Successful Clinic Operations for “Incident To” Billing

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Many physicians hire mid-level providers, such as Physician Assistants and Nurse Practitioners, to work in their practice as a way to expand capacity and provide more services to more patients. However, services provided by mid-levels are typically paid at only 85% of the rate that would have been paid had the physician provided the service instead. “Incident To” billing exists as a way to acknowledge the physician’s active role in the patient’s care, and when supervised mid-level services are billed as “Incident To”, they are reimbursed at 100% of the physician rate instead of being subject to the 15% discount. RPM Billing has expertise and a demonstrated track record of success with “Incident To” billing as it relates to billing, collections, and physician clinic practice operations.

RPM Billing has helped numerous clients successfully implement strategies such as these, with both Medicare and commercial insurance.
— Jonathan Marshall, RPM Billing

According to Medicare, to qualify as “Incident To” services, the following conditions must be met:

1.       The services must be part of the patient’s normal course of treatment.

2.       The physician must have performed the initial visit on that same course of treatment.

3.       The physician must provide “direct supervision” and be actively involved in the patient’s care.

4.       The physician does not have to be present in the exam room, or even see the patient during every visit, but he or she must be physically present in the clinic location where the visit occurs.

5.       The patient’s chart should document the physician’s involvement and communication with the mid-level provider.

6.       The mid-level provider must represent a direct expense to the physician (such as an employee, a leased employee, or a contractor).

7.       The mid-level provider must be an actively licensed provider, such as a physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, or clinical psychologist. 

8.       Services provided by Registered Nurses do not qualify for “Incident To” billing.

9.       If the physician is in a group, any of the physicians in that same group qualify as the on-site supervising physician during that patient’s visit.

A recently published Medicare summary document on this topic can be found here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf

Some simple tricks can help practices stay in compliance. RPM Billing recommends designing simple steps and then doing thorough training and staff support. There is no need to make this complicated. First, all new patients should be scheduled with a physician. Also, any patient whose course of treatment changes should be scheduled with a physician for the first visit of that new service. Scheduling staff should make sure that a qualifying supervising physician is scheduled in each practice location every day that a mid-level will also be working there. The physician should quickly review each visit note, add some comments of his or her own, and make those part of the patient visit record. Additionally, physicians should simply conference briefly each morning with the mid-levels in the same clinic location about which patients are being seen that day, so that input and supervision can be provided and documented by the mid-level. Finally, it is a good idea to have the physician scheduled as part of an occasional visit with each patient. RPM Billing helps their clients practices design and implement procedures such as these, as well as write policies to support a compliant “Incident To” billing environment.

When these criteria are met, the claim is simply billed under the physician’s NPI number and it is reimbursed at 100% of the allowable physician rate. Physicians and their clinic managers should diligently design and enforce policies and procedures to make sure that all of these criteria are met on each patient, so that it is clearly documented that a qualifying physician was on-site, the physician performed the initial visit for that same course of treatment, and that the physician is actively involved with the patient’s care. Audits from Medicare and commercial insurance companies can occur, and can result in costly takebacks, so we do not recommend “Incident To” billing for practices that do not have the ability to create and consistently enforce the above-listed conditions. However, with professional leadership, good organizational behavior and communication, and a commitment to doing things the right way, a practice can appropriately maximize its revenues through “Incident To” billing.  Also, many commercial insurance companies support “Incident To” billing, but the rules are subject to vary, so it is good to reach out to provider relations staff with each insurance company.

RPM Billing is a professional medical billing and consulting firm based in Las Vegas and Reno, Nevada, and serving clients nationwide. We have an experienced professional billing team, and we work with our clients to develop processes that make sure 100% of the encounters get processed, billed, and paid appropriately and timely. We have helped numerous clients successfully implement strategies such as these, with both Medicare and commercial insurance. Led by Jonathan Marshall, who holds a Healthcare MBA and two decades of experience as CEO, CFO, and COO of hospitals and physician practices, RPM Billing was created as a commitment to excellent processes, results, and customer service for its clients. To contact us for a free review of your company’s opportunities to improve revenues, please call us at 775-501-9820, email us at jon@rpmbilling.com, or visit us at www.rpmbilling.com.