Nurse practitioners are one of the most important key players in any health establishment. As a health service provider, you should make sure that you properly select and hire your next nurse practitioner. It would be useful to plan and define the following before you even begin the selection process:
Once you identify the role of your nurse practitioner (limited to work with established patients or given to new patients as well), you can start to look up your local state regulations related to nurse practitioner and physician collaboration and make sure that you comply with.
Credentialing, Billing, and Reimbursement
Your nurse practitioner may be credentialed to insurance companies and billed under his/her NPI for the services rendered. However, not all payers may accept nurse practitioners. You should take note that contracted nurse practitioners have lower reimbursement (e.g., Medicare covers NPs’ services at 85% of the Medicare physician fee schedule). Other payers also have lower rates of around 75%-95%.
Billing “Incident to” for a 100% Fee Schedule Rate
Billing “Incident to” may be beneficial. When “Incident to” guidelines are met, services performed by nurse practitioners may be billed under the supervising physician NPI and therefore approved at a 100% rate of the fee schedule. But take note— this strategy will not work for all types of services and practices.
For example as according to Medicare, incident to billing does not apply in the urgent care setting. The nurse practitioner cannot perform a service and bill that service under a physician’s NPI, even when the physician is available in the urgent care suite and perform required supervision.
Practicing in Urgent Care Setting and the Patient’s Home Place of Service
Care provided in the urgent care setting is generally intended to address a new patient problem, requiring all elements of care to be completed by the performing/billing provider, whether that provider is a physician or a nurse practitioner.
As guided by Medicare, for the patient’s home place of service, in general, the supervising physician must be present in the patient’s home for the service to qualify as an “incident to” service. There are some exceptions to this direct supervision requirement that apply to homebound patients in medically underserved areas only for certain limited services.
Identifying Your Nurse Practitioner’s Role: Type of services
Considering the type of services, for example, diagnostic tests are subject to their own coverage requirements. Depending on the particular tests, the supervision requirement for diagnostic tests or other services may be more or less stringent than supervision requirements for services and supplies furnished incident to a physician’s or other practitioner’s services.
What Does Medicare require? “Incident to”
To qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.
In other words, incident to billing does not apply to new patients or established patients who present with new problems.
To qualify as “incident to,” the supervising physician does not have to be physically present in the patient’s treatment room, while these services are provided. However, he or she must provide direct supervision and must be present in the office suite to render assistance, if necessary.
Documentation must support evidence that a supervising physician was present and available. The documentation submitted to support billing “incident to” services must clearly link the services of the NP to the services of the supervising physician.
Make sure your payer recognizes “incident to” guidelines
If you have payers other than Medicare, you have to make sure the payer recognizes the “Incident to” guidelines. Also, considering commercial payers, some may require special modifiers to be submitted on claims when services performed “incident to.”
You must communicate with your biller to make sure you are providing all the necessary information for accurate billing and stay in compliance with the payer's requirements.
Contact us today if you need professional guidance in credentialing and billing!
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