There are many rules that need to be followed in billing Medicare. But one of the more complicated ones is for services provided that are “incident to” a physician’s care.
If your initial reaction to that was, “Say what?” you’re not alone.
“It’s not something people learn in medical school,” says Carolyn Buppert
, a healthcare attorney who specializes in legal and reimbursement issues for nurse practitioners and physicians. “It’s not something that anyone is necessarily tested for. And if you try to become a Medicare provider, it’s not like the first thing they send you is the incident-to rules.”
And if you don’t follow the rules, the consequences can be costly.
The guidelines surrounding incident-to billing are detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60
. They’re long and complicated, but Buppert summarizes the essentials.
“The physician or the practice needs to employ the nurse practitioner, or whoever else is doing the work and is going to be billed under the physician’s number,” she explains. “So, there needs to be an employment relationship.”
But that’s not all. The physician has to have conducted the initial service – and usually that means the new patient visit, but it can also mean the initial service for an episode of illness.
For example, a patient is originally diagnosed with high blood pressure, and the physician says, “Okay, I want you to come in for a blood pressure check next week; you’ll see the nurse practitioner.” In that case, the physician has provided the initial service, and the next visit will be with the nurse practitioner, and they’ll be billing that incident-to, given that all the other rules are followed.
However, if in that same scenario the patient returns and says they’re bruising all over, you now have a new episode of illness.
“The bruising has to be evaluated,” Buppert says. So in that case, the auditors have been saying you can’t bill incident-to because the initial service for that episode of illness would need to be provided by a physician.”
Essentially, you can resolve that situation in one of two ways. Send the patient back to the physician so he or she can provide the initial service for the bruising; or bill that visit under the nurse practitioner’s number, thereby forgoing the extra 15 percent reimbursed under Medicare.
“And,” Buppert adds, “the physician has to be in the office suite at the time of the visit. Not in the same room as the patient and nurse practitioner, but not one floor up in the lab.”
In years past, the onus for ensuring that incident-to billing is handled correctly has fallen on the physician, or whoever owns the medical practice and does the billing. Prosecutors were not going after the nurse practitioners. But according to Buppert, that’s changing.
“In the last few years they have been prosecuting the nurse practitioners who are involved, saying that this information has been around for a long time, and everybody should know about it by now,” Buppert explains. “I see cases going that way now.”
Buppert advises nurse practitioners who don’t want to worry about these rules to just bill under the nurse practitioner’s number. The practice may lose 15 percent – Medicare typically reimburses 85 percent of fee schedule for billings by non-physician practitioners – but that can be made up efficiency-wise.
“It’s not like the whole visit is lost,” she says. “Just bill it under the nurse practitioner’s number.”
Improper billing, it must be noted, can be costly. For starters, practices can be required to pay back the 15 percent – the difference between 85 percent and 100 percent reimbursement. And depending on how many Medicare visits were scheduled during the year, that can add up if an audit is performed.
“They usually start with 30 charts,” Buppert explains. “Let’s say that half of them have an error. They extrapolate the monetary owings from the mistake on those 15 charts and extrapolate the medical billing for the whole year. So, 15 percent for one visit could be like $15, but when you multiply it by the Medicare visits for the whole year, it becomes a lot.”
The medical practice could also have to pay the auditor, and might be put on probation. In a worst-case scenario, there could be criminal prosecution.
“Because there’s a third party paying, there are rules involved,” Buppert says. “Some practices throw up their hands and say we don’t want to be involved with all these rules, so we’re going to opt out. In that case, they don’t bill Medicare. But if you’re going to bill Medicare, you have to follow the rules.”