In the State of California, Nurse Practitioner (NP) needs to practice under the supervision or with a physician and doesn't allow NP to practice independently (SB 421, 2013). Supervision is where the APRN needs to be supervised and guided by the physician and described that it is where critically watching and directing activities or a course of action and is a mainstay of any hierarchical structure (Joel, 2013) Having that said, I have interviewed some NP's from the California Association of Nurse Practitioners Symposium I have attended and found out that, physician supervision doesn't mean that they need to check everything before an NP perform/initiate the treatment. They are there to guide and work with the NP's to meet the patient’s goals and provide optimum care needed by the patient. Team-Based approach is the current setting of NP and Doctors in California and some other states who doesn't allow NP to practice independently. Having a common goal for the patient’s outcome and to maintain the individuals health gives both NP and MD advantage to care for the patient. It allows the NP to practice with the physician and to render health care services that are within the scope of the practitioner’s expertise. The setup of a provider’s office always depends to the state law. And also, Medicare and other insurances always defer to the state law requirements upon billing. The Definition of Incident to Billing Having all that said, Centers for Medicare and Medicaid Services (CMS), have provisions using "Incident to Billing" saying that Physicians can bill for the services provided by the NPs and staff who are in the same practice and working together as long as they are within an institution (CMS 2013). Thus, it also requires that the MD should provide the initial service or treatment and would supervise or get involve in the following treatment (CMS 2013). According to Joel (2013, p. 492), It also allows the physician to bill for the services provided by other staff (APNs, Nurses, Medical Assistants and PA’s). This is almost the same as "physician-supervised services" but NP and other practitioners have more independency with the "Incident to" billing. According to Joel (2013, P. 492), Nurse Practitioners can only reimburse 85% of what the physician can reimburse, wherein using the “incident to” services can actually reimburse 100% of the physician’s rate. As long as the physician continuous to actively participate in management of the treatment nurse practitioners are able to reimburse in full amount under the name of the MD (Joel 2013 p492).
The Criteria of CMS to be able to bill using the “Incident to” Medicare provisions must be met upon billing using "incident to" services. Also, compliance to these will decrease the chance of getting fraud accused to the practitioner (TMA, 2014). According to Texas Medical Association the following are the said guidelines: 1. Nurse Practitioner should be employed or at least an independent contractor of the Physician. 2. Physician should have an active participation and management in the patient’s course of treatment and should reflect to the patient’s chart. 3. The patient’s initial visit must be initiated by the physician and the follow-ups can be done by the Nurse Practitioner. Thus, It doesn't mean that every incident services that NP is performing; the patient should see the MD too. It doesn't mean that there must be a direct/personal and professional service. 4. The Physician should have a direct personal supervision. The physician should be in the same office and available immediately to render assistance if necessary. Therefore, Satellite clinic is not recognizing.
One great example is, if the NP is working in a Providers office with a group of doctors working with her. The NP can bill services under "incident to" as long as the rules are being followed. The physician must then at least conducted the initial visit and have an active participation in the course of treatment of the patient.
Avoiding Billing Fraud using “incident to” services Fraudulent activity can be anywhere and it is significant for the practitioners to learn and to be aware of the possible cause of it. Also, state guidelines and Medicare protocol adherence is also important to be able to avoid fraud. The following are the possible billing as "incident to" wherein it is incorrectly used: 1. If the above requirements are not followed and thus billed as "incident to" services. For example, the NP is working in her own provider’s office and consults to the Doctor within at least 20 miles away from the office of the NP and still billing under "Incident to". Lets say that the patient had the initial visit with the physician and referred to the nearby NP, the services cannot be billed as "incident to" because the physician is not present at the same office and not immediately available to render assistance if needed or if the NP are able to call the Physician right away without the physical presence is still not valid. This can be a good example of the Satellite Clinic (Buppert, 2002)
2. According to Hill (2011), Medicare requires a provider to examine and document thoroughly so that the coding can be maximized and determined the right level of care that can be billed. There are cases wherein kickbacks exploiting Medicare loopholes cause from over billing. As provider documenting a treatment/assessment that is not done during the visit/examination is also considered as fraud. Thus, overcharging the patient and the insurance for something they don't receive is unethical and can greatly affect the future budget for healthcare. An example of this is, Mr. X a new patient of the NP who was seeking for treatment for his skin condition. After the visit the NP documented a few assessment and treatment regarding the skin disease and charted more notes regarding gait, blood pressure and anxiety of the patient. Instead of prioritizing the skin problem of the patient the patient has been billed for an unnecessary procedure because the provider can get more reimbursement from the other procedure that is not done.
Using “Incident to” and avoiding Fraud The importance of having knowledge in billing and coding rules so as the Medicare and state policies is very important to every provider. This will determine the extent care that can be provided to the patient and if the patient is receiving the right care needed. In health care industry, there can be loopholes and issues related to billing, as future NP avoiding this to protect my patients and my license would be a key in having a good practice. Most of the providers nowadays hire biller or a coder who are specialist in preventing this kind fraud issues. Reference: * Nurse Practitioners, Senate Bill – SB 491 Hernandez (2013) Retrieved fromhttp://www.leginfo.ca.gov/pub/11-12/bill/sen/sb_1501-1550/sb_1524_bill_20120929_chaptered.pdf * Centers for Medicare and Medicaid Services (CMS) (2013), "Incident to" Services, MLN Matters Number SE0441 Retrieved from: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf * Joel, L. (2013). The Law, the courts, and the Advance Practice Nurse. In Advanced practice nursing essentials for role development. (3rd ed., pp. 483-495). Philadelphia: F.A. Davis. * Texas Medical Association (TMA) (2014). Incident to Billing Criteria (Medicare Option #2). Retrieved from http://www.texmed.org/templateprint.aspx?id=2274 * Buppert, C. (2002). Billing For Nurse Practitioner Services: Guidelines for NPs, Physicians, Employers, and Insurers. Medscape. * Hill, H., & Hill, M. (2011). The ethics of coding: Are we committing fraud? Journal of the American Academy of Physician Assistants, 67-68.