rules)
2.) If any one has documentation , please send.

I work for a large RCM company and providers are just billing under themselves as the supervising provider - I do not agree with this at all and when I address the issue to our (compliance person)they state do as the practice wants.

Thank you all
 
If you know the 'incident to' guidelines then you should already have your answer to #1 - an NP or PA can bill under the MD only when those requirements are met.

For #2, this article pretty well sums up the requirements:

https://www.cms.gov/Outreach-and-Ed...k-MLN/MLNMattersArticles/downloads/se0441.pdf

Also, you can refer to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

and to the Medicare Benefit Policy Manual, Chapter 15, Section 60, which discusses 'incident to' requirements in great detail:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

I'm not sure what you mean in your last statement by "providers are just billing under themselves as the supervising provider" - billing under the provider's own credentials is OK and does not require 'incident to' guidelines be met. If the practice is always billing the NP/PA services under their own credentials instead of the supervising MD, they may be losing some money by getting the lower rate paid to a mid-level provider, but as far as I know there's nothing wrong with that. I've heard of many practices that do this because they don't feel it's worth the audit risk and the trouble it takes to monitor every service to see whether or not all of the 'incident to' rules have been met.
 
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midnight1995 said:
thank you - what I mean is the claims are being billed under the MD for the NP/PA regardless if the NP/PA is credentialed.
Click to expand...

As I understand it, that's inappropriate unless 'incident to' requirements have been met, or unless directed to do so by a payer policy or contract in writing. Credentialing really has nothing to do with it. Billing under a different provider than the one who rendered the services is a false claim unless you have guidelines or documentation to fall back on to show otherwise.
 
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