A Look on Payers’ Billing Policies for Non Physician Practitioners (NPPs)

Healthcare organizations and hospitals are increasingly using non physician practitioners (NPPs) to enhance patient satisfaction, increase the therapeutic reach of physicians and boost their bottom line. With the implementation of the Patient Protection and Affordable Care Act— which is making healthcare accessible to more that 10 million Americans— roles and responsibilities of these skilled individuals are expanding. Over the last few years, healthcare organizations in the United States have been increasingly using NPPs, since practices with NPPs perform better financially, generating higher physician income.

On the other hand the risk for noncompliance with NPPs are greater, because every health plan, which includes Medicare, has its own rules regarding NPP billing, and each state has its own laws for NPP licensing and scope of practice.

Want to avoid compliance issues relating to NPPs? Take a look on these payers’ billing policies for NPPs:

“Incident-to” Billing

“Incident to” billing with an NPP’s own Nation Provider Identifier (NPI) is one option provided by the Medicare. “Incident to” billing permits services provided by NPPs to be billed under the physician’s NPI. To qualify as “incident-to”, the services provided must be performed under the supervision of a physician that too in his clinic. Also, according to the CMS, the service provided needs to be an integral part of a Medicare patient’s normal course of treatment, where the physician personally performed the initial service and remained involved in the course of treatment.

The rate of reimbursement is higher in “Incident to” billing, since you’re billing under a physician and will receive the physician rate, although in some cases it can be difficult to do it administratively.

Directly billing Medicare with NPI

NPPs are required to complete correct Medicare enrollment forms (CMS-855I application) to be paid for providing care to Medicare beneficiaries, unless except all services fall under the “incident to” definition. Credentialing NPPs independently requires less administrative work; however you will receive lower reimbursement as NPP services are reimbursed at a lower rate than physician fee schedule rate. For instance, suppose a physician was present at the group in the morning and the “incident to” criteria is met, the NPP could bill for appointments under that physician’s NPI. Though, at times when the physician leaves to see patients in the middle of the day, the NPP would not be able to bill “incident to” using physician’s NPI because the appropriate supervising physician was not physically present.

CMS/Medicare’s rules for NPP, incident to and direct services can become confusing. To educate you on the billing and compliance issues of NPPs, expert speaker Jill M.Young will be taking an audio session on Wednesday, April 15, 2015. If you are using the services of Non Physician Practitioners in your practice, this training session will definitely help you.

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