Billing

The U.S. Department of Health and Human Services (HHS) is more closely scrutinizing services billed at physician reimbursement levels but performed by nonphysicians, according to a Medical Economics report

HHS indicated its intention to take a closer look at these "incident-to" services, which are often performed by nurse practitioners and physician assistants, in its Office of Inspector General's 2013 Work Plan.

According to the Work Plan, the HHS "... will review physician billing for 'incident-to' services to determine whether payment for such services had a higher error rate than that for non-incident-to services. We will also assess Medicare's ability to monitor services billed as 'incident-to.' Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident to a physician office visit. A 2009 OIG review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a day, half of the services were not performed by a physician. We also found that unqualified nonphysicians performed 21 percent of the services that physicians did not personally perform. Incident-to services are a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record. They may also be vulnerable to overutilization and expose beneficiaries to care that does not meet professional standards of quality."

Billing for "incident to" services are permissible under Medicare Part B as long as practices follow Medicare's criteria as identified by the American Academy of Physician Assistants in this report(which also provides answers to frequently asked questions about "incident to").

The five criteria are as follows:

  1. Services are provided in a physician’s office or physician’s clinic;
  2. Physician sees Medicare patient on initial visit, establishes a diagnosis and treatment plan. PA sees patient on follow up visit;
  3. For established Medicare patients with a new problem, the physician sees the patient first for the new problem, establishes a diagnosis and treatment plan, PA sees patient on follow up visit;
  4. Physician is on site, within the suite of offices; and
  5. Services are within the PA's state law scope of practice.
X